Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
What is your approach to patients requesting prescription sleep aids, such as trazodone, quetiapine, or olanzapine, at discharge after they have found them beneficial during a prolonged hospitalization?
I don't see the harm in continuing a patient on trazodone or melatonin on discharge until they see their PCP, if they were benefiting from it in the hospital. For example, if you see a dementia patient with sundowning and have helped them sleep peacefully with trazodone, melatonin, or low-dose Remer...
When do you refer patients with difficult-to-treat depression for consideration of TMS or esketamine?
We typically tend to refer patients with treatment-resistant depression (TRD), which is defined as failure to respond to two or more adequate trials of antidepressant medications. An adequate trial is determined by both dose and duration and generally requires at least 4 weeks of treatment at a dose...
What resources/ancillary staff do you utilize for school re-entry after cancer treatment to decrease anxiety, improve self-confidence, and support emotional functioning?
Facilitating school re-entry for children and adolescents undergoing cancer treatment is an important component of comprehensive care. Maintaining engagement in school can help preserve a sense of normalcy and mitigate feelings of isolation and loneliness. However, the transition back to school may ...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
How do you discuss lithium with patients who are hesitant due to concerns about side effects or monitoring requirements?
I inform patients that lithium is one of the oldest and most studied mood stabilizers. Many people do well on it for years with no or minimal side effects. Patients report that after years of suffering, it provides a sense of calm and helps with sleep. There is some evidence that it reduces suicide ...
When do you order brain imaging in young adults presenting with first-episode psychosis in the absence of clear neurologic red flags?
All the time.
What strategies have you found effective in improving acceptance of long-acting injectable antipsychotics in patients with serious mental illness who are ambivalent about treatment?
Good question. I think it's important to understand the patient's perspective, because everyone can have a unique fear regarding LAIs. It could be that they have a fear of needles, are concerned about a lack of autonomy, or are worried about the mechanism of action and potential adverse events. You ...
How do you transition severely agitated ICU patients off a dexmedetomidine infusion when it is being used primarily for psychiatric agitation?
Even if initial agitation is felt to be psychiatric, it is important to remember (and remind involved teams) that following intubation and sedation in the ICU, rebound agitation as dexmedetomidine is weaned may have become multifactorial. As such, interventions such as monitoring for contribution fr...
When do you consider starting an antidepressant without a mood stabilizer in a patient with a historical diagnosis of bipolar II disorder who has not had hypomanic episodes in many years?
I happen to have a patient just like this now on my inpatient service. One of the problems we run into often is uncertainty around the validity of the bipolar spectrum in the first place. We see so much complicated trauma, maladaptive behaviors, and disordered personality structures that periods of ...