Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach when the child refuses to separate from parents during psychiatric evaluation?
Children sometimes refuse to separate from parents during a psychiatric evaluation. The simple answer to how I respond when this occurs is that I complete the interview with the parent(s) in the room. For preschoolers and many school-age children, a refusal to separate is not necessarily something t...
When do you consider using dual orexin receptor antagonists (DORAs) for the treatment of insomnia?
I only consider using any hypnotic in insomnia when the patient is getting only 5 hours or less of sleep. In those cases, I will sometimes try using DORAs. I am a sleep neurologist who sees patients with MCI/early dementia, and I have found these medications useful in this population of patients wit...
How do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
How do you approach treatment of obsessive behavior in patients with autism spectrum disorder?
This is such a rich topic, which comes up frequently in my practice, and the diagnostic distinction has real treatment implications. I think it’s helpful to start with some definitions, in which the key is function, not topography. OCD obsessions/compulsions: ego-dystonic, anxiety-driven, patient r...
What is the best way to support a pediatric oncology survivor with fears about 2nd neoplasm or relapse?
Many survivors of childhood cancer are managing ongoing post-traumatic stress, which can include the persistent concern for relapse or a second neoplasm. It is important to note that these are rational concerns - the risks of relapse or second malignancies are real and can give survivors a sense of ...
In the psychiatric ER, how do you address the issue of child/adolescent patients being left there by caregivers and becoming extended stay patients?
Unfortunately, then it becomes a matter of contacting the Department of Children's Services for intervention. However, that is often a slow and arduous road.
What is your diagnostic approach to patients presenting for ADHD concerns when you suspect untreated sleep apnea?
When discussing a potential ADHD diagnosis with my patients (of note, I only treat adults), I always discuss sleep patterns and sleep hygiene/CBT-I techniques (and recommend stopping any THC usage). I also refer patients with suspected sleep apnea for a sleep study. Some ADHD symptoms may solely be ...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
It is important that patients understand that fibromyalgia (FM) is a nociplastic (CNS-driven) pain condition, rather than primarily a peripheral musculoskeletal pain disorder. This provides a framework for linking the treatment of pain to that of sleep, fatigue, and mood. Patients then generally acc...
How do you approach ADHD treatment in patients with psychotic disorders who are now psychiatrically stable?
In my practice, I find that we often move too quickly to label ADHD in patients who are already struggling with a psychotic disorder. We seem to have forgotten the value of hierarchical diagnosis. In my view, psychotic disorders are global in nature; they impair the entire "stream" of a patient’s ex...