Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What treatments have you found to be most effective in patients with a schizo-obsessive disorder?
This is a good question, as this happens in about 30% of our patients who have this. It depends on the severity of the psychosis versus OCD. Sometimes it’s hard to tease out are we're dealing with psychosis or the OCD is so severe it comes across as psychosis. That’s the first step. Then, as I said ...
When do you consider the use of an MAOI in treatment-resistant major depressive disorder?
MAOIs can be great in treatment-resistant depression, but after you explain how there might need to be some dietary restrictions, patients generally refrain from wanting to try them. To be frank, the dietary restrictions are overblown (A concise guide to monoamine oxidase inhibitors). There are 2 pa...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
In residency, we had to get patient permission to videotape sessions and allow our supervisors to watch sessions from behind a one-way mirror. If I were to use a scribe, especially an AI scribe, or if I were audio or video taping the sessions, I would definitely want to get a patient’s approval. I d...
Do you screen for MTHFR polymorphisms in your patients with treatment-resistant depression?
In the trial by Papakostas et al., PMID 23212058, we have shown that adjunctive L-methylfolate at 15 mg/day had significantly greater efficacy compared with continued SSRI therapy plus placebo on both primary outcome measures (response rate and degree of change in depression symptom score) and two s...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How do you approach liver function testing and monitoring when using xanomeline/tropsium (Cobenfy)?
Good question, as it’s a newer medication on the market. I prefer a CMP as a baseline but since I’ve come across the first reported case of neutropenia with Cobenfy, I would suggest getting a CBC weekly, but move to monthly after a few CBCs, and when getting the CBC with diff, get a CMP. It can’t hu...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...
How do you manage anxious children who are somatically focused and do not tolerate SSRIs?
Treatment of an anxious child ideally involves a holistic bio-psycho-sociocultural approach to understand the nature and underlying reasons for the anxiety, and importantly, the family's response and accommodations to their child's anxiety. So individual CBT-focused therapy can be very helpful, but ...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...