Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you decide when to obtain a brain CT and/or MRI in hospitalized patients with altered mental status?
Always, unless the patient can be quickly awakened by glucose, etc., or it DNR, so I guess this means often.
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...
What alternative ADHD medications would you consider in a child with a complex cardiac history unresponsive to guanfacine?
Choosing another medication to treat ADHD in a child with a complex cardiac history who has already failed guanfacine is not a straightforward task. To make this decision, one would need to understand which symptoms of ADHD are causing the most functional impairment (inattention, hyperactivity, both...
How do you approach antidepressant selection in patients with prolonged QTc?
In 2018, the American Psychiatric Association published a resource document on "QTc Prolongation and Psychotropic Medications," which was later followed up by a 2020 American Journal of Psychiatry publication: These manuscripts highlighted a few key points when making clinical decisions related to Q...
How do you titrate lithium for patients with bipolar affective disorder during pregnancy and immediately after delivery in the context of fluid shifts and changing levels?
Great question! Lithium clearance increases during pregnancy, and some women may require a dose increase to maintain therapeutic benefits. It is not my practice to prophylactically increase the dose during pregnancy, but I do recommend monitoring labs (lithium level, BUN and creatinine, and TSH) ea...
How do you approach firearm safety counseling for outpatients with elevated suicide risk who do not meet the criteria for involuntary psychiatric hospitalization?
I have found the framework outlined by the BulletPoints Project (created by the California Firearm Violence Research Center at UC Davis) to be very helpful. I start by asking about the patient’s goals for owning firearms. I think it is important to recognize that guns often form an important part o...
How do you differentiate between hyperactive delirium and excited catatonia?
This is a highly complex distinction to make for several reasons, not the least of which is that the two conditions can coexist in the same patient at the same time. This has been demonstrated in some recent studies of mainly intensive care delirious patients, though the reported very high incidence...
What has been your experience with the new ADHD medication centanafadine?
Centanafadine was FDA-approved, but it has not been scheduled by the DEA yet; thus, it is not yet commercially available.
What are your practice's policies for terminating patients from your psychiatry clinic?
I rarely terminate care, but when I do, it’s usually because the patient needs a higher level of treatment than I can provide in a solo practice. I explain at intake that I’m accessible, but I’m not the right setting for frequent crises or intensive team‑based care. I refer out if someone becomes ac...