Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
What psychiatric medications do you consider for treatment of chronic fatigue syndrome?
When a patient comes to me with a diagnosis of chronic fatigue syndrome, I know we’re dealing with something incredibly complex and deeply personal. My first job isn't to start checking boxes; it’s to sit with them and really listen. I make sure they know that their experience - the way their energy...
How do you change your approach for treatment of depression in adolescents with cannabis use disorder?
In my clinical experience, it is very difficult to disentangle the two. Cannabis use can certainly contribute to and exacerbate depression, and adolescent depression can contribute to cannabis use as well as use of other substances. It's imperative to address both issues at the same time. How this i...
During inpatient hospitalizations, do you inform patients you are diagnosing them with a personality disorder?
It would be a bit presumptuous to diagnose a personality disorder based on a brief hospital stay. I generally try to avoid labeling people as much as possible. I usually discuss their presentation's symptoms and how they affect them and their well-being. Whenever possible, I discuss their experience...
When do you consider using modafinil as an adjunctive treatment for depression?
While modafinil is off-label for depression, I frequently add it in if patients have persistent low-energy states despite other treatments, or if they can not tolerate bupropion. The biggest holdup in its use is often insurance barriers, which frequently prevent psychiatrists who are not sleep-certi...
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...
How do you approach treatment of obsessive behavior in patients with autism spectrum disorder?
This is such a rich topic, which comes up frequently in my practice, and the diagnostic distinction has real treatment implications. I think it’s helpful to start with some definitions, in which the key is function, not topography. OCD obsessions/compulsions: ego-dystonic, anxiety-driven, patient r...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
How do you track improvement in overall functioning with treatment of depression?
I prefer the QIDS-SR (Quick Inventory of Depression Scale-Self Report) done weekly. It was created and validated by John Rush et al. and used for the STAR-D study.
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...