Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach effectively diagnosing ADHD within the time constraints of outpatient practice?
I approach diagnosing ADHD by asking a series of questions. Questions 1 - 3 are pretty straightforward, the others can be more nuanced depending on the case: 1) Do enough ADHD symptoms apply (6 symptoms in 1 category for kids, 5 symptoms in adults)? I ask about specific symptoms and encourage the pa...
What non-medication interventions or resources do you provide parents of children with oppositional behaviors?
Behavioral therapies, including parent management training, are the most evidence-based treatments. For children under 7, a well-respected intervention is PCIT (Parent-Child Interaction Therapy). There are also the Triple-P Positive Parenting Program, Incredible Years, and Coping Power Program. The ...
When do you start pharmacotherapy for PTSD in children?
The only medications to be used are to address sleep disturbance and nightmares. Poor sleep has been shown to increase PTSS. So prazosin and, on occasion, clonidine should be used. And they should be used as early as possible. SSRIs are generally not that effective and should only be considered if t...
Do you include a specific risk assessment in your outpatient clinic notes?
I typically include a risk assessment in my outpatient notes. I address the risk of violence and self-harm. I try to approach violence and suicide risk in a manner analogous to the primary care approach to cardiovascular risk: continuous risk reduction. In most outpatients, there is no imminent risk...
How do you address/manage the recreational use of dextromethorphan (sometimes called "robo-tripping") that has risen to the level of use disorder?
This problem of "robo-tripping" has become an increasingly observed clinical issue, namely the misuse of dextromethorphan with cough medication (Robitussin). This is often in conjunction with alcohol misuse. We recently published a case report in The American Journal of Drug and Alcohol Abuse (Ledwo...
How do you manage atomoxetine-related fatigue?
Fatigue is a common side effect of atomoxetine, especially during the early part of treatment. Fatigue associated with usage wanes over time for many users (one to three weeks usually; if it still persists for up to six weeks, fatigue is less likely to resolve on its own), but if not addressed, it c...
Do you recommend lavender oil for the treatment of anxiety in your practice?
As a child and adolescent psychiatrist, I am more conservative when considering treatments for children vs. adults. Lavender oil is approved for use in Germany but has no FDA approval in the US. In the studies on lavender oil, there has been evidence of benefit. The problem in the US is that it is m...
What has your experience been with using SSRIs to treat negative symptoms of schizophrenia?
Thirty years ago, I tried various SSRIs for negative symptoms, with no improvement according to the patient and caregivers.
What is your approach to using prazosin to treat day-time symptoms in PTSD?
I use doxazosin, which has a very similar mechanism of action (it hits different subunits on the alpha receptor), but it does not have as much of an effect on blood pressure, which can limit the dosing of prazosin. It also does not have as many other side effects documented, such as palpitations. Th...
How do you distinguish between antidepressants losing effectiveness vs. not being effective in the first place?
This is a common conundrum in antidepressant therapy. An antidepressant is prescribed, and the patient improves beginning 2-5 weeks later (perhaps after a dose increase), with remission following in the next few weeks. While continuing to take that antidepressant at the same dose (perhaps after seve...