Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider the use of an MAOI in treatment-resistant major depressive disorder?
MAOIs can be great in treatment-resistant depression, but after you explain how there might need to be some dietary restrictions, patients generally refrain from wanting to try them. To be frank, the dietary restrictions are overblown (A concise guide to monoamine oxidase inhibitors). There are 2 pa...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How do you approach liver function testing and monitoring when using xanomeline/tropsium (Cobenfy)?
Good question, as it’s a newer medication on the market. I prefer a CMP as a baseline but since I’ve come across the first reported case of neutropenia with Cobenfy, I would suggest getting a CBC weekly, but move to monthly after a few CBCs, and when getting the CBC with diff, get a CMP. It can’t hu...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...
How do you manage anxious children who are somatically focused and do not tolerate SSRIs?
Treatment of an anxious child ideally involves a holistic bio-psycho-sociocultural approach to understand the nature and underlying reasons for the anxiety, and importantly, the family's response and accommodations to their child's anxiety. So individual CBT-focused therapy can be very helpful, but ...
How do you approach agitation management, especially the use of neuroleptics in hospitalized patients with a prolonged QTc?
First, I'd wonder how long the QTc actually is. Especially in tachycardic and bradycardic situations (let alone non-sinus rhythms), hand calculation (e.g. via the hodges formula) is advised since the electronic reading is often off. Also, textbook-prolonged and prolongation that would indicate conce...
At what point would you recommend initiating psychotherapy or psychotropic medications to manage mood and anxiety symptoms following a new oncology diagnosis in pediatric patients?
Perhaps the most important piece to this question is missing, and that is that more history is required to determine what to do with a recently diagnosed cancer patient. What was the patient’s psychiatric status pre-cancer? If the patient had undiagnosed mental health problems–anxiety or depressio...
What strategies have you found most effective for obtaining prior authorization for newer antipsychotics and antidepressants?
My EMR has an integrated PAR feature. It is clunky; the other resource is CoverMyMeds. You have to enter basic demographics of the patient, but the interface will send the information to the insurance company. Many times, the approval is automatic. If not, there is a "further information" which is a...
What is your approach to GLP-1 agonists as a psychiatrist in patients who are overweight or have eating-related disorders?
More and more of my patients have been asking for these medications in the past 12 months. For context, my niche is psychotic and bipolar disorders. Most (if not all) of my patients are on a combination of mood stabilizers and antipsychotics that are notorious for causing significant weight gain. Co...
How do you assess for trauma-related symptoms in children and adolescents who have experienced chronic bullying?
Assessment for trauma-related symptoms in youth who have been victims of bullying is similar to assessment for trauma-related symptoms due to other factors, with special attention paid to symptoms such as school avoidance, being a perpetrator of bullying themselves, threats of harm to self or others...