Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
What is your preferred PRN for management of pediatric agitation in the emergency department?
Choice of drugs depends on specific clinical presentation, psychotropic medication history, and comorbid medical conditions. Many, perhaps most, children's hospitals have electronic order sets for agitation in urgent settings, with allowances for override as these specific variables dictate. My typi...
Do you screen for MTHFR polymorphisms in your patients with treatment-resistant depression?
In the trial by Papakostas et al., PMID 23212058, we have shown that adjunctive L-methylfolate at 15 mg/day had significantly greater efficacy compared with continued SSRI therapy plus placebo on both primary outcome measures (response rate and degree of change in depression symptom score) and two s...
What are your considerations when treating insomnia in perimenopausal patients with comorbid anxiety or mood disorders?
I would choose to first try nortriptyline for such a patient. While being an older medication, I find it to be excellent. It is generally well tolerated and helps with insomnia, anxiety, and depression. It isn’t studied much, because it’s been generic for so long, and oftentimes, clinicians are unfo...
What is your approach in counseling a patient with delusions of parasitosis?
Delusions of parasitosis (DOP) or delusions of infestation (DOI) are among the most challenging conditions we treat as dermatologists. I am not sure there is one approach to treating these patients and it can often feel very frustrating and unsatisfying. Nonetheless, we all will encounter these pati...
After remission from a first episode of psychosis how long do you continue antipsychotic treatment before attempting taper or discontinuation?
I don't think this is a one-size-fits-all question. This will depend on a number of factors. Probably most important is the client's attitude toward medication and their experience with it. Those who have done well with medication and have had no problems with side effects may be more comfortable co...
What are your concerns regarding long term stimulant use in geriatric patients with ADHD?
I agree with @Dr. First Last; however, I had a patient in their mid-70s with small vessel disease (Parkinsonism) who had a gait disturbance, cognitive, and organizational problems. He was a lawyer who was trying to close his practice, and I gave him 10-20 mg of dextroamphetamine ER. It helped him co...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
When do you consider using dual orexin receptor antagonists (DORAs) for the treatment of insomnia?
I only consider using any hypnotic in insomnia when the patient is getting only 5 hours or less of sleep. In those cases, I will sometimes try using DORAs. I am a sleep neurologist who sees patients with MCI/early dementia, and I have found these medications useful in this population of patients wit...