Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach discussing possible dementia with an older adult who is presenting with depression, when you are concerned that raising this possibility could worsen their depressive symptoms?
I think the concern of bringing up a potentially devastating diagnosis, such as dementia, in this or any other context, is valid. And yet, when someone is experiencing depression, a disease that is multifactorial and sometimes difficult to treat, it is important to diagnose, evaluate, and treat any ...
How do you approach mood stabilizer selection for older adults with bipolar II disorder?
Depending upon age, medical illnesses, other medications the patient is on, and the symptoms, the appropriate medication will be decided. If the patient is hypomanic, a mood stabilizer will help. Also, if the patient is on an antidepressant, reducing the dose or even stopping it can be a choice. If ...
How would you manage a healthcare provider with major depressive disorder when their condition is suspected to impact their job performance?
This is a complicated issue that makes us all a little uncomfortable. There are several issues one must consider. First, from the treatment side, the provider should be treated like all other patients. You should be mindful of the side effect/benefit profile of the treatments and avoid or use them t...
How do you approach evaluating sudden mental status changes in telepsychiatry patients, particularly older adults, when medical causes such as infection or metabolic disturbance may be contributing factors?
I am dealing with a few now, but during the pandemic, I had more. Sudden changes in mental status definitely need medical clearance. Helpful questions try to elicit findings about urinary changes, fever, and weakness, especially if I'm certain parts of the body show other symptoms like nausea, vomit...
How do you manage anxiety for patients who are experiencing a myasthenic crisis?
For a long time, we have been taught that we should avoid benzodiazepines in this setting (also applies to patients with ALS, myositis, etc.) because of their suppressive effect on the CNS respiratory drive and the risk of exacerbating hypercarbic respiratory failure. Based on recent conversations w...
What strategies do you use for patients on medications for ADHD who experience afternoon rebound/withdrawal?
There are several strategies to try. The first thing I do to address withdrawal dysphoria is usually a high-protein snack about 30 minutes before the symptoms are typically noted. In most of my pediatric patients, this is a game-changer. If that's not helpful, you can consider using a short-acting s...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
How do you approach the treatment of anxiety disorders in children with a significantly family history of bipolar disorder?
First, I always question the validity of a family history of bipolar disorder and clarify as best as possible bipolar 1 vs. 2. Nine times out of ten, it is "mood swings" that with further clarification were never formally diagnosed and were anger outbursts/irritability. If there is bona fide bipola...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...