Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you recommend neuropsychological testing in adults being evaluated for ADHD?
We should consider “testing” only when our main tool of diagnosis, a thorough psychiatric interview, history, and physical (mental status exam), demands more data for a diagnosis. Demanding neuropsych testing would be akin to relying more on an MRI than on a clinical assessment for a headache diagno...
How do you approach disposition planning when a patient makes homicidal threats on presentation to the emergency department but later recants?
Tarasoff rules.Tarasoff v. Regents of the University of CaliforniaEr department remains in the purview of all medicine in the USA in my opinion.“How to you approach” is the same regardless of setting. The thought of the clinician remains superordinate. Is this really a question?Recant. …. ”imminent”...
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
When do you consider the use of lumateperone to treat schizophrenia spectrum disorders?
It is obscene that these drugs cost $1,400-$1,800/month retail.
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...
When do you consider the use of N-acetylcysteine (NAC) in patients with trichotillomania?
Great question! NAC comes up frequently in clinical discussions of trichotillomania, and it's worth being clear-eyed about what we actually know. NAC restores extrasynaptic glutamate homeostasis via the cystine-glutamate antiporter (system Xc⁻), which increases tonic activation of presynaptic mGluR2...
How do you handle requests for disability or accommodations in clinical settings with limited administrative support or documentation time?
If you are working in private practice without ancillary support like case managers, I highly recommend having patients make appointments while you complete the forms for them. Clinically, if paperwork is being sprung on you out of nowhere, an evaluation is necessary anyways to determine if it's app...