Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach transplant psychiatric evaluations when ongoing mental illness raises concerns about adherence to post-transplant treatment?
Mentally ill parents who need a transplant need a very supportive caregiver team. I count on families where available, and I provide very frequent supportive sessions myself. Where possible, Adult Protective Services may help. During my years of practice, I have dealt with three such patients.
How do you handle child/adolescent patients on the inpatient unit who have developed medication-seeking behaviors as a primary way of coping with distress?
This question can be interpreted in several ways, but here it is taken to mean a pediatric inpatient who repeatedly seeks medications for psychological distress instead of engaging in psychotherapeutic work or other coping strategies. And not including chronic pain patients. In this context, the aim...
What approaches have you used to reduce boarding times for patients in the emergency department awaiting inpatient psychiatric admission?
Every emergency room and health system has unique challenges that impact boarding times. One strategy that UCI implemented was to switch from a consultation model to a co-management model. We noted that patients would be boarding on average 70 hours even prior to the COVID-19 pandemic, and boarding ...
How do you incorporate rating scales such as the PHQ-9 into your treatment of major depressive disorder?
My practice has evolved (more therapy now), but for 20+ years, I administered the PHQ-9 and the GAD-7 at every visit for every patient. During those years, everyone was on some form of medication, and it felt relevant to see how they were responding. Also, occasionally someone would have worse numbe...
What treatment and management recommendations do you have for amphetamine-induced skin picking disorder without insight?
Assuming the stimulant is prescribed for ADHD, I recommend dose reduction or switching to a different medication, or, rarely, I recommend the patient consider a "stimulant holiday" for at least 1-2 months. I explain that most of my patients notice improvement with adjustments or breaks from their st...
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...
What medication management strategies exist for children with neurodevelopmental disorders who respond poorly to stimulants and have intolerable side effects on antipsychotics?
Although neurodevelopmental disorders include ASD, ADHD, communication disorders, intellectual developmental disorders, tic disorders, and motor disorders, I will focus on ASD and ADHD, based on the question. And although the various stimulants and antipsychotic medications have different side effec...
What medications best treat Intermittent Explosive Disorder?
Anecdotally (based on my experiences only), anything and nothing. It appears to be an intellectual/cognitive issue and most often a symptom of a wider pathology e.g., a history of trauma. Pharmacological treatments therefore seem only partially effective at best. With PTSD as the most common parent ...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
How do you manage acting-out behaviors in children in short-term crisis settings?
Managing behavior is a complex concept and difficult to address in a generic way. In general, it's helpful to conceptualize behaviors using the ABCs of a behavioral analysis. First, what is the antecedent to the behavior? This may take different forms depending on the environment. A general emergenc...