Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach buprenorphine dosing and titration in older adults with opioid use disorder?
I apply the same care and principles here with buprenorphine dosing in persons age 65 and older as I do with starting other psychoactive medications and medications that are metabolized by the liver. I also see many persons younger than 65 who have the physical health of persons older than 65 becaus...
How do you counsel breastfeeding parents with postpartum depression when sleep deprivation appears to be worsening mood symptoms?
My position is that breastfeeding is a sometimes difficult practical issue, not a medical or moral imperative. I try to normalize the difficulties of breastfeeding, based on my own experience and that of my daughters and sisters, countering the exploitation of anxiety around this issue with problem-...
How do you introduce patients with obsessive-compulsive disorder to the concept of exposure and response prevention (ERP) therapy when they may be hesitant to engage in exposure-based work?
This is a fantastic question, and I agree with the others who responded! I like to first validate their thoughts and feelings about ERP and explore their reluctance, noting that it is very reasonable. There are a few steps that can be helpful in introducing ERP to the patient. Metaphors can be very ...
How do you discuss lithium with patients who are hesitant due to concerns about side effects or monitoring requirements?
I inform patients that lithium is one of the oldest and most studied mood stabilizers. Many people do well on it for years with no or minimal side effects. Patients report that after years of suffering, it provides a sense of calm and helps with sleep. There is some evidence that it reduces suicide ...
When do you consider using modafinil as an adjunctive treatment for depression?
While modafinil is off-label for depression, I frequently add it in if patients have persistent low-energy states despite other treatments, or if they can not tolerate bupropion. The biggest holdup in its use is often insurance barriers, which frequently prevent psychiatrists who are not sleep-certi...
What is your approach to recommending bright light therapy devices to patients with (seasonal) depressive disorders?
Bright light therapy has a strikingly positive evidence base for seasonal affective disorder, major depressive disorder, and even bipolar depression. I recommend shopping for a lamp with 10,000 lux, a large format, diffusion screen (possibly fewer headaches), and one that is on a stand so that it sh...
How do you handle requests for medication refills from patients who were formally terminated from care but report difficulty accessing a new psychiatrist?
It is essential when terminating a patient that you provide at least three formal referral names with a 30-day notice. One of these should be an agency that cannot refuse patients. This could be a county or state mental health clinic. If the referrals you provide refuse the patient, then you are obl...
How do you manage patients who develop SIADH secondary to an SSRI but have had a strong positive response to that same medication?
Management of SSRI-induced SIADH depends on the severity of hyponatremia and the patient’s psychiatric response to treatment. In mild cases (serum sodium >130), I always continue SSRI with close monitoring and fluid restriction. Moderate to severe hyponatremia, I discontinue SSRI and actively correc...
How long do you continue benzodiazepines in patients who have recovered from catatonia?
As others have already responded, it is case-dependent. In an otherwise healthy patient whose underlying medical or psychiatric condition causing catatonia had stabilized, there is likely a way to gradually taper off benzodiazepines without a risk of relapse.However there are other cases that are mo...
How often do you require patients seen via telehealth to have in-person visits in outpatient psychiatry?
Great topic, and I'd love to hear others' experiences. For stable, low-acuity patients, I've largely moved to telehealth-primary with in-person visits annually or as clinically indicated. I still prefer at least one in-person intake before transitioning - the observational data matters. Factors push...