Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you decide whether to request a welfare check (police or mobile crisis) when a typically responsive outpatient becomes suddenly unreachable?
Patient safety and welfare come first. If a patient suddenly becomes unreachable, a welfare check is in order. A reasonable person would comprehend that this is borne of concern and should not cause a breach in the therapeutic relationship. On the contrary, most would be grateful for the concern.
How do you decide when a patient with dementia needs additional support at home versus a transition to a more structured living environment?
This is a challenging decision for most families, as it can often be related to factors outside of the patient’s or the family’s control, for example, having the financial means to pay for caregiving. Also, as the patient’s dementia progresses, they can become fully dependent on others for all of th...
How do you evaluate and manage brain fog in patients with underlying rheumatic disease?
For Brain fog – Most important this is I stress to patients – there are likely MULTIPLE different things contributing to brain fog, so there are MULTIPLE different things we are going to have to work on to improve it. Active inflammation might be contributing, but there is likely several other facto...
How do you incorporate psychological care into the surveillance and treatment of a pediatric patient found to have a cancer predisposition syndrome?
Psychological care is critical for patients with a lifetime genetically increased risk for cancer, with different needs at different stages of life.This was recently explored in an excellent article published in Pediatric Blood and Cancer "How We Approach the Integration of Psychological Services in...
At what point do you consider referring for neuromodulatory treatments (TMS, deep brain stimulation) for treatment refractory-OCD?
This is a fantastic question! Although I do not use a standardized "protocol" to determine when to refer for TMS or DBS, I typically think about this in terms of (a) medication trials, (b) comorbidities, and (c) OCD severity.Medication TrialsI would only consider TMS after trialing multiple serotone...
How do you approach the management of behavioral disturbance/aggression in patients with a recent traumatic brain injury?
Subacute/Acute TBI agitation approach and managementIf in the inpatient setting, the first step is to optimize verbal deescalation, ensure adequate medical work-up has been completed to rule out contributing factors (such as pain, delirium, seizures), environmental and behavioral interventions first...
When do you consider using Uzedy, the subcutaneous long-acting injectable version of risperidone?
It depends on how much risperidone they need. The maximum dose of Uzedy is only equivalent to 5 mg, so it’s not indicated for someone who needs more. The injection is different than Invega and has a smaller needle. It reaches steady state faster, but I have noticed a wearing off quicker in patients ...
How do you treat agitation in progressive supranuclear palsy?
Benzodiazepines are generally avoided due to adverse effects on cognition, the increased risk of falls, and disinhibition.Pharmacologic treatment for agitation is generally reserved for patients with severe agitation, when a patient is a threat to themselves and others, when agitation is the cause o...
How do you approach requests from patients with social anxiety disorder or agoraphobia to work remotely as a medical accommodation?
I would approach this request with a lot of compassion and also humility. One of my first questions would be whether working remotely would actually be the most therapeutic approach for this patient. I would worry that remote work would act a bit like avoidance of an anxious trigger and could, over ...
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...