Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Where in your treatment approach to fibromyalgia will you recommend sublingual cyclobenzaprine?
The choice of medication for any given patient is based on a lot of factors and, realistically, is often highly dependent on affordability and insurance coverage across different pharmacy plans. Despite other FDA-approved options, oral cyclobenzaprine is usually the medication I reach for first with...
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
How do you determine disposition when a patient presents to an outpatient psychiatry visit with recent self-injury that may require medical attention?
I agree with the responses that it has to be individualized, but if the self-injury is severe enough to warrant "medical attention" (I assume that means requiring sutures?), then in most cases that would warrant an emergency detention order in my opinion. Even in the case of borderline patients, thi...
When do you consider low-dose buprenorphine for the management of treatment resistant depression?
At doses of 0.25-2 mg, buprenorphine has potent kappa opioid receptor antagonism, and this conveys anxiolytic and antidepressant activities. It can be used in an augmentation mode with other antidepressants. See (Karp et al., PMID 25191915; Fava et al., PMID 26869247; Thase et al., PMID 31254971; Fa...
What is your pharmacological approach to treating depressive disorders in patients who develop serotonin toxicity?
I would try bupropion. Not Auvelity, as dextromethorphan has serotonergic activity. I would want to see if they were on any medication other than psychiatric that contributed to serotonin syndrome, like tramadol, and get rid of that or replace it as needed. I would probably want to transition to a n...
How do you approach requests from attorneys to complete paperwork supporting your patient’s application for long-term disability?
If the diagnosis does not support disability, I will give the attorney a call. This saves time, money, and my effort of writing a report. They may provide more collateral, or they may not use me. Either way, I am not stuck defending an untenable position. In terms of ambiguous questions, I try to be...
What are your experiences with lithium target levels in the maintenance of bipolar 2 disorder?
I prefer maintenance lithium levels at the 0.7-0.8 range, because I wish to provide a more rigorous test of lithium's ability to prevent recurrence in each BPII patient.
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
What workup do you consider necessary for “medical clearance” when patients present to the emergency department with altered mental status and possible psychiatric illness?
In the emergency room, whenever there is a question of altered mental status, we request UA+UTOX, CBC, CMP incl. LFTs, thyroid panel, B12, folate, b-HCG if applicable, and any related plasma medication levels +EKG. Based on a patient's substance use history or medical history, we might order additio...
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...