Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...
What is your preferred antipsychotic for augmenting treatment of major depressive disorder?
Over the years, the overpromotion of antipsychotics as augmenting agents was largely initiated by experts with industry ties, often underemphasizing their significant neurological and metabolic side-effect burden. Today, the trend I see is that their primary use has shifted toward primary care physi...
In your experience, when do antidepressants begin to take effect for depression?
Postsynaptic down-regulation is known to occur at the four- to six-week mark. And I tend to delay dose changes until that point, if at all possible. Although this mechanism of action is now less solid with some of the meta-analysis data on the serotonin hypothesis, the time frame still holds for obs...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
In your clinical experience, has T3 augmentation been effective for treatment-resistant depression?
I have used T3 as Cytomel for this purpose, after hearing Dr. Lee Cohen describe his research on the subject. However, over time I have found that simply using thyroxine, which I think is a mix of T3 and T4, for augmentation works about as well. The response, as I recall, to either one has been mean...
What are your practice's policies for terminating patients from your psychiatry clinic?
I rarely terminate care, but when I do, it’s usually because the patient needs a higher level of treatment than I can provide in a solo practice. I explain at intake that I’m accessible, but I’m not the right setting for frequent crises or intensive team‑based care. I refer out if someone becomes ac...
What is your therapeutic approach to strengthening the therapeutic alliance and improving medication acceptance/adherence in patients with delusional disorder?
The Carlat Report just had an article on Xavier F Amador, PHD, who specializes in working with people who are unaware of having a psychotic condition and so reluctant to take medication. His book: I am Not Sick, I Don't Need Help, links anosognosia, the failure to recognize a part of the self that o...
After a medication overdose, do you restart that same medication if the patient reports it had been effective?
This is a good question, because intuitively it doesn't make sense to resume it (also, you would look really bad if your patient OD'd on the same medication that you prescribed). Truth is, patients can OD on anything. Generally, in my experience, people OD on meds that make them sleepy because they ...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
A recent cohort study (Meng et al., PMID 41733407) utilizing national databases in Norway and Taiwan examined associations between exposure to paternal valproate monotherapy during the 90 days preceding conception and incidence of neurodevelopmental disorders (NDDs) among offspring after at least 6 ...