Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach requests from patients with social anxiety disorder or agoraphobia to work remotely as a medical accommodation?
I would approach this request with a lot of compassion and also humility. One of my first questions would be whether working remotely would actually be the most therapeutic approach for this patient. I would worry that remote work would act a bit like avoidance of an anxious trigger and could, over ...
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
How do you approach discussing possible dementia with an older adult who is presenting with depression, when you are concerned that raising this possibility could worsen their depressive symptoms?
I think the concern of bringing up a potentially devastating diagnosis, such as dementia, in this or any other context, is valid. And yet, when someone is experiencing depression, a disease that is multifactorial and sometimes difficult to treat, it is important to diagnose, evaluate, and treat any ...
How do you approach mood stabilizer selection for older adults with bipolar II disorder?
Depending upon age, medical illnesses, other medications the patient is on, and the symptoms, the appropriate medication will be decided. If the patient is hypomanic, a mood stabilizer will help. Also, if the patient is on an antidepressant, reducing the dose or even stopping it can be a choice. If ...
How would you manage a healthcare provider with major depressive disorder when their condition is suspected to impact their job performance?
This is a complicated issue that makes us all a little uncomfortable. There are several issues one must consider. First, from the treatment side, the provider should be treated like all other patients. You should be mindful of the side effect/benefit profile of the treatments and avoid or use them t...
How do you approach evaluating sudden mental status changes in telepsychiatry patients, particularly older adults, when medical causes such as infection or metabolic disturbance may be contributing factors?
I am dealing with a few now, but during the pandemic, I had more. Sudden changes in mental status definitely need medical clearance. Helpful questions try to elicit findings about urinary changes, fever, and weakness, especially if I'm certain parts of the body show other symptoms like nausea, vomit...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
Often, if someone has an underlying condition that may artifactually elevate their symptom monitor scores (such as essential tremor in CIWA-Ar or tachycardia from cancer or sepsis in mMINDS), I will do any of the following: Increase the threshold for the symptom-triggered med by a few points (if th...
When do you consider starting an antidepressant without a mood stabilizer in a patient with a historical diagnosis of bipolar II disorder who has not had hypomanic episodes in many years?
I happen to have a patient just like this now on my inpatient service. One of the problems we run into often is uncertainty around the validity of the bipolar spectrum in the first place. We see so much complicated trauma, maladaptive behaviors, and disordered personality structures that periods of ...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How do you manage lamotrigine or lithium-induced acne?
For Lithium, I have referred patients to dermatology but it seems the interventions suggested such as Doxycycline, Spironolactone, or Bactrim do not fully help. I try to reduce the dose if possible or switch to another mood stabilizer if the acne is severe and bothersome that it is making the patien...