Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach patient requests for long-term disability for major depressive disorder?
There is the medical side to this question and the documentation. Incidentally, oftentimes if there is a forensic issue to the disability, it is very difficult for the disability to be resolved until the forensic piece has been resolved. Have you and the patient determined that disability is clearly...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...
How do you decide whether to request a welfare check (police or mobile crisis) when a typically responsive outpatient becomes suddenly unreachable?
Patient safety and welfare come first. If a patient suddenly becomes unreachable, a welfare check is in order. A reasonable person would comprehend that this is borne of concern and should not cause a breach in the therapeutic relationship. On the contrary, most would be grateful for the concern.
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...
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 ...