Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you believe that buspirone is ineffective in patients who are previously treated with benzodiazepines?
I've found buspirone helpful for patients who don't want to taper their benzo unless they have another medication on board. I wait until the buspirone is at a stable dose (typically at least 15 mg BID) before tapering the benzo. I specifically avoid cross-tapering/titration as I worry they will asso...
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 approach firearm safety counseling for outpatients with elevated suicide risk who do not meet the criteria for involuntary psychiatric hospitalization?
I have found the framework outlined by the BulletPoints Project (created by the California Firearm Violence Research Center at UC Davis) to be very helpful. I start by asking about the patient’s goals for owning firearms. I think it is important to recognize that guns often form an important part o...
How do you approach requests from attorneys to complete paperwork supporting your patient’s application for long-term disability?
If the diagnosis does not support disability, I will give the attorney a call. This saves time, money, and my effort of writing a report. They may provide more collateral, or they may not use me. Either way, I am not stuck defending an untenable position. In terms of ambiguous questions, I try to be...
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 is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
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 ...
Do you recommend lavender oil for the treatment of anxiety in your practice?
As a child and adolescent psychiatrist, I am more conservative when considering treatments for children vs. adults. Lavender oil is approved for use in Germany but has no FDA approval in the US. In the studies on lavender oil, there has been evidence of benefit. The problem in the US is that it is m...