Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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 ...
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...
How do you manage expectations around response time and durability of benefit in patients starting TMS?
Re: response time, I tell patients it is typical to not notice a lot of change in the first few weeks. Sometimes the clinician will observe brightening of affect earlier, but the patient him/herself often does not notice a whole lot. I use the 'going to the gym' analogy... a few days will not yield ...
How do you counsel patients interested in neuromodulation (tDCS, rTMS) for ADHD?
i have not used rTMS for ADHD but have used for adolescent depression. It is advised to spend a full appointment to go over the evidence, the strength of evidence, possibilities of failure, etc. I generally let parents and patients come back to me to ask for the procedure. in my opinion, for any new...
How do you approach the management of behavioral disturbance/aggression in patients with a recent traumatic brain injury?
Subacute/Acute TBI agitation approach and managementIf in the inpatient setting, the first step is to optimize verbal deescalation, ensure adequate medical work-up has been completed to rule out contributing factors (such as pain, delirium, seizures), environmental and behavioral interventions first...
When do you consider using Uzedy, the subcutaneous long-acting injectable version of risperidone?
It depends on how much risperidone they need. The maximum dose of Uzedy is only equivalent to 5 mg, so it’s not indicated for someone who needs more. The injection is different than Invega and has a smaller needle. It reaches steady state faster, but I have noticed a wearing off quicker in patients ...
How do you treat agitation in progressive supranuclear palsy?
Benzodiazepines are generally avoided due to adverse effects on cognition, the increased risk of falls, and disinhibition.Pharmacologic treatment for agitation is generally reserved for patients with severe agitation, when a patient is a threat to themselves and others, when agitation is the cause o...
How do you navigate requests from your employers to see patients for shorter appointment times or less frequently than you feel is clinically indicated?
It takes an hour to get the basic data and an hour to 'really find out what's going on' and to begin to establish some rapport.