Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How do you treat decreased libido from SSRIs?
Serotonin-1 agonism will revert it in about 60% of cases. You have a choice of adding buspirone at about 30 mg bid or going to vilazodone which has already an SR1 agonism. Some bupropion, not clearly understood at about 300 mg can also do it. Or if possible, use vilazodone, bupropion, or mirtazapine...
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...
What is your approach to addressing dementia-related agitation for patients living at home with family?
There is absolutely no simple way to answer that question. Even when the family is providing a very calm and nonconfrontational environment, avoiding any possible way of causing the agitation, it is virtually impossible to predict when and why a person with dementia would become agitated, angry, unp...
How do you discuss sexual and gender identity-related anxiety with teens when family dynamics are rigid or culturally conservative?
First and foremost is safety. Never put children or teens in danger by hostile family or neighbors. In other words, don’t out them or encourage them to out themselves if they don’t feel safe doing so. You never know how people around them might react. That means be careful with your documentation, t...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
Do you recommend GLP-1s for antispychotic induced weight gain?
When antipsychotic induced weight gain causes obesity (BMI>30), I recommend a trial of tirzepatide or semaglutide. I have observed the typical benefits in my patients, including decreases in lipids, lower HgbA1c, lower BPs, improved mobility, and loss of 10-20% of body weight over 6 months. Expense ...
How do you address sleep disturbance related to cessation of daily cannabis use?
First of all, I think challenges with sleep and daily cannabis use are underappreciated. We often hear that individuals use cannabis to help them relax and fall asleep. I'm going to highlight findings from a recent review by Kaul et al., PMID 33580483. Similar to what our patients report, acute or s...
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...