Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
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...
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
How do you counsel patients interested in neuromodulation (tDCS, rTMS) for ADHD?
I have not used rTMS for ADHD but have used it for adolescent depression. It is advised to spend a full appointment to go over the evidence, the strength of evidence, possibilities of failure, etc. I generally let parents and patients come back to me to ask for the procedure. In my opinion, for any ...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
How do you decide when dangerous or illegal behaviors in youth with conduct disorder require legal involvement?
This is a hard question to answer. If your JJ system provides support and treatment options, then it is useful for youth who can't be overseen by their caregivers to refer to JJ. However, many systems are more punitive and may not be helpful. In those situations, I would refer if the youth were enga...
What is your experience in the efficacy of vortioxetine for treating anxiety disorders?
Although vortioxetine (currently branded as Trintellix in the USA) is only FDA-approved for the treatment of Major Depressive Disorder, many of the SSRI medications can be used off-label for anxiety disorders, panic disorder, or OCD. Clinical studies often have mixed results, though. Because it has ...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
When do you use guanfacine instead of stimulant medication for adults with ADHD?
The premise that guanfacine could simply replace stimulants due to its non-controlled status misrepresents the complexity of adult ADHD. ADHD is a heterogeneous neurodevelopmental disorder, and treatment must address distinct, often overlapping, neurobiological pathways. Stimulants and non-stimulant...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...