Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
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...