Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
What strategies have you found most effective for obtaining prior authorization for newer antipsychotics and antidepressants?
I attempt to avoid all insurance issues, as I have a cash-based outpatient practice, and make it clear to patients that my interactions with their insurers will be minimal, if at all. But what I have found, in limited cases, is that demonstrating a failure on 2 of the formulary-approved choices tend...
How do you approach a case of apparent worsening catatonia despite high-dose benzodiazepines and ongoing ECT?
In my experience, this may reflect an incorrect or incomplete diagnosis, comorbid medical problems, or side effects of medications. ECT is a great treatment for catatonia, and I start to have doubts about everything, but ECT, if ECT doesn't work. I think re-evaluating diagnosis, ensuring that we kno...
How do you determine when ongoing outpatient treatment is no longer beneficial, and it may be appropriate to transition a patient to another provider?
To answer this question, I’d want to first set aside the issue of patient abandonment by taking it for granted that any transition would occur in a manner consistent with ethical and legal guidelines (for example, but not exclusively, those set out by the AMA, the literature, and in murky or content...
What is your approach to GLP-1 agonists as a psychiatrist in patients who are overweight or have eating-related disorders?
More and more of my patients have been asking for these medications in the past 12 months. For context, my niche is psychotic and bipolar disorders. Most (if not all) of my patients are on a combination of mood stabilizers and antipsychotics that are notorious for causing significant weight gain. Co...
What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder?
I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you assess for trauma-related symptoms in children and adolescents who have experienced chronic bullying?
Assessment for trauma-related symptoms in youth who have been victims of bullying is similar to assessment for trauma-related symptoms due to other factors, with special attention paid to symptoms such as school avoidance, being a perpetrator of bullying themselves, threats of harm to self or others...
What antidepressant medications do you usually use alongside ketamine or esketamine treatment in patients with difficult-to-treat depression?
Hello--ketamine clinic psych here. In our clinic's experience, quite a few ketamine-responders can drop the number of medications or lower the doses of medications once ketamine is part of the treatment plan. We don't see a lot of difference between which medication works best since that is so varia...