Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What psychiatric medications do you consider for treatment of chronic fatigue syndrome?
When a patient comes to me with a diagnosis of chronic fatigue syndrome, I know we’re dealing with something incredibly complex and deeply personal. My first job isn't to start checking boxes; it’s to sit with them and really listen. I make sure they know that their experience - the way their energy...
How do you change your approach for treatment of depression in adolescents with cannabis use disorder?
In my clinical experience, it is very difficult to disentangle the two. Cannabis use can certainly contribute to and exacerbate depression, and adolescent depression can contribute to cannabis use as well as use of other substances. It's imperative to address both issues at the same time. How this i...
During inpatient hospitalizations, do you inform patients you are diagnosing them with a personality disorder?
It would be a bit presumptuous to diagnose a personality disorder based on a brief hospital stay. I generally try to avoid labeling people as much as possible. I usually discuss their presentation's symptoms and how they affect them and their well-being. Whenever possible, I discuss their experience...
When do you consider using modafinil as an adjunctive treatment for depression?
While modafinil is off-label for depression, I frequently add it in if patients have persistent low-energy states despite other treatments, or if they can not tolerate bupropion. The biggest holdup in its use is often insurance barriers, which frequently prevent psychiatrists who are not sleep-certi...
When do you refer patients with difficult-to-treat depression for consideration of TMS or esketamine?
We typically tend to refer patients with treatment-resistant depression (TRD), which is defined as failure to respond to two or more adequate trials of antidepressant medications. An adequate trial is determined by both dose and duration and generally requires at least 4 weeks of treatment at a dose...
How do you approach treatment of obsessive behavior in patients with autism spectrum disorder?
This is such a rich topic, which comes up frequently in my practice, and the diagnostic distinction has real treatment implications. I think it’s helpful to start with some definitions, in which the key is function, not topography. OCD obsessions/compulsions: ego-dystonic, anxiety-driven, patient r...
How do you track improvement in overall functioning with treatment of depression?
I prefer the QIDS-SR (Quick Inventory of Depression Scale-Self Report) done weekly. It was created and validated by John Rush et al. and used for the STAR-D study.
How do you decide who to rechallenge clozapine after it was discontinued for a neutropenic episode?
The clozapine rechallenge of the patient previously treated with clozapine but having it discontinued due to clozapine induced neutropenia or absolute neutropenia now has a sizable evidence-based literature suggesting that it can be done safely and successfully. Selecting patients with previous disc...
Would you consider starting a stimulant in an inpatient or crisis setting for patients whose severe behavioral issues are due to untreated ADHD?
For an adult without an established diagnosis, I don't believe initiating stimulant therapy during an acute inpatient stay is appropriate. ADHD is a legitimate neurodevelopmental condition, but it shouldn't be used as a catch-all explanation for behavioral disruptions in a hospital setting. Starting...
How do you approach the psychiatric evaluation and disposition of adolescents presenting after an overdose that was not a suicide attempt?
There is much to learn. If previous history of SIB, OD-likely admit. Known psychiatric disorder - perhaps IOP/PHP. What triggered the OD? For instance, breakup, argument - perhaps IOP/PHP. Recent traumatic event - perhaps IOP/PHP Family functioning: Is the family supportive, dismissive, chaotic, or...