Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients with depression who ask about the role of the gut–brain axis (e.g., probiotics, diet, or microbiome-targeted interventions) in their symptoms?
I usually explain to patients that the gut-brain connection is real, and one of the most consistent findings is that diet matters. A Mediterranean-style, fiber-rich diet - high in vegetables, fruits, whole grains, legumes, and healthy fats - has good evidence showing meaningful improvement in mild t...
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 determine disposition when a patient presents to an outpatient psychiatry visit with recent self-injury that may require medical attention?
Self-injury can present a complicated and anxiety-provoking clinical situation, yet it is not uncommon in psychiatric practice. Such behavior may reflect a range of psychological processes, including acute distress, personality pathology, or genuine suicidal intent. Because the underlying meaning of...
In your opinion, when does a psychiatric medication regiment become "polypharmacy"?
I feel like that question is likely to start a fight (just kidding). I imagine most psychiatrists have their own strongly held opinion on this matter. When I was a resident, someone told me that once the number of psychiatric medications increases past 3, they become concerned that it is too difficu...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
What findings help you differentiate between catatonia and NMS?
This is a cogent and very interesting problem that is not uncommon, especially in emergency rooms. In the spirit of full disclosure, your author must admit to a theoretical approach to this topic that views catatonia and Neuroleptic Malignant Syndrome (NMS) as both being forms of catatonia, with dif...
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
Have you used cannabinoid-based products for insomnia?
No, but patients report it helps. I don't encourage it due to a lack of research supporting long-term positive effects.
Do you find that hydroxyzine worsens cognitive symptoms in patients who are already susceptible to cognitive impairment?
Hydroxyzine should not have a direct negative effect on cognition. For decades after its inception, it was lopped in with Benadryl in terms of its receptor binding affinity profile and is listed in several anticholinergic burden scales as being anticholinergic. Similar to the child’s game ‘telephone...