Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...
How do you treat decreased libido from SSRIs?
Serotonin-1 agonism will revert it in about 60% of cases. You have a choice of adding buspirone at about 30 mg bid or going to vilazodone which has already an SR1 agonism. Some bupropion, not clearly understood at about 300 mg can also do it. Or if possible, use vilazodone, bupropion, or mirtazapine...
What medications do you recommend for a patient with ADHD and anxiety who becomes more anxious on a stimulant?
Consider non-stimulant ADHD medications such as atomoxetine and viloxazine. Although these are not as effective for nearly as many patients as the stimulants, they are a reasonable alternative and generally well tolerated. Despite the potential for bupropion to also cause a patient to feel more anx...
What is your approach to titration of sublingual cyclobenzaprine in your patients with fibromyalgia?
Follow the FDA instructions: start at 2.8 mg sublingually at bedtime for 14 days, if tolerating, then increase to 5.6 mg nightly starting day 15 onwards. Ensure the mouth is not too dry as saliva is needed for it to fully dissolve, which could take 2-3 mins. This may be a concern in patients with SI...
What is your approach when evaluating a child brought in by parents who suspect PANS/PANDAS as the cause of the child's psychiatric symptoms?
I encourage reading of the recent comprehensive review of all aspects of PANS in Pediatrics, This is a policy statement by the American Academy of Pediatrics. It is comprehensive and balanced, acknowledging key controversies in diagnostic and treatment approaches. In my clinical practice, the greate...
How do you approach patient requests for long-term disability for major depressive disorder?
There is the medical side to this question and the documentation. Incidentally, oftentimes if there is a forensic issue to the disability, it is very difficult for the disability to be resolved until the forensic piece has been resolved. Have you and the patient determined that disability is clearly...
How do you decide whether to request a welfare check (police or mobile crisis) when a typically responsive outpatient becomes suddenly unreachable?
Patient safety and welfare come first. If a patient suddenly becomes unreachable, a welfare check is in order. A reasonable person would comprehend that this is borne of concern and should not cause a breach in the therapeutic relationship. On the contrary, most would be grateful for the concern.
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...
How do you decide when a patient with dementia needs additional support at home versus a transition to a more structured living environment?
This is a challenging decision for most families, as it can often be related to factors outside of the patient’s or the family’s control, for example, having the financial means to pay for caregiving. Also, as the patient’s dementia progresses, they can become fully dependent on others for all of th...