Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How should psychotherapy techniques for patients with autism spectrum disorder be adjusted, if at all?
The answer depends, at least in part, on the level of ASD with which the patient presents. Psychotherapy can be very useful for patients with Level 1 ASD, but some individuals with Level 1 ASD are more capable of benefiting from therapy than others. In general, using a more structured approach, allo...
How do you counsel patients when they ask whether the SSRI or SNRI antidepressant you have recommended will result in weight gain?
This recent study on antidepressant-associated weight gain has generated a lot of interest and press, and can be a helpful starting point: Petimar et al., PMID 38950403.As with all studies, it has its limitations, but highlights that many people will experience minimal-modest weight change on antide...
When do you consider using ketamine to treat depressive symptoms in patients with borderline personality disorder?
It's understandable to exhibit caution when treating patients with borderline personality disorder (BPD) with ketamine. Naturally, questions arise as to the efficacy of the treatment and whether they may experience destabilization while under the influence of the drug. Still, there is no literature ...
What treatments have you found to be most effective in patients with a schizo-obsessive disorder?
This is a good question, as this happens in about 30% of our patients who have this. It depends on the severity of the psychosis versus OCD. Sometimes it’s hard to tease out are we're dealing with psychosis or the OCD is so severe it comes across as psychosis. That’s the first step. Then, as I said ...
When do you consider the use of an MAOI in treatment-resistant major depressive disorder?
MAOIs can be great in treatment-resistant depression, but after you explain how there might need to be some dietary restrictions, patients generally refrain from wanting to try them. To be frank, the dietary restrictions are overblown (A concise guide to monoamine oxidase inhibitors). There are 2 pa...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
In residency, we had to get patient permission to videotape sessions and allow our supervisors to watch sessions from behind a one-way mirror. If I were to use a scribe, especially an AI scribe, or if I were audio or video taping the sessions, I would definitely want to get a patient’s approval. I d...
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...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
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 approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...