Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?
There are so many factors that play into my decision-making; it truly is a case-by-case basis. In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first mon...
What is your approach to managing sexually inappropriate behaviors in hospitalized patients with psychotic symptoms?
Sexually inappropriate behaviors, commonly abbreviated as ISB in the behavioral and sex offender treatment communities are very often problematic, especially when combined with psychosis. ISB can vary from relatively mild, such as accidental self-exposure by a confused patient, to the very severe, s...
How do you approach continuation of benzodiazepines in elderly patients with anxiety who have had poor response to other medications?
This is a risk/benefit analysis question, and will be unique for each patient. The biggest danger is making an internal rule that ignores the patient's needs. Many variables come into play: if the person has been on them for years or decades, then it probably causes more harm to discontinue, as they...
What is the role of cognitive training exercises in older patients with short-term memory problems and/or are diagnosed with mild cognitive impairment?
You are correct. The evidence so far is level C - as far as I know. No robust RCTs. Exercise gets a Level B recommendation. You may maximize benefit by offering more supervision (supervised computerized cognitive training), combining with resistance training, and/or increasing frequency. Most effect...
What medications do you recommend for a patient with ADHD and anxiety who becomes more anxious on a stimulant?
Consider non-stimulant ADHD medications such as atomoxetine and viloxazine. Although these are not as effective for nearly as many patients as the stimulants, they are a reasonable alternative and generally well tolerated. Despite the potential for bupropion to also cause a patient to feel more anx...
What is your approach to titration of sublingual cyclobenzaprine in your patients with fibromyalgia?
Follow the FDA instructions: start at 2.8 mg sublingually at bedtime for 14 days, if tolerating, then increase to 5.6 mg nightly starting day 15 onwards. Ensure the mouth is not too dry as saliva is needed for it to fully dissolve, which could take 2-3 mins. This may be a concern in patients with SI...
How do you approach patient requests for long-term disability for major depressive disorder?
There is the medical side to this question and the documentation. Incidentally, oftentimes if there is a forensic issue to the disability, it is very difficult for the disability to be resolved until the forensic piece has been resolved. Have you and the patient determined that disability is clearly...
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...