General Adult Psychiatry

What conditions do you treat? What does an assessment involve?  

I provide treatment for attention deficit conditions (ADD/ADHD), mood disorders such as bipolar disorder and monopolar/unipolar depression, thought disorders such as schizophrenia and schizoaffective disorder, anxiety, and substance use disorders that are CO-MORBID or occur with other mental health conditions, cognitive decline and dementia.

What’s involved in an Initial Psychiatric Diagnostic Evaluation?

In an initial formal psychiatric evaluation, I conduct an in depth standardized interview during which I ask you detailed assessment questions which will guide my recommendations for treatment of the issues for which you are seeking care. I will ask you about your current and previous symptoms, trauma history, any history of previous treatment including hospitalizations, therapy, medications (did they help, why did you stop the medication, did you have adverse or intolerable side effects?), previous suicide attempts and self-harming behavior. I will ask you if you have access to weapons including guns. I will ask detailed questions about substance use—both current and historical.  I’ll ask questions about any active medical conditions, your developmental history, your genetic psychiatric history (family history of mental illness), and your social history, recent lab/diagnostic testing results, etc.  I will perform a “mental status exam” including a brief cognitive evaluation which will tell me about your current level of cognitive function and/or distress.  Once the assessment is complete, I will discuss with you my diagnostic hypotheses and offer you treatment suggestions/options.  There are usually several possible courses of treatment, and I work in partnership with my patients to determine which are best for you.   

My formal psychiatric assessment is based on the American Psychiatric Association Adult Psychiatric Assessment.  I have added other subject questions to this assessment from my background in holistic psychiatric nursing and my experience and knowledge of body/mind/spirit components of mental health.

How long is a typical counseling session?

Your initial psychiatric assessment with me will last for ~ 90 minutes for telemedicine and in person office visits. Assessments in home care visits are scheduled for 2.5 hours or 150 minutes.

At the end of your assessment I will share with you my therapeutic hypotheses (also called ‘differential diagnoses’) and my recommendations which may include laboratory diagnostic testing, medications and/or medication changes/adjustments, dietary adjustments, nutritional supplements and/or adjustments to your current nutritional supplements, psychotherapy with me in some cases or with another therapist in other cases when I believe that a special form of psychotherapy will benefit you. I also routinely recommend lifestyle adjustments which may include adjustments to your diet, exercise, sleep hygiene, nature therapy, mindfulness, spirituality, bibliotherapy, etc. We will discuss and negotiate the best plan for you.  

If you decide that you would like to enter into psychotherapy/talk therapy/life coaching with me, the length of those sessions vary depending on the specific work you want to do with me, ranging from 30, 45, 60 and even 120 minutes sessions in some cases. We negotiate the frequency and duration of your sessions.

How many sessions should I expect to have?

The number and frequency of sessions for psychotherapy/talk therapy varies based on your goals and what you are working on. 

For ongoing stimulant therapy for attention conditions, daily benzodiazepine/sedative therapy for anxiety and insomnia and for daily opioid therapy either for pain management or Medication Assisted Therapy for opioid dependence, I require assessment visits every 90 days by telemedicine/office visit with a required annual face to face, in person office visit + additional in person assessments on an “as needed” basis when symptoms emerge that I must assess in person.

What is Treatment Planning?

There are usually several ways to address each mental health issue. I believe that you are the best expert on yourself, your mental health, your history and coping strategies and patterns as well as your personal goals. I work in partnership with each patient—offering what I know about your condition/options which is informed by daily review of new literature and research studies, with you offering what you know about yourself/history/patterns and we negotiate the best course of treatment with the greatest likelihood of success.  In psychiatry, we sometimes have to try a few different medication strategies before we land on something that works for each individual.

How will you help manage my medications?

Where indicated, based on the result of the formal psychiatric assessment, I may suggest medications.  Usually, there are several medication choices for the presenting condition and I will discuss with you the differences between the medications including the side effect profiles, costs, availability, etc., and together we will select the medicine most likely to be beneficial to you.  If you have already had many medication trials, I may recommend pharmacogenetics testing for detailed gene-drug interactions to learn how your specific body metabolizes various medications which helps determine what medications should help with the least negative side effects for you.  If you have already had psychiatric pharmacogenetics testing, for instance through Genomind, or Genesight, please make that report available to me.

Once you are stable on the right medication for you, for non controlled/non narcotic medication management, I require biannual assessment visits with the understanding that you will reach out to me between your biannual assessment visits if you have questions or any adverse effect or new symptom emerges, OR if your medication “poops out” and your symptoms begin to increase even though you have been adherent. If you decide to stop a prescribed medication due to side effects or another reason, please reach out to me so that I can assess any side effect at the time you are having it so that we can plan your next intervention.

What does lab/diagnostic testing mean?

Annual basic annual lab/diagnostic testing is recommended for all mental health conditions because so many mental health symptoms and conditions are directly caused or affected by medical conditions that may be reflected in routine lab testing results.

The effects of some medications MUST be monitored with regular lab testing.  These include lithium, Depakote/divalproex and clozapine.  In the case of lithium and Depakote, testing is required in order to make certain that your serum blood level of the medication is in the “therapeutic window,” not too high, not too low, but just right to maintain your mood stability. Lithium can also affect thyroid and renal function—if this occurs it is reflected in lab testing, sometimes before you become symptomatic from thyroid or renal effects. Weekly blood tests are required by the FDA for the first 6 months for clozapine and less frequently thereafter to monitor your absolute neutrophil count (ANC) which can suddenly and unexpectedly drop which makes you vulnerable to serious medical issues including severe infection.  

Some medications may cause “metabolic syndrome” which includes weight gain, blood sugar irregularities, and hyperlipidemia.  This adverse side effect contributes to the development of cardiovascular problems over time.  For this reason, I will ask for an annual standard lab battery to monitor for signs of these adverse side effects and I include lifestyle coaching for diet, exercise and sleep in every assessment visit. You may have your primary care provider order and send me your annual lab results, or I can order them via Quest Diagnostics or LabCorp.  It is also necessary and useful to monitor your weight because this is usually the earliest indicator of metabolic syndrome. I will ask for a recent weight at every telemedicine visit. During office visits I will ask you to step onto the scale in my office. I will also routinely check your blood pressure during office visits. For telemedicine sessions, you are on the honor system for your weight! These biological measurements are added your record and I monitor these for trends up or down.

Some medications may cause your serum prolactin level to go up. This is called “hyper-prolactinemia.”  We suspect this when inappropriate lactation develops in both women and men. Men may also develop breast tissue. In this case we test your serum prolactin and if it is elevated, we make appropriate medication changes/adjustments to normalize the prolactin level. Prolonged elevation in prolactin increases risks for osteoporosis/bone loss, infertility, decreased sex drive in both sexes and may be associated with breast cancer.

Syphilis/gonorrhea is on the rise again in our community and can cause serious neurocognitive problems when left untreated. This particular infectious disease may be “asymptomatic,” which means the person doesn’t perceive any symptoms when they have it so they do not seek care for this or get diagnostic testing. I may recommend testing for sexually transmitted illnesses based on the results of the psychiatric assessment. 

Some nutritional/vitamin deficiencies can cause depressive symptoms, confusion, disorganization, delirium and psychosis.  I may recommend B12/Folate/Thiamine and Vitamin D testing in some cases. We now know that inflammation plays a role in many psychiatric/mental health conditions, especially chronic systemic inflammation which includes “neuroinflammation” and certain inflammation biomarkers traditionally associated with cardiovascular risks are also biomarkers for depression and “treatment resistant” depression. I may include lab testing for inflammation biomarkers in orders for your annual labs.

If you require treatment with stimulants for ADHD, ADD, or other purposes, I will ask that you have your primary care provider perform a focused cardiovascular exam and an EKG and send me the results in some cases after your initial assessment based on your medical history and symptoms.  I may recommend that an EKG be repeated as indicated to monitor for cardiovascular side effects depending on the risks in your particular case. For persons receiving ongoing stimulant therapy, I require assessments with me every 90 days and an annual physical exam which includes a focused cardiovascular exam with your primary care provider.

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