Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
For children under the age of 7 with ADHD who continue to have significant impairment with behavioral interventions, how do you decide between starting with a stimulant vs starting with an alpha agonist?
If the ADHD symptoms are still impairing despite being treated with behavioral interventions, pharmacotherapy is indicated. First-line pharmacotherapy for ADHD, even in elementary school-age or younger, is stimulants. I would treat them with stimulants unless there is a contraindication or a reason ...
How do you manage expectations around response time and durability of benefit in patients starting TMS?
Re: response time, I tell patients it is typical to not notice a lot of change in the first few weeks. Sometimes the clinician will observe brightening of affect earlier, but the patient him/herself often does not notice a whole lot. I use the 'going to the gym' analogy... a few days will not yield ...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...
How much flexibility do you allow around LAI (long acting injectable) antipsychotic injection dates to accommodate patient logistics?
Some patients need Invega Sustenna or Haldol every 3 weeks than 4…or if they need a higher dose but are paranoid about making any changes to the dose, then I try to have them come in every 3 instead of 4. Most insurances will cover the week early as long as you document why it is necessary. Unfortun...
What is your policy on prescribing controlled substances for patients you've only ever seen via telehealth?
The short answer is yes, but only with thorough clinical judgment. Too often, this debate gets pushed into two bad extremes. On one side, there is the blanket refusal to ever manage these medications virtually. On the other, there are virtual pill mills handing out prescriptions after a brief chat. ...
Have you found aripiprazole effective for treatment of psychosis and bipolar mania in practice?
While aripiprazole is approved for schizophrenia, I rarely use it for treating this condition. I do not find that it is effective enough to treat true psychotic symptoms when compared to almost all other SGAs. The same goes for bipolar mania. Instead, I tend to use aripiprazole for less severe cases...
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 do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
What approach to antipsychotics do you take with patients with primary thought disorder who are now geriatric?
The primary goal is to manage psychotic symptoms effectively while minimizing adverse effects, particularly those that may exacerbate cognitive impairment. Older adults may experience altered pharmacokinetics and pharmacodynamics, which can affect the efficacy and safety of antipsychotic medication...