Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
How do you handle requests for disability or accommodations in clinical settings with limited administrative support or documentation time?
If you are working in private practice without ancillary support like case managers, I highly recommend having patients make appointments while you complete the forms for them. Clinically, if paperwork is being sprung on you out of nowhere, an evaluation is necessary anyways to determine if it's app...
When, if ever, do you consider using dronabinol to treat agitation in dementia?
Dronabinol should be considered for treating agitation in dementia when non-pharmacological interventions and standard pharmacological options, such as antidepressants or antipsychotics, have failed or are poorly tolerated. I have a handful of patients in my practice who fit that scenario and benefi...
How do you address a patient who may be getting Adderall from another non-prescribed source while you're treating them with Adderall for ADHD?
I believe every physician treating adults with ADHD must approach their practice through an addiction-informed lens. I make this clear at the first visit, emphasizing that our therapeutic relationship is built on absolute transparency and essential safety parameters. When a patient demonstrates beha...
How do you approach mood stabilizer initiation in an older adult with a new diagnosis of bipolar disorder?
First off, it is going to depend on the age of the patient. There are different mood stabilizers and depending on which one to pick, the patient will need to have labs done, as well as how responsible the patient is. If we are talking lithium, we want to make sure GFR is okay, as it tends to decline...
When do you refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?
For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...
When do patients presenting with self harm but no suicidal ideation in an outpatient setting require a higher level of care?
This will be highly specific to the individual patient, and like all treatment decisions, hinges on a comprehensive evaluation of risks vs. benefits. Considerations include the underlying psychiatric diagnoses, the degree of self harm (severity, timing, etc.), participation in/response to treatment ...
How many of your patients continue medications for ADHD after they turn 18?
Keep in mind that discontinuing medications at that time does not mean permanently discontinuing. As an adult psychiatrist, I see a lot of patients with ADHD who stopped medications after childhood but eventually decided to resume treatment. Most of the time, their strategies for compensating in one...
What adjustments do you make for patients with ADHD who report their long-acting stimulant wears off too quickly?
There are essentially 3 options: 1) administer the medication later in the morning; 2) add a short-acting booster dose; 3) switch to a similar formulation with a longer duration of action. I typically discuss these options with patients/families and make individualized decisions depending on the par...
When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?
I have read a recent JAMA Psychiatry paper concerning clozapine initiation after 1 antipsychotic trial, which was not successful (Li et al., PMID 41811299). I have not changed my practice, which is to require 2 such trials (which blood level confirmation to eliminate non-compliance) before prescribi...