Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
How do you approach continued prescribing of benzodiazepines when a patient who is already prescribed benzodiazepines reports concurrent illicit benzodiazepine use?
The management of patients who are prescribed benzodiazepines while concurrently using illicit benzodiazepines has become increasingly complex, particularly with the growing prevalence of synthetic benzodiazepine analogs within the illicit drug supply. Over the past decade, benzodiazepine prescribin...
In a frail older adult with depression unresponsive to two SSRI trials, what's your next step in management?
This is certainly a longer and nuanced conversation. Depends on the intensity of symptoms. Ensuring the diagnosis is accurate, reviewing the role of co-morbid cognitive disorders, organic issues masquerading as depression, and so on. Augmentation of an SSRI, e.g., mirtazapine, stimulating medication...
When is the best time to get a valproate level if a patient is taking Depakote DR once daily?
Levels should be obtained at steady state - which is 5 half lives. For ER formulation, figure about 5 days and it should be a trough level (immediately before the next dose).
When do you recommend neuropsychological testing in adults being evaluated for ADHD?
We should consider “testing” only when our main tool of diagnosis, a thorough psychiatric interview, history, and physical (mental status exam), demands more data for a diagnosis. Demanding neuropsych testing would be akin to relying more on an MRI than on a clinical assessment for a headache diagno...