Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Has the April 2026 Cochrane review on anti-amyloid antibodies changed how you counsel older adults with early Alzheimer's disease about whether to pursue treatment with lecanemab or donanemab?
The April 2026 Cochrane review has not fundamentally changed my counseling, but it has strengthened my caution. It reinforces that lecanemab and donanemab clearly remove amyloid, yet any average clinical benefit appears small and remains difficult to interpret confidently given the numerous threats ...
In your opinion, when does a psychiatric medication regiment become "polypharmacy"?
I feel like that question is likely to start a fight (just kidding). I imagine most psychiatrists have their own strongly held opinion on this matter. When I was a resident, someone told me that once the number of psychiatric medications increases past 3, they become concerned that it is too difficu...
Have you found clinical differences between the branded and generic forms of psychiatric medications?
I definitely saw a difference between various forms of bupropion when it became generic. At the time, research suggested that the different delivery systems for bupropion produced very different blood levels and differently timed release. I usually hear about differences between the generics and bra...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
Have you used cannabinoid-based products for insomnia?
No, but patients report it helps. I don't encourage it due to a lack of research supporting long-term positive effects.
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
Do you find that hydroxyzine worsens cognitive symptoms in patients who are already susceptible to cognitive impairment?
Hydroxyzine should not have a direct negative effect on cognition. For decades after its inception, it was lopped in with Benadryl in terms of its receptor binding affinity profile and is listed in several anticholinergic burden scales as being anticholinergic. Similar to the child’s game ‘telephone...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
In your experience, when do antidepressants begin to take effect for depression?
Postsynaptic down-regulation is known to occur at the four- to six-week mark. And I tend to delay dose changes until that point, if at all possible. Although this mechanism of action is now less solid with some of the meta-analysis data on the serotonin hypothesis, the time frame still holds for obs...