Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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?
If I find out a patient is abusing/misusing Adderall from another source, even having it prescribed by another licensed provider at the same time they are having it prescribed by me, I immediately stop prescribing any dea controlled medication (I once had a patient tell me “I’m selling the meds from...
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...
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...
How do you use lithium levels to adjust treatment during mania?
If someone is getting manic, the mania in itself reduces lithium levels. You need for a period of about 6 weeks maintain a level close to 1 in contrast to a maintenance level of 0.75. I would, of course, use the appropriate antipsychotic to help during this period. If the patient has been Li respons...
How do you counsel patients regarding using stimulants for attention-deficit/hyperactivity disorder during pregnancy?
There is limited research evaluating the course of ADHD across pregnancy and postpartum. The individual woman’s severity of illness and impairment inform treatment decisions across pregnancy. As with the treatment of all disorders during pregnancy, the risks and benefits of medications need to be ca...
What is your approach when evaluating a child brought in by parents who suspect PANS/PANDAS as the cause of the child's psychiatric symptoms?
I encourage reading of the recent comprehensive review of all aspects of PANS in Pediatrics, This is a policy statement by the American Academy of Pediatrics. It is comprehensive and balanced, acknowledging key controversies in diagnostic and treatment approaches. In my clinical practice, the greate...
In the psychiatric ER, how do you address the issue of child/adolescent patients being left there by caregivers and becoming extended stay patients?
Unfortunately, then it becomes a matter of contacting the Department of Children's Services for intervention. However, that is often a slow and arduous road.