Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
When do you refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?
For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...
How do you address parental concern about children becoming addicted to stimulants for ADHD treatment?
In the current environment with an epidemic of fatalities from opiates, the question about addiction to stimulants is timely. I present the parents with the data, which shows that controlled dosing leads to a steady level of dopamine and does not produce a high. Further, studies find that treated ki...
How do you approach managing perioperative anxiety in Mohs patients?
Great question. Music, stress balls, having your team engage in conversations with the patient, and other distraction techniques are helpful. Some patients may need medications such as Halcion to help with anxiety but this should be given after the patient signs consent and has a verified driver aft...
How do you determine the appropriate level of care for an adolescent with a substance use disorder?
This is a very timely question, as the use of substances in childhood and adolescence is an often-overlooked issue. A recent survey of high schoolers revealed that 11% of 8th graders, 21.5% of 10th graders, and 32.6% of 12th graders have engaged in substance use in the past month. (Miech et al, NIDA...
How do you manage cannabinoids (ex: medicinal, recreational) in dermatology?
I use dronabinol 2.5-10 mg qd-tid for recalcitrant pruritus (typically neuropathic or CPUO as an adjunct treatment). Very cheap using GoodRx if not covered by insurance. It’s a scheduled drug, so it requires DEA, but you don’t need a “medical marijuana license,” and it’s very well tolerated outside ...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Clinical ...
When, if ever, do you consider increasing Adderall above the FDA-approved maximum daily dose of 40 mg for adult patients?
I titrate the dose based on the patient's needs, functioning, and tolerances.
When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?
There are so many factors that play into my decision-making; it truly is a case-by-case basis. In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first mon...