Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Would you be comfortable using isotretinoin in a female teenage patient who has a history of depression that is now stable but with a prior suicide attempt two years ago?
Yes. There is ample evidence that isotretinoin does not cause depression. In the large Canadian study, there was a slightly negative association with suicide. As the good doctors noted above, using appropriate step therapy, with informed consent (especially regarding pregnancy and birth defects), is...
How reliable do you find it to make the diagnosis of bipolar disorder based on a patient report of prior symptoms or questionnaire and not the actual observation of hypo/mania on the exam?
I agree that direct observation is always nice, but we certainly don't want to wait for a manic episode to determine the correct diagnosis. I find that by asking lots of detailed questions, most people who have experienced and manic episode can report enough history to correctly. Identify the episod...
How do you approach the management of mild to moderate tics induced by stimulants in children?
If dose reduction or medication switch is not possible, first-line treatment includes adding an alpha agonist like guanfacine or clonidine. I prefer guanfacine as clonidine is more sedating and less tolerated by kids. CBIT (Comprehensive Behavioral Interventions for Tics) would be great but hard to ...
In addition to a therapist, what are your favorite resources for tackling perfectionism?
Perfectionism is a pattern of thinking and behaving characterized by rigid, unrealistic, harsh judgments about the performance of the self and others. For a perfectionist, the outcome of their actions is almost never sufficient. Even the measurement itself of each outcome is distorted by their perf...
How do you manage patients with body dysmorphic disorder who pursue repeated dermatologic or other cosmetic procedures despite reassurance or prior interventions?
I run a monthly psychodermatology clinic, and over the years, I’ve met quite a few patients with body dysmorphic disorder who come in asking for recommendations or referrals for cosmetic or surgical treatments. Many of them are genuinely convinced there’s something seriously wrong with the way they ...
How do you address mental health and online presence with teenage patients?
There are four variables that I talk to parents/teens about: Volume of screen exposure; low vs high. There is some data that pure volume is a risk factor, but not uniformly so. Psychiatric vulnerability; low vs high. Some kids are more vulnerable (e.g., social and generalized anxiety disorder and d...
What is the best way to manage low systolic blood pressures on clozapine when the patient has failed multiple other antipsychotic trials?
Orthostatic hypotension is considered a common side effect during clozapine titration, specifically due to its alpha-1 receptor antagonism. This effect is most commonly seen when initiating clozapine or with dose increases.General initial strategies to address this side effect include reevaluating t...
How do you approach cognitive impairment in the assessment of transplant candidacy?
Three main elements of cognitive impairment in organ transplantation present themselves: Impact on the candidate's ability to qualify for organ listing. Impact on the candidate's future ability to care for themself including adherence to the post-operative immunosuppressant regimen. Ability to cons...
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...