Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Are there any potentially successful pharmacologic interventions (instead of CBT or behavioral interventions alone) for Schizoid personality disorder?
This is a tricky question to answer in part because people with schizoid personality disorder do not typically present for treatment. If they do, it is often due to co-morbid symptoms such as mood or anxiety symptoms. Therefore, these symptoms are often what are targeted pharmacologically. People wi...
Have you found aripiprazole effective for treatment of psychosis and bipolar mania in practice?
While aripiprazole is approved for schizophrenia, I rarely use it for treating this condition. I do not find that it is effective enough to treat true psychotic symptoms when compared to almost all other SGAs. The same goes for bipolar mania. Instead, I tend to use aripiprazole for less severe cases...
For breakthrough psychosis on a maximized LAI, do you add oral supplementation or shorten the injection interval first?
It depends on the timeline of symptomatology and the LAI; if the individual has resolution of symptoms that return temporally as they get closer to their scheduled LAI, I will try to shorten the interval. If there are significant symptoms despite use of the LAI, I would augment with oral supplementa...
How do you counsel patients with bipolar disorder who want to breastfeed?
This is a great question! Many women desire to breastfeed their babies, and providers often encourage the initiation of breastfeeding in the immediate postpartum period. For women with underlying bipolar disorder, this decision can be more nuanced. Nursing a young infant requires multiple feedings ...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
How have you incorporated wearables such as fitness trackers, smartwatches, or sleep monitors into your practice?
While pulse may be accurate on some devices, blood pressure and sleep data are notoriously inaccurate, and I would not include those. There is a great Curbsiders podcast about hypertension and measuring blood pressure properly that addresses the disadvantages of wearables for this purpose.
As a psychiatrist, do you treat vitamin D deficiency without consulting PCP?
Vitamin D deficiency can be a clue to celiac disease and even lymphoma. I support psychiatrist testing (and sometimes prescribing if there is a delay in seeing a PCP), but the PCP needs to be notified to rule out other conditions.
How do you cross-taper when switching from an SSRI to an SNRI?
It depends on which SSRI and SNRI are involved, as well as the dose of the SSRI. If switching from a low-dose SSRI, a cross-taper is not typically necessary given that both SSRIs and SNRIs increase serotonergic transmission and therefore a withdrawal effect will likely not be felt. If switching from...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
When do you use bupropion standard release or intermediate release instead of extended release?
Never