Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you recommend acamprosate vs. naltrexone for medication-assisted therapy in alcohol use disorder?
I would suggest starting naltrexone for about a week and then transitioning to Vivitrol shots. Continue Vivitrol every four weeks as a maintenance treatment regardless of drinking levels. I would also recommend at the start of the treatment, getting some baseline labs to include a CBC, comprehensive...
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...
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?
There are no accepted pharmacotherapies for stimulant use disorder and the most important component of an integrated pharmacopsychosocial approach is the psychosocial part. Two medications that are probably the best in my hands (but certainly not evidence-based) are ADHD medications and mood-stabili...
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 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...