Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you support recovery in patients with MDD and AUD experiencing anhedonia and social isolation after losing alcohol-based social networks?
Although the availability of possible sources of social contact varies with age and setting, I usually ask about prior personal experience, particularly in religious organizations that involve social connection. Anhedonia is a matter of degree. It may be possible to get people to chart during the da...
What are the best initial treatments for unprescribed stimulant use in patients who are using stimulants periodically to improve occupational or academic functioning?
This is such an important and increasingly common question—and I’m not sure there's a single "best" initial treatment, but I’ll share how I approach it. First, I think it’s worth pausing on the assumption that someone who uses unprescribed stimulants for performance must have a focus problem or ADHD...
What’s your approach when a parent declines mental health services for their child due to cultural stigma or fear of CPS involvement?
This is always challenging, but the most important part is establishing a relationship of trust with the family, exploring their concerns and reservations regarding the recommended treatment, and also emphasizing the rationale and risks associated with not following treatment recommendations. CPS ca...
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...
How do you counsel patients and caregivers on dietary interventions for autism?
Whole foods diet, e.g., Whole30.com. All the information on that website is free. I will remove common food allergens. Remove all synthetic food dyes. 100% organic to protect the microbiome. Consider a spore-based probiotic for a few months.
When do you decide to switch stimulants vs. continuing to maximize dosage in ADHD treatment?
I definitely agree with Dr. @Dr. First Last about the core concept that this question appears to be asking - "When do you know if a stimulant is just not working for your patients symptoms, and/or when do you decide to change to a different stimulant?" Before answering the second part of this core q...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...
When would you consider transdermal treatments for ADHD?
Agree with the above, plus if I have a kiddo having a really difficult time in the mornings with tardiness at school and tantrums in the AM because of ADHD, patch can do wonders if applied 2 hours prior to wake-up time. So I have parents apply the patch when they are still asleep, and then the morni...
What has been your experience using mindfulness-based interventions for patients with somatic anxiety symptoms?
Excellent. Here's why. Somatization with anxiety The science All emotions, positive or negative, are felt as physical sensations in the body because the limbic system has no direct conscious pathways to the cortex. Pathways from the limbic system first go to serotonin receptors in the body such as ...
How do you most effectively dose melatonin for children with insomnia?
As is the answer for most questions - it depends on the variables. First, I trial "chronobiologic dosing" (0.3-0.5 mg) about 3-4 hours before bedtime. I find this most helpful for delayed sleep phase, but not so much for maintenance. If they need a little more help with falling asleep, I will add ...