Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
When do you use guanfacine instead of stimulant medication for adults with ADHD?
The premise that guanfacine could simply replace stimulants due to its non-controlled status misrepresents the complexity of adult ADHD. ADHD is a heterogeneous neurodevelopmental disorder, and treatment must address distinct, often overlapping, neurobiological pathways. Stimulants and non-stimulant...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
Would you consider starting a stimulant in an inpatient or crisis setting for patients whose severe behavioral issues are due to untreated ADHD?
For an adult without an established diagnosis, I don't believe initiating stimulant therapy during an acute inpatient stay is appropriate. ADHD is a legitimate neurodevelopmental condition, but it shouldn't be used as a catch-all explanation for behavioral disruptions in a hospital setting. Starting...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...
How do you approach continued prescribing of benzodiazepines when a patient who is already prescribed benzodiazepines reports concurrent illicit benzodiazepine use?
The management of patients who are prescribed benzodiazepines while concurrently using illicit benzodiazepines has become increasingly complex, particularly with the growing prevalence of synthetic benzodiazepine analogs within the illicit drug supply. Over the past decade, benzodiazepine prescribin...