Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage acute agitation or psychosis in patients who are already taking aripiprazole (oral or long-acting injectable)?
Episodes of acute agitation are considered a psychiatric emergency, and considering treatment with dual antipsychotics (which will only be temporary) should have a lower threshold of consideration. Dual antipsychotic treatment is controversial, but there are promising results as well however (Ortiz-...
How do you approach buprenorphine dosing and titration in older adults with opioid use disorder?
I apply the same care and principles here with buprenorphine dosing in persons age 65 and older as I do with starting other psychoactive medications and medications that are metabolized by the liver. I also see many persons younger than 65 who have the physical health of persons older than 65 becaus...
How do you introduce patients with obsessive-compulsive disorder to the concept of exposure and response prevention (ERP) therapy when they may be hesitant to engage in exposure-based work?
This is a fantastic question, and I agree with the others who responded! I like to first validate their thoughts and feelings about ERP and explore their reluctance, noting that it is very reasonable. There are a few steps that can be helpful in introducing ERP to the patient. Metaphors can be very ...
How do you handle requests for medication refills from patients who were formally terminated from care but report difficulty accessing a new psychiatrist?
It is essential when terminating a patient that you provide at least three formal referral names with a 30-day notice. One of these should be an agency that cannot refuse patients. This could be a county or state mental health clinic. If the referrals you provide refuse the patient, then you are obl...
How do you manage patients who develop SIADH secondary to an SSRI but have had a strong positive response to that same medication?
Management of SSRI-induced SIADH depends on the severity of hyponatremia and the patient’s psychiatric response to treatment. In mild cases (serum sodium >130), I always continue SSRI with close monitoring and fluid restriction. Moderate to severe hyponatremia, I discontinue SSRI and actively correc...
How often do you require patients seen via telehealth to have in-person visits in outpatient psychiatry?
Great topic, and I'd love to hear others' experiences. For stable, low-acuity patients, I've largely moved to telehealth-primary with in-person visits annually or as clinically indicated. I still prefer at least one in-person intake before transitioning - the observational data matters. Factors push...
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...
How do you schedule follow-up visits for pregnant patients with a history of depression, both during pregnancy and in the postpartum period?
The frequency of visits is not, or not simply related to diagnosis, though the presence of a very severe depression or any bipolar episode would require more frequent visits than a history of depression alone. It would be important to know from a thorough longitudinal history what the patient's depr...
How do you manage obsessive-compulsive symptoms secondary to clozapine?
You have to find a good balance, which can be very challenging if the psychosis and OCD are prominent. Clozapine exacerbates OCD the most out of any antipsychotic. You can use Luvox to help boost clozapine levels and decrease norclozapine levels, which is the main culprit of metabolic side effects; ...
For pediatric patients who are being successfully treated for migraines with a TCA such as amitriptyline, would you consider starting an additional SSRI or SNRI for mood/anxiety symptoms, given the risk of serotonin syndrome?
My first inclination would be to just increase the TCA that is already being used and bring it up to therapeutic levels for antidepressant and anxiolytic effects. The TCAs are very effective antidepressants but come with a wider array of side effects, which makes compliance a bigger issue with these...