How do you start buprenorphine for a patient with opioid use disorder?

Mike is a 37 year old man with persistent depressive disorder (formerly dysthymia) who presents to establish primary care. His girlfriend is with him, and he’s okay speaking in front of her about his medical history. Mike starts off the visit saying he wants to discuss opioids. He had a few injuries playing basketball 15 […]

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How do you know when a patient has recovered from PTSD (and you can consider de-prescribing medications)?

Nina is a 65 year old woman with PTSD and hypertension. She takes sertraline 100 mg daily, prazosin 10 mg every night, and losartan 25 mg in the morning. She taken these medications, at these doses, for 10+ years. She recently moved to San Francisco to be closer to her grandchildren and is establishing care

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How do you make a safety plan with a patient who has suicidal thoughts?

Liam is a 28-yo-man with a history of one major depressive episode during which he was involuntarily hospitalized for 3 days for suicidal thoughts. After discharge, he saw a therapist for 6 months and a psychiatrist who titrated his sertraline to 150mg daily. His symptoms remitted after several months. A year later, Liam stopped the sertraline, and

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What options can be considered to help women stop smoking?

Nicole is a 43 year old woman who just established with you for primary care. She has a history of bipolar 1 (currently in remission on lithium, with 1 prior psychiatric hospitalization for suicidality) and high blood pressure for which she takes amlodipine. On the BP log she brings in, there are occasional 140 systolics

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How do you counsel patients about taking medications for depression during pregnancy?

Sophia is a 33-year-old woman with a history of major depressive disorder (MDD). She is currently euthymic and taking sertraline 100mg daily. She has had 3 lifetime severe major depressive episodes and has taken sertraline on and off for the past 13 years. She has never participated in psychotherapy. During your most recent visit, she tells

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How do you talk with patients about suicidal thoughts and behaviors?

David is a 60 yo man with chronic pain on opioids, PTSD, alcohol use disorder, and major depression, who was introduced in our last PsychSnap. He calls his primary care clinic every few weeks saying that he is going to kill himself if his pain isn’t better controlled. He now presents to a routine follow-up

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Can suicide risk assessments prevent your patients from dying by suicide?

David is a 60 yo man with a history of chronic low back from severe disc disease on long-term opioids, PTSD, alcohol use disorder, and major depression. After his husband died 30 years ago, he tried to kill himself twice by hanging and was psychiatrically hospitalized for severe depression after each attempt. Since that time, he

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What treatments help patients stop using methamphetamine?

Carter is a 41 year old man who comes to see you for a routine follow-up visit. He previously used cocaine on nights out with friends. Today, Carter tells you that he stopped using cocaine entirely because he found something better: crystal (methamphetamine). For the last year, he has used a little bit of crystal

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How do you navigate chronic delusions to provide effective medical care?

Ms. Wren, an 80-year-old woman with heart failure and diabetes, was recently hospitalized for a heart failure exacerbation. She has been on your panel for a year, but you have not met her. The inpatient notes describe her as having chronic fixed paranoid delusions of a man who follows her and occasionally threatens to kill

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When should you stop an SSRI trial for depression due to lack of efficacy?

30 yo woman with generalized anxiety disorder presents in her first major depressive episode. She is depressed, hopeless, sleeping poorly, exhausted, and losing weight (6 pounds in the last month). She has never taken psychiatric medications before. She would like to try a medication to treat both depression and anxiety (so bupropion is out).  You prescribe

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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.