Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
How do you decide when to formally re-assess and document decisional capacity in a hospitalized patient who initially lacks it?
This is a great question and tricky to answer in every scenario. In general, we should be reassessing decisional capacity with each clinical encounter, though formal documentation may not be necessary each time. My approach is based on considering several factors: What is the underlying cause of th...
In dementia, how do you respond to paranoid accusations against caregivers, such as claims that they are stealing?
It’s not uncommon for patients to be paranoid about the caregivers. Many times, families are unable to retain caregivers due to patient paranoia. Try to manage without medication at first. Caregiver and family member can be present together to reduce the fear, as paranoia arises out of fear. Family ...
What unique factors do you take into consideration for geriatric patients with a first lifetime episode depression?
I agree with the suggestions to check for vascular and early dementia, but a very neglected cause is hypothyroidism. This is a very common cause of depression in all ages. The internists are relatively clueless. It should be a clinical diagnosis, with labs used to guide treatment. In Europe, a TSH >...
What has been your experience with balance problems or falls in patients taking mirtazapine?
I find that patients in long-term care facilities tolerate mirtazapine quite well. I have noticed that “younger” patients seem much more likely to have excessive sedation with Remeron, which I rarely encounter in patients > 65-70 years of age. Not quite sure why older patients tolerate this drug muc...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
What strategy do you find most effective for outpatient induction of buprenorphine in opioid use disorder?
The method for induction of Buprenorphine for OUD needs to be tailored for the specific patient and the environment. The standard induction was introduced during the time when heroin was the most common opioid being used on the streets, as well as diverted prescription narcotics. Also it was mainly ...
When, if ever, do you consider increasing Adderall above the FDA-approved maximum daily dose of 40 mg for adult patients?
I titrate the dose based on the patient's needs, functioning, and tolerances.
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
When do patients presenting with self harm but no suicidal ideation in an outpatient setting require a higher level of care?
This will be highly specific to the individual patient, and like all treatment decisions, hinges on a comprehensive evaluation of risks vs. benefits. Considerations include the underlying psychiatric diagnoses, the degree of self harm (severity, timing, etc.), participation in/response to treatment ...