Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you treat postpartum obsessive-compulsive disorder?
The ideal treatment for women who are breastfeeding is transcranial magnetic stimulation. TMS has a 50% response rate for OCD, higher if treatment is extended past the typical course of 30-36 treatments. This is similar to the response rates reported for SSRI treatment of OCD. Most women with post-p...
What would prompt you to consider a sleep study for narcolepsy in a child or adolescent with new-onset hallucinations?
It would depend on other elements of the history. The age of the child, the timing of the hallucinations, particularly if they are associated with sleep, onset or awakening, other hypersomnia disorder symptoms, and the child's psychiatric history. Generally, I have a very low threshold for an in-lab...
How do you distinguish between borderline personality disorder and complex PTSD in patients with chronic relational trauma?
In my experience, the best differentiating factor is what occurs in the transference and the degree of distortion that occurs in the therapeutic relationship. Patients with complex PTSD may have issues with trust, fear of abandonment, and feelings of victimization, but this generally does not exhibi...
How do you counsel patients who want to use vaping to quit smoking cigarettes?
My patient population is largely persons with severe opioid use disorder. Most use tobacco/ nicotine in some form - typically cigarettes and/or vaping. I have seen people minimize their use of cigarettes with vaping and feel very happy with their results. I don't see, however, a lot of patients stop...
When do you consider using valproate to manage behavioral disturbances in patients with delirium?
Multiple studies have identified valproate as a potential option for the management of agitation in hyperactive delirium. This has particularly been investigated for patients in ICU settings with some studies finding positive outcomes such as reduction of the total number of concomitant psychoactive...
How do you treat a patient with moderate dementia who experiences a recurrence of depression?
When I get a patient with moderate dementia and depression, I make sure the basic potential reversible medical contributors have been looked into and corrected (i.e., B12/D3 deficiency, OSA, etc). If the patient is on medications that could contribute to depression, I discuss with PCP and family if ...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
When a dementia patient is in the moderately severe or severe stages of the disease and has palliative goals of care, they would be eligible for palliative care FAST 6 or hospice FAST 7. Caregivers are no longer trying to maximize independence. The patient has 24/7 supervision. The caregiver is at r...
Given some of the theoretical relationship between glutamate and OCD, do you ever consider the use of NMDA (or AMPA) antagonists for the treatment of refractory OCD?
We recently published a systematic review and meta-analysis on glutamate-modulating agents in the treatment of OCD as augmenting agents to SSRIs or as monotherapy. Overall, we found that glutamatergic medications led to significant improvement (statistically and clinically) in OCD symptoms. We also ...
What strategies have you found effective in reducing intake no-show rates among patients with severe and persistent mental illness?
Reducing no-shows for community-based intakes depends on how people are initially engaged. Relationship building is always an important factor. Maintaining contact with the referral source and providing several prompts for the appointment to the client begins the process. Providing incentives to att...
How do you monitor patients who are symptomatically well-managed on clozapine with supratherapeutic drug levels?
I generally adhered to the published NIH guidelines (Correll et al., PMID 35759211). It also looks like we will be changing everything pretty soon as these recommendations will change.I still plan to do regular neutrophil and WBC counts, definitely not as frequently as previously recommended, but I ...