Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to augmenting treatment for depressive disorders in those continuing to take a tricyclic antidepressant at baseline due to historical effectiveness?
Depends on the risk of suicidality. If there is any history or any hint of a possibility of it, I do not continue with a TCA. I would augment with a dopamine agonist. I only use TCA to help with multiple comorbidities, such as migraines, insomnia, neuropathic pain, along with depression - knowing I ...
What is your pharmacological approach to treating depressive disorders in patients who develop serotonin toxicity?
I would try bupropion. Not Auvelity, as dextromethorphan has serotonergic activity. I would want to see if they were on any medication other than psychiatric that contributed to serotonin syndrome, like tramadol, and get rid of that or replace it as needed. I would probably want to transition to a n...
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...
How do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
How do you counsel breastfeeding parents with postpartum depression when sleep deprivation appears to be worsening mood symptoms?
My position is that breastfeeding is a sometimes difficult practical issue, not a medical or moral imperative. I try to normalize the difficulties of breastfeeding, based on my own experience and that of my daughters and sisters, countering the exploitation of anxiety around this issue with problem-...
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
How do you approach requests from attorneys to complete paperwork supporting your patient’s application for long-term disability?
If the diagnosis does not support disability, I will give the attorney a call. This saves time, money, and my effort of writing a report. They may provide more collateral, or they may not use me. Either way, I am not stuck defending an untenable position. In terms of ambiguous questions, I try to be...
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 manage patients with bipolar I disorder who report emotional blunting or numbness while taking lithium?
Adjusting the once-daily bedtime dose to a lower level in the therapeutic range may help. I always tell patients that this is a recognized side effect of lithium. A discussion about the often unavoidable depressive episode following a manic episode may convince patients that avoiding a manic or hypo...
What are your experiences with lithium target levels in the maintenance of bipolar 2 disorder?
I prefer maintenance lithium levels at the 0.7-0.8 range, because I wish to provide a more rigorous test of lithium's ability to prevent recurrence in each BPII patient.