Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...
How do you decide when a patient with dementia needs additional support at home versus a transition to a more structured living environment?
This is a challenging decision for most families, as it can often be related to factors outside of the patient’s or the family’s control, for example, having the financial means to pay for caregiving. Also, as the patient’s dementia progresses, they can become fully dependent on others for all of th...
How do you evaluate and manage brain fog in patients with underlying rheumatic disease?
For Brain fog – Most important this is I stress to patients – there are likely MULTIPLE different things contributing to brain fog, so there are MULTIPLE different things we are going to have to work on to improve it. Active inflammation might be contributing, but there is likely several other facto...
When do you consider using olanzapine/samidorphan?
I prefer to use olanzapine/samidorphan combo in mildly obese patients when I decide to start olanzapine, and the patient does not have the info and skills yet to work on self-care. Unfortunately, there is still some weight gain on this combo, but at least not the usual 20-30 or even more in olanzapi...
How do you approach ADHD treatment in patients with psychotic disorders who are now psychiatrically stable?
Non-stimulant so atomoxetine, guanfacine, and clonidine. However, it needs to be teased apart is the deficit in concentration and focus due to symptoms of schizophrenia. It can be a tough call, but I also use modafinil sometimes.
How do you approach effectively diagnosing ADHD within the time constraints of outpatient practice?
I approach diagnosing ADHD by asking a series of questions. Questions 1 - 3 are pretty straightforward, the others can be more nuanced depending on the case: 1) Do enough ADHD symptoms apply (6 symptoms in 1 category for kids, 5 symptoms in adults)? I ask about specific symptoms and encourage the pa...
How do you manage patients who develop SIADH secondary to an SSRI but have had a strong positive response to that same medication?
Management of SSRI-induced SIADH depends on the severity of hyponatremia and the patient’s psychiatric response to treatment. In mild cases (serum sodium >130), I always continue SSRI with close monitoring and fluid restriction. Moderate to severe hyponatremia, I discontinue SSRI and actively correc...
For children under the age of 7 with ADHD who continue to have significant impairment with behavioral interventions, how do you decide between starting with a stimulant vs starting with an alpha agonist?
If the ADHD symptoms are still impairing despite being treated with behavioral interventions, pharmacotherapy is indicated. First-line pharmacotherapy for ADHD, even in elementary school-age or younger, is stimulants. I would treat them with stimulants unless there is a contraindication or a reason ...
How do you incorporate psychological care into the surveillance and treatment of a pediatric patient found to have a cancer predisposition syndrome?
Psychological care is critical for patients with a lifetime genetically increased risk for cancer, with different needs at different stages of life.This was recently explored in an excellent article published in Pediatric Blood and Cancer "How We Approach the Integration of Psychological Services in...
At what point do you consider referring for neuromodulatory treatments (TMS, deep brain stimulation) for treatment refractory-OCD?
This is a fantastic question! Although I do not use a standardized "protocol" to determine when to refer for TMS or DBS, I typically think about this in terms of (a) medication trials, (b) comorbidities, and (c) OCD severity.Medication TrialsI would only consider TMS after trialing multiple serotone...