Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
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...
How often do you repeat a formal suicide risk screen at follow-up visits?
Patient safety and suicide, in my practice, is always my number one priority. However, that does not translate into plastering every patient encounter with a formal suicide risk assessment. Once I come to know my patient's history, stability, and life situation, for most ongoing patients in my outpa...
How do you determine when ongoing outpatient treatment is no longer beneficial, and it may be appropriate to transition a patient to another provider?
To answer this question, I’d want to first set aside the issue of patient abandonment by taking it for granted that any transition would occur in a manner consistent with ethical and legal guidelines (for example, but not exclusively, those set out by the AMA, the literature, and in murky or content...
What medication strategies do you find most effective for treatment-resistant depression with a history of trauma?
If the depression is not responsive to first-line and newer antidepressants, a trial of mood stabilizers such as Lamictal or Lithium or atypical antipsychotics such as Abilify can be tried. If the anxiety is additionally severe, quetiapine can be tried.
When do you consider referring to residential mental health facilities for patients in your adolescent psychiatry clinic?
In general, I do my best to avoid placements in residential facilities. I rarely find that they provide effective treatment. So, I refer to residential facilities when the teen is either a danger to themselves or others and when they are chronically gravely disabled. I think the data supports that g...
How do you approach a case of apparent worsening catatonia despite high-dose benzodiazepines and ongoing ECT?
In my experience, this may reflect an incorrect or incomplete diagnosis, comorbid medical problems, or side effects of medications. ECT is a great treatment for catatonia, and I start to have doubts about everything, but ECT, if ECT doesn't work. I think re-evaluating diagnosis, ensuring that we kno...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
What is the best approach to treatment for cenestopathies (sensation of electric current in patient's brain) accompanied by anxiety and inability to sleep?
Thank you for your question. Cenestopathies (referring to the feeling of being ill and this feeling not localized to one region of the body) may not be the correct term for this interesting phenomenon, commonly called "brain zaps". Brain zaps are a poorly understood symptom of antidepressant withdra...
When do you decide to switch stimulants vs. continuing to maximize dosage in ADHD treatment?
I definitely agree with Dr. @Dr. First Last about the core concept that this question appears to be asking - "When do you know if a stimulant is just not working for your patients symptoms, and/or when do you decide to change to a different stimulant?" Before answering the second part of this core q...