Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...
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.
When do you select cholinesterase inhibitors vs NMDA-antagonist medications in patients with moderate Alzheimer’s dementia?
Cholinesterase inhibitors should be given to all patients (unless there is a contraindication) with Alzheimer's dementia since this class slows cognitive and functional decline as well as reduces all-cause mortality. Memantine, an NMDA receptor antagonist, is only FDA-approved for moderate to severe...
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 prescribing stimulants for ADHD in patients who are concurrently using cannabis?
Cannabis use can confound the assessment and management of ADHD symptoms. I believe the only way to differentiate ADHD symptoms vs. symptoms related to cannabis use is to discontinue the cannabis use and monitor. Also, keeping track of the amount and frequency of cannabis consumed will give us some ...
How do you approach antidepressant selection in patients with prolonged QTc?
In 2018, the American Psychiatric Association published a resource document on "QTc Prolongation and Psychotropic Medications," which was later followed up by a 2020 American Journal of Psychiatry publication: These manuscripts highlighted a few key points when making clinical decisions related to Q...
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.