Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What are your preferred treatments for disrupted nighttime sleep in elderly patients with narcolepsy already taking sodium oxybate?
The treatment depends on what is causing the disruption. Before I consider any medication, I recommend a thorough investigation of possible causes of the disruption. For example, has sleep apnea been ruled out? Is the patient taking alerting substances close to bedtime? What is the sleep environment...
Have you completed any training to prepare for offering psilocybin treatment in the event that it eventually becomes FDA-approved for difficult-to-treat depression?
It seems that places that offer TMS and ketamine will be the ones to adopt it, as they already have the infrastructure for it. I don't see generalists using it that much.
How do you talk to patients about psychedelic clinical trials for the treatment of major depressive disorder or PTSD?
These discussions usually come up with patients who have not been satisfied with prior pharmacologic treatments for depression or PTSD. I see my role as educating patients so that they can make the choice that is best for them. I will talk to them about the potential risks and benefits of psychedeli...
How do you approach diagnosing ADHD in patients with significant trauma histories?
It is critical to differentiate significant post-traumatic stress from ADHD. They both present with similar symptoms including anxiety, mood disturbance, emotional dysregulation, hyperactivity, difficulty concentrating and feeling "scattered", impulsivity, and interpersonal difficulties. As with any...
When do you refer patients with difficult-to-treat depression for ECT rather than other interventional psychiatric treatments, such as TMS or esketamine?
First, you have to take into account the patient's wants. A decent amount of patients are scared of ECT and want to exhaust all pharmacological options possible. After I deem it necessary that ECT is in the best interest of the patient, I will explore their willingness. Also, access to ECT can be a ...
How do you address akathisia for patients who have had otherwise an excellent response to their antipsychotic treatment?
Try lowering the dosage of the antipsychotic, if possible. If this is not effective and the patient is on a high-potency FGA medication, try switching to a lower-potency antipsychotic. If the above is not possible, suggest treatment with propranolol (if there is no contraindication) at 10 mg twice d...
What strategies do you have for obtaining collateral information about ADHD symptoms when a child is homeschooled or in virtual school?
This is definitely a challenge that I've encountered more frequently since 2020! I first found out more about the virtual school program. Some programs do have students meet with a teacher virtually on a regular basis, or have a hybrid component where students go in person for some classes. Basicall...
How do you approach early interventions to reduce the risk of developing post-traumatic stress disorder following a traumatic event?
When I was at the Yale Child Study Center, we developed an early intervention (secondary prevention) called the Child and Family Traumatic Stress Intervention (CFTSI), which decreased PTSD by 63% in the RCT. You can search for it and request training. On the pharmacologic side, it has been shown tha...
How do you approach patients using off-label GLP-1 agonists for alcohol or opioid cravings?
More often than not, the use of GLP-1 agonist treatment for alcohol or opiate cravings is started by patients themselves. They may resort to a boutique-type medical practice to get the medications. Our approach in that situation is to advise them that there is very limited data for use with 1 study ...
How do you decide when to initiate medical workup (e.g., thyroid, B12, infection) in a geriatric patient experiencing new onset or worsening low mood?
It is important to distinguish between low mood, which can occur from a host of environmental stressors, and frank depression, and there are 3 ways to look at either in the older patient: Early onset depression in someone now older, and the patient feels the present one is exactly the same as previo...