Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In what cases do you recommend the use of gabapentin for off-label use in alcohol use disorder?
Often patients with AUD who decline first-line medication treatments, i.e., naltrexone or acamprosate, are more open to gabapentin when advised of its potential benefits for anxiety, mood, and sleep, as these are common issues that drive alcohol cravings and use. Flexible dose titrations starting wi...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
What medications have you found to be effective for childhood-onset speech fluency disorder?
I believe that speech therapy is needed for this and not a problem that medications will help, or I would not recommend it for this condition. There are no FDA-approved medications.
How do you differentiate cognitive inflexibility due to autism from similar patterns in anxiety or OCD?
This is a nuanced and often confused area. In ASD, behavioral rigidity is typically automatic and ego-syntonic. While often distressing to others, an individual with ASD is not bothered by their inflexible thinking. In OCD and other anxiety disorders, compulsive behaviors or mental acts are more vol...
What medications have you found helpful in the treatment of stimulant use disorder?
I don't have a slam-dunk 'go-to' medication for stimulant use disorder. I try to employ community reinforcement and contingency management strategies and treat any comorbidity with medication targeted to the symptoms of that comorbid condition. While there is some data supporting stimulants for stim...
How do you manage obsessive-compulsive disorder refractory to high-dose SSRI and cognitive behavioral therapy?
In general, I follow a decision tree based on refractoriness and comorbid conditions. Let us first assume that we have already provided an adequate dose of an SSRI for an adequate duration of 12 weeks. I use the following doses as general targets for SSRI treatment: Fluoxetine 80 mg/d Escitalopram ...
How do you approach stimulant-related insomnia for pediatric patients who are otherwise good responses to low-dose stimulant treatment for ADHD?
Clonidine 0.1 mg qhs is my first choice if I have to use something. However, first consider decreasing the stimulant dose or changing to a shorter-acting stimulant. Or go with Strattera so you can use a lower dose of stimulant. Or go with guanfacine so you can also use a lower dose of stimulant. Sti...
How do you counsel patients regarding risks of cannabis use?
I am in agreement with Dr. @Dr. First Last. Both alcohol and cannabis are legal in most states now, and use is not uncommon in patients of all ages. My stance: Rare/occasional use... probably not going to cause much problem (physical or mental) unless you are addiction prone, or if there is any fami...
What are your considerations when treating insomnia in perimenopausal patients with comorbid anxiety or mood disorders?
I would choose to first try nortriptyline for such a patient. While being an older medication, I find it to be excellent. It is generally well tolerated and helps with insomnia, anxiety, and depression. It isn’t studied much, because it’s been generic for so long, and oftentimes, clinicians are unfo...
How do you approach antidepressant selection in patients with prominent fatigue but minimal mood symptoms?
I'm puzzled by this question, in that prominent fatigue without mood symptoms warrants a proper medical workup before assuming it is depression related. This would include a full set of labs, a sleep study to rule out sleep apnea or other causes of fatigue (and with daytime MSLT to rule out narcolep...