Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
What non-pharmacologic recommendations do you provide for patients with ADHD?
It might surprise many colleagues, but in my psychiatric practice, the most powerful non-pharmacological intervention for adult ADHD is not an elaborate productivity system. It is simply bearing witness. By the time an adult with ADHD reaches our care, they have usually spent decades interpreting ex...
How do you decide when to obtain a brain CT and/or MRI in hospitalized patients with altered mental status?
Always, unless the patient can be quickly awakened by glucose, etc., or it DNR, so I guess this means often.
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...
When do you recommend HLA testing prior to prescribing lamotrigine, carbamazepine, or oxcarbazepine to patients of Asian descent?
This is one of the few actionable tests to avoid the more frequent occurrence of DRESS (Drug Rash with Eosinophilia Syndrome) or SJS (Stevens-Johnson Syndrome). Practically speaking, it is unusual for clinicians to have these HLA tests available in a fashion timely enough to match the usual need for...
What has your experience been counseling on and prescribing Cobenfy?
I have good results from it - but just like with any medication in psychiatry, there isn't "one size fits all". There is data that shows a more rapid titration to the highest dose (125-30) works the best. It goes 2 days with 50-20, then 5 days with 100-20, then transitions to 125-30. You have to mak...
Has the April 2026 Cochrane review on anti-amyloid antibodies changed how you counsel older adults with early Alzheimer's disease about whether to pursue treatment with lecanemab or donanemab?
The April 2026 Cochrane review has not fundamentally changed my counseling, but it has strengthened my caution. It reinforces that lecanemab and donanemab clearly remove amyloid, yet any average clinical benefit appears small and remains difficult to interpret confidently given the numerous threats ...
What alternative ADHD medications would you consider in a child with a complex cardiac history unresponsive to guanfacine?
Choosing another medication to treat ADHD in a child with a complex cardiac history who has already failed guanfacine is not a straightforward task. To make this decision, one would need to understand which symptoms of ADHD are causing the most functional impairment (inattention, hyperactivity, both...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...