How do you treat insomnia with medications if CBTi doesn’t help?

Part 2 of “When the sheep are gone, how do you treat insomnia?” In a prior PsychSnap, we met Ms. Rose, a 65 year old woman with diabetes who is the primary caregiver for her adult son. She has been struggling with sleep maintenance, waking up multiple times in the middle of the night and taking 30-90 …

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When a young adult is hearing voices and psychiatry is unavailable for months, how can you help? (part 2)

The initial published case has been modified slightly in response to feedback from colleagues. We return to Juan, the 20 yo man from our last PsychSnap. He started hearing the voice of a little boy saying things like “why won’t you help me” three months ago. He now hears the voice multiple times a day, which …

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When a young adult is hearing voices and psychiatry is unavailable for months, how can you help? (part 1)

The initial published case has been modified slightly in response to feedback from colleagues. Juan is a 20 yo young man who is brought to his PCP’s office by his mother for “hearing voices.” You speak with Juan alone first. For 3 months, he has been hearing the voice of a young boy, talking directly to him, …

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How do you manage behavioral and psychological symptoms in a patient with dementia?

Special Guest Authors: Anna Chodos, Anna Hines, Ashley Johnson Lisa is a 78yo woman with moderate stage dementia. Two years ago, she became more irritable. She was snapping at people and refusing medications. At that time, you taught her family a couple of strategies for managing these behaviors and connected them to a local organization that provided education and …

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Which antidepressants are least likely to cause weight gain?

After almost 2 years of discussing pharmacotherapy, a 48 year old woman with severe generalized anxiety disorder (GAD) agrees to take medication. She starts taking escitalopram and increases the dosage. After 8 weeks on a daily dose of escitalopram 20mg, her anxiety symptoms are in remission. She has no side effects. However, when you see her 6 months …

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Chaos with Cannabis? How to diagnose and treat cannabis use disorder

Jake is a 28 yo man with a history of anxiety since adolescence who comes to you to establish care. He is generally healthy and uses cannabis every evening to “help calm down.” He started smoking heavily in high school. For the last decade, he has smoked one joint nightly. His partner doesn’t like his smoking, and …

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If Adderall XR is unavailable, what else can you prescribe?

Your patient is a 34 yo man with ADHD who has been stable on Adderall XR 30mg for 15 years. He can’t get the medication due to the nationwide shortage. What else can you prescribe if Adderall XR is not available in pharmacies? There are only two types of stimulants that are prescribed for ADHD – methylphenidate …

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How do you choose an antidepressant?

You see a 24 yo woman in a severe major depressive episode and offer her sertraline and a referral to therapy. After the visit, the medical student rotating with you asks why you chose sertraline for this patient. He follows with, “I guess I’m asking…how do you choose an antidepressant?” You answer his question in three …

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How can we help depressed but not (majorly) depressed patients?

Eric is a 60 year old man presenting with a depressed mood, low energy, and low appetite for the past 2 months. He notes increasing conflict with his partner, but no anhedonia, insomnia, difficulty concentrating, or thoughts of worthlessness or suicide. A year ago, he experienced a depressed mood and low energy for 2 months that …

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The opinions expressed in PsychSnaps do not necessarily represent the views and opinions of the University of California, San Francisco. The opinions in PsychSnaps should not be used as a substitute for medical advice from a qualified, board-certified practicing clinician.