Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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 refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?
For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...
What non-pharmacologic interventions or resources do you recommend for parents of patients with severe anxiety?
It depends on the type of anxiety, but a few things that I have found helpful over the years... Education about the physiology of anxiety, amygdala info, and the body’s response/cycle to anxiety is key. Help the patient understand that the goal cannot be to “get rid of” all anxiety; trying to contr...
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 patients presenting with self harm but no suicidal ideation in an outpatient setting require a higher level of care?
This will be highly specific to the individual patient, and like all treatment decisions, hinges on a comprehensive evaluation of risks vs. benefits. Considerations include the underlying psychiatric diagnoses, the degree of self harm (severity, timing, etc.), participation in/response to treatment ...
How many of your patients continue medications for ADHD after they turn 18?
Keep in mind that discontinuing medications at that time does not mean permanently discontinuing. As an adult psychiatrist, I see a lot of patients with ADHD who stopped medications after childhood but eventually decided to resume treatment. Most of the time, their strategies for compensating in one...
What adjustments do you make for patients with ADHD who report their long-acting stimulant wears off too quickly?
There are essentially 3 options: 1) administer the medication later in the morning; 2) add a short-acting booster dose; 3) switch to a similar formulation with a longer duration of action. I typically discuss these options with patients/families and make individualized decisions depending on the par...
When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?
I have read a recent JAMA Psychiatry paper concerning clozapine initiation after 1 antipsychotic trial, which was not successful (Li et al., PMID 41811299). I have not changed my practice, which is to require 2 such trials (which blood level confirmation to eliminate non-compliance) before prescribi...
How do you use lithium levels to adjust treatment during mania?
If someone is getting manic, the mania in itself reduces lithium levels. You need for a period of about 6 weeks maintain a level close to 1 in contrast to a maintenance level of 0.75. I would, of course, use the appropriate antipsychotic to help during this period. If the patient has been Li respons...
How do you counsel patients regarding using stimulants for attention-deficit/hyperactivity disorder during pregnancy?
There is limited research evaluating the course of ADHD across pregnancy and postpartum. The individual woman’s severity of illness and impairment inform treatment decisions across pregnancy. As with the treatment of all disorders during pregnancy, the risks and benefits of medications need to be ca...