Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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.
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 ...
How do you weigh the risks of overdose with medications that treat severe mental illness?
Lithium is a double-edged sword… I don’t usually use it for only the anti suicidal properties but if I do, then I prescribe it in weekly dosing. There was a case report from Russia where they used clozapine to poison someone. Besides that, I’m not too worried about a clozapine overdose but lithium i...
Do you treat 45 mg/day as a practical ceiling before switching strategies in a child with ADHD and incomplete methylphenidate response?
This is a very good question, and generally, the guidelines are not clear. In clinical practice, I almost never prescribe more than 45 mg/day of methylphenidate for a patient. Some sources recommend not exceeding 60 mg/day for immediate-release methylphenidate, and others set the limit at 72 mg/day ...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
How do you approach the evaluation and treatment of insomnia in children?
The evaluation and treatment of insomnia in children requires a structured assessment of sleep patterns, contributing medical or behavioral factors, and the implementation of primarily behavioral interventions, with selective use of pharmacologic treatments. Identify Sleep Complaint: Difficulty fall...
When do you consider the use of N-acetylcysteine (NAC) in patients with trichotillomania?
Great question! NAC comes up frequently in clinical discussions of trichotillomania, and it's worth being clear-eyed about what we actually know. NAC restores extrasynaptic glutamate homeostasis via the cystine-glutamate antiporter (system Xc⁻), which increases tonic activation of presynaptic mGluR2...