Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What pharmacologic therapy, if any, do you recommend for treatment of borderline personality disorder?
Given the mood instability in patients with bipolar disorder, I thought it would be a rational option to a trial of a mood stabilizer. I explained my thinking and each agreed. So far, with a very small number of patients, the results have been excellent. I start with a small dose, and slowly and gra...
How have you gone about implementing TMS in your practice or institution?
For me, the hardest issues with TMS are getting insurance to approve it and the time it takes from a patient’s perspective to see a benefit.When I first invested in the TMS machine, I calculated it could take up to 3 years to pay off the equipment cost. In actuality, I was able to recoup the initial...
What is your experience with transcutaneous vagal nerve stimulation for the treatment of anxiety disorders and major depressive disorder?
Just starting to recommend, have had a few folks with side effects and unclear results. A colleague noted about a 30-40% response rate.
How will the removal of the clozapine REMS requirement change your clinical practice?
The recent developments in regards to the clozapine REMS program are steps in the right direction, to improve access to a very effective medication with a safer side effect profile than initially known. Hopefully, more psychiatrists will take the challenge of prescribing clozapine more once their co...
What is your response when child/adolescent patients who are already seeing a therapist tell you they have also been using chatbots as additional support?
I agree with Dr. @Dr. First Last's thoughtful response. Getting to the heart of why the youth is seeking additional support outside therapy is key. I would also add to the discussion of limitations that chatbots are not mandated reporters and are not bound by the same ethical obligations as clinicia...
How might meditation be helpful for a patient with obsessive compulsive disorder?
Negative habits: compulsions and other unwanted behaviors. Unwanted behaviors are part of a reinforcing pattern in which a trigger activates an urge, which then compels an action, which usually produces an immediate pleasant outcome followed by a later feeling of stressful self-criticism, judgment, ...
How do you facilitate access to interventional treatments such as TMS for patients with difficult-to-treat depression who are on Medicaid?
I think the rules vary by state for Medicaid, but here in MD, we do a consultation appointment and then submit for preauthorization from Medicaid. We typically do not start the treatments until we hear back that the course is approved. Lately, some of our Medicaid patients who have been approved hav...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
Would you consider prescribing NAC for a patient with OCD and a documented sulfa allergy?
I would consider using NAC if needed in a patient with a documented sulfa allergy because, although NAC is a sulfur-containing compound, it is chemically different from sulfonamides.However, as with any new medical trial on a patient, individual hypersensitivity is a possibility. Provided there is a...
How do you manage patients who report complex sleep behaviors while taking zolpidem or another Z-hypnotic?
At first, I'd prefer to rule out sleep-disordered breathing, and if sleep-disordered breathing is present, ensure that it is adequately treated. Addressing sleep-disordered breathing will decrease the likelihood of parasomnia behavior as well as insomnia in general. Then, if the patient still requir...