Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you facilitate access to interventional treatments such as TMS for patients with difficult-to-treat depression who are on Medicaid?
I think the rules vary by state for Medicaid, but here in MD, we do a consultation appointment and then submit for preauthorization from Medicaid. We typically do not start the treatments until we hear back that the course is approved. Lately, some of our Medicaid patients who have been approved hav...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
Would you consider prescribing NAC for a patient with OCD and a documented sulfa allergy?
I would consider using NAC if needed in a patient with a documented sulfa allergy because, although NAC is a sulfur-containing compound, it is chemically different from sulfonamides.However, as with any new medical trial on a patient, individual hypersensitivity is a possibility. Provided there is a...
How do you manage patients who report complex sleep behaviors while taking zolpidem or another Z-hypnotic?
At first, I'd prefer to rule out sleep-disordered breathing, and if sleep-disordered breathing is present, ensure that it is adequately treated. Addressing sleep-disordered breathing will decrease the likelihood of parasomnia behavior as well as insomnia in general. Then, if the patient still requir...
How do you approach anxiety management for patients who have been on long-term (years or more) daily benzodiazepines?
For patients that I have been seeing for several years, and who have been taking a benzodiazepine for several years, every 1-2 years I inquire as to their thoughts about their medication. After they (almost always) say they want to continue, when they get up in age I advise them of the risks of cont...
What behavioral interventions have you found most effective for managing self-injurious behavior in autism?
I think you'll find some good information in this related post: https://www.themednet.org/question/21993
What is your approach to addressing dementia-related agitation for patients living at home with family?
There is absolutely no simple way to answer that question. Even when the family is providing a very calm and nonconfrontational environment, avoiding any possible way of causing the agitation, it is virtually impossible to predict when and why a person with dementia would become agitated, angry, unp...
How do you treat postpartum obsessive-compulsive disorder?
The ideal treatment for women who are breastfeeding is transcranial magnetic stimulation. TMS has a 50% response rate for OCD, higher if treatment is extended past the typical course of 30-36 treatments. This is similar to the response rates reported for SSRI treatment of OCD. Most women with post-p...
What would prompt you to consider a sleep study for narcolepsy in a child or adolescent with new-onset hallucinations?
It would depend on other elements of the history. The age of the child, the timing of the hallucinations, particularly if they are associated with sleep, onset or awakening, other hypersomnia disorder symptoms, and the child's psychiatric history. Generally, I have a very low threshold for an in-lab...
How do you distinguish between borderline personality disorder and complex PTSD in patients with chronic relational trauma?
In my experience, the best differentiating factor is what occurs in the transference and the degree of distortion that occurs in the therapeutic relationship. Patients with complex PTSD may have issues with trust, fear of abandonment, and feelings of victimization, but this generally does not exhibi...