Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
What adjunctive therapies to you recommend for symptom control in acute opioid withdrawal beyond full/partial opioid agonists?
Here are some general recommendations below. I recommend asking the patient what symptoms are most bothersome or what they anticipate to be the most bothersome when prescribing adjuncts. I routinely recommend APAP/ibuprofen, and then usually prescribe something for anxiety and nausea. Tizanidine can...
How do you approach the evaluation and treatment of insomnia in children?
The evaluation and treatment of insomnia in children requires a structured assessment of sleep patterns, contributing medical or behavioral factors, and the implementation of primarily behavioral interventions, with selective use of pharmacologic treatments. Identify Sleep Complaint: Difficulty fall...
How do you counsel patients on lithium about NSAID use?
I recommend not using NSAIDs altogether, since there are so many variables to consider if the patient is to remain safe. The patient needs to be highly aware and knowledgeable about their medications, medical problems, age, baseline labs, etc. There are not very many patients like that.
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...
Given the mixed evidence for N-acetylcysteine in adolescent cannabis use disorder, how do you approach discussing this with families?
A thoughtful addition to the discussion on NAC in adolescents with cannabis use disorder is to emphasize how and when it is used. In many young patients, cannabis use is not simply recreational or oppositional, but a compulsive attempt to manage obsessional anxiety. When this pattern is recognized—p...
What strategies do you find helpful to stop zolpidem in patients who have been taking the medicine for months or years?
Zolpidem has significant withdrawal, and if not careful, the patient will perceive it as a need for zolpidem for sleep. Technically, it is not working after about 6-8 months due to the accommodation of receptors. Please use lemborexant hintly for 1 week, reduce to 2.5 mg zolpidem for 1 month, and th...
Would you consider starting a stimulant in an inpatient or crisis setting for patients whose severe behavioral issues are due to untreated ADHD?
For an adult without an established diagnosis, I don't believe initiating stimulant therapy during an acute inpatient stay is appropriate. ADHD is a legitimate neurodevelopmental condition, but it shouldn't be used as a catch-all explanation for behavioral disruptions in a hospital setting. Starting...
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...