Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage withdrawal symptoms after stimulant discontinuation?
I have not witnessed bradycardia as a withdrawal symptom of stimulants at therapeutic dosages, although this is common with misuse/SUD. I have noticed increased behavioral and mood symptoms due to stimulant discontinuation, which may be related to shortages. I simply use whatever formulation is avai...
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Weimer et...
How do you evaluate and manage patients who report vivid, distressing dreams or “epic dreaming” that disrupt sleep quality?
Nicotine or nicotine replacement being used? (Very common cause) Varenicline (Chantix) for smoking cessation being used? (Known effect) Melatonin being used? (Possible, more likely with high/excessive doses) Recent reduction or cessation of an antidepressant resulting in REM rebound? (Known to cause...
What is your approach to recommending bright light therapy devices to patients with (seasonal) depressive disorders?
Bright light therapy has a strikingly positive evidence base for seasonal affective disorder, major depressive disorder, and even bipolar depression. I recommend shopping for a lamp with 10,000 lux, a large format, diffusion screen (possibly fewer headaches), and one that is on a stand so that it sh...
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
What is your approach when the child refuses to separate from parents during psychiatric evaluation?
Children sometimes refuse to separate from parents during a psychiatric evaluation. The simple answer to how I respond when this occurs is that I complete the interview with the parent(s) in the room. For preschoolers and many school-age children, a refusal to separate is not necessarily something t...
When do you consider using dual orexin receptor antagonists (DORAs) for the treatment of insomnia?
I only consider using any hypnotic in insomnia when the patient is getting only 5 hours or less of sleep. In those cases, I will sometimes try using DORAs. I am a sleep neurologist who sees patients with MCI/early dementia, and I have found these medications useful in this population of patients wit...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
What is the best way to support a pediatric oncology survivor with fears about 2nd neoplasm or relapse?
Concerns regarding recurrence of the primary malignancy or the development of a second malignant neoplasm are common among pediatric cancer survivors and may be a significant source of ongoing anxiety. It is therefore important to routinely assess for these concerns, as well as to screen for anxiety...
What is your diagnostic approach to patients presenting for ADHD concerns when you suspect untreated sleep apnea?
When discussing a potential ADHD diagnosis with my patients (of note, I only treat adults), I always discuss sleep patterns and sleep hygiene/CBT-I techniques (and recommend stopping any THC usage). I also refer patients with suspected sleep apnea for a sleep study. Some ADHD symptoms may solely be ...