Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What medications do you consider for patients with premenstrual dysphoric disorder who do not respond to SSRIs?
In addition to emphasizing how helpful self-care can be (a little more sleep than usual, exercise, healthy nutrition, including limiting carbs, mindfulness), calcium carbonate 600 mg BID, judicious benzodiazepines, and gabapentin 100-300 mg hs can be helpful. Continuous OCPs can also be very useful....
How do you counsel patients about the risks and benefits of mood stabilizers (e.g., lithium, lamotrigine) during pregnancy?
Great question! The risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and discontinuation of medications increases the risk of relapse during pregnancy and postpartum. The majority of women who stop mood stabilizers for p...
How do you manage acute agitation or psychosis in patients who are already taking aripiprazole (oral or long-acting injectable)?
Episodes of acute agitation are considered a psychiatric emergency, and considering treatment with dual antipsychotics (which will only be temporary) should have a lower threshold of consideration. Dual antipsychotic treatment is controversial, but there are promising results as well however (Ortiz-...
How do you approach buprenorphine dosing and titration in older adults with opioid use disorder?
I apply the same care and principles here with buprenorphine dosing in persons age 65 and older as I do with starting other psychoactive medications and medications that are metabolized by the liver. I also see many persons younger than 65 who have the physical health of persons older than 65 becaus...
How do you introduce patients with obsessive-compulsive disorder to the concept of exposure and response prevention (ERP) therapy when they may be hesitant to engage in exposure-based work?
This is a fantastic question, and I agree with the others who responded! I like to first validate their thoughts and feelings about ERP and explore their reluctance, noting that it is very reasonable. There are a few steps that can be helpful in introducing ERP to the patient. Metaphors can be very ...
How do you handle requests for medication refills from patients who were formally terminated from care but report difficulty accessing a new psychiatrist?
It is essential when terminating a patient that you provide at least three formal referral names with a 30-day notice. One of these should be an agency that cannot refuse patients. This could be a county or state mental health clinic. If the referrals you provide refuse the patient, then you are obl...
How do you manage patients who develop SIADH secondary to an SSRI but have had a strong positive response to that same medication?
Management of SSRI-induced SIADH depends on the severity of hyponatremia and the patient’s psychiatric response to treatment. In mild cases (serum sodium >130), I always continue SSRI with close monitoring and fluid restriction. Moderate to severe hyponatremia, I discontinue SSRI and actively correc...
How often do you require patients seen via telehealth to have in-person visits in outpatient psychiatry?
Great topic, and I'd love to hear others' experiences. For stable, low-acuity patients, I've largely moved to telehealth-primary with in-person visits annually or as clinically indicated. I still prefer at least one in-person intake before transitioning - the observational data matters. Factors push...
How do you schedule follow-up visits for pregnant patients with a history of depression, both during pregnancy and in the postpartum period?
The frequency of visits is not, or not simply related to diagnosis, though the presence of a very severe depression or any bipolar episode would require more frequent visits than a history of depression alone. It would be important to know from a thorough longitudinal history what the patient's depr...
What adjunctive therapies to you recommend for symptom control in acute opioid withdrawal beyond full/partial opioid agonists?
Here are some general recommendations below. I recommend asking the patient what symptoms are most bothersome or what they anticipate to be the most bothersome when prescribing adjuncts. I routinely recommend APAP/ibuprofen, and then usually prescribe something for anxiety and nausea. Tizanidine can...