Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you navigate requests from your employers to see patients for shorter appointment times or less frequently than you feel is clinically indicated?
It takes an hour to get the basic data and an hour to 'really find out what's going on' and to begin to establish some rapport.
How do you approach requests from patients with social anxiety disorder or agoraphobia to work remotely as a medical accommodation?
I would approach this request with a lot of compassion and also humility. One of my first questions would be whether working remotely would actually be the most therapeutic approach for this patient. I would worry that remote work would act a bit like avoidance of an anxious trigger and could, over ...
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
How do you approach discussing possible dementia with an older adult who is presenting with depression, when you are concerned that raising this possibility could worsen their depressive symptoms?
I think the concern of bringing up a potentially devastating diagnosis, such as dementia, in this or any other context, is valid. And yet, when someone is experiencing depression, a disease that is multifactorial and sometimes difficult to treat, it is important to diagnose, evaluate, and treat any ...
How do you approach mood stabilizer selection for older adults with bipolar II disorder?
Depending upon age, medical illnesses, other medications the patient is on, and the symptoms, the appropriate medication will be decided. If the patient is hypomanic, a mood stabilizer will help. Also, if the patient is on an antidepressant, reducing the dose or even stopping it can be a choice. If ...
How would you manage a healthcare provider with major depressive disorder when their condition is suspected to impact their job performance?
This is a complicated issue that makes us all a little uncomfortable. There are several issues one must consider. First, from the treatment side, the provider should be treated like all other patients. You should be mindful of the side effect/benefit profile of the treatments and avoid or use them t...
How do you approach evaluating sudden mental status changes in telepsychiatry patients, particularly older adults, when medical causes such as infection or metabolic disturbance may be contributing factors?
I am dealing with a few now, but during the pandemic, I had more. Sudden changes in mental status definitely need medical clearance. Helpful questions try to elicit findings about urinary changes, fever, and weakness, especially if I'm certain parts of the body show other symptoms like nausea, vomit...
How do you manage anxiety for patients who are experiencing a myasthenic crisis?
For a long time, we have been taught that we should avoid benzodiazepines in this setting (also applies to patients with ALS, myositis, etc.) because of their suppressive effect on the CNS respiratory drive and the risk of exacerbating hypercarbic respiratory failure. Based on recent conversations w...
Is there a role for functional medicine approaches in psychiatric treatment?
Functional medicine is a pretty broad term that encompasses stressors underlying biological, hormonal, nutritional, and environmental impacts on a person’s health. While I am a big fan of trying to get to the root causes of health conditions, including mental health conditions, and think in terms of...
What strategies do you use for patients on medications for ADHD who experience afternoon rebound/withdrawal?
There are several strategies to try. The first thing I do to address withdrawal dysphoria is usually a high-protein snack about 30 minutes before the symptoms are typically noted. In most of my pediatric patients, this is a game-changer. If that's not helpful, you can consider using a short-acting s...