Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
What alternative ADHD medications would you consider in a child with a complex cardiac history unresponsive to guanfacine?
Choosing another medication to treat ADHD in a child with a complex cardiac history who has already failed guanfacine is not a straightforward task. To make this decision, one would need to understand which symptoms of ADHD are causing the most functional impairment (inattention, hyperactivity, both...
How do you handle requests for disability or accommodations in clinical settings with limited administrative support or documentation time?
If you are working in private practice without ancillary support like case managers, I highly recommend having patients make appointments while you complete the forms for them. Clinically, if paperwork is being sprung on you out of nowhere, an evaluation is necessary anyways to determine if it's app...
When, if ever, do you consider using dronabinol to treat agitation in dementia?
Dronabinol should be considered for treating agitation in dementia when non-pharmacological interventions and standard pharmacological options, such as antidepressants or antipsychotics, have failed or are poorly tolerated. I have a handful of patients in my practice who fit that scenario and benefi...
How do you address a patient who may be getting Adderall from another non-prescribed source while you're treating them with Adderall for ADHD?
If I find out a patient is abusing/misusing Adderall from another source, even having it prescribed by another licensed provider at the same time they are having it prescribed by me, I immediately stop prescribing any dea controlled medication (I once had a patient tell me “I’m selling the meds from...
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 approach mood stabilizer initiation in an older adult with a new diagnosis of bipolar disorder?
First off, it is going to depend on the age of the patient. There are different mood stabilizers and depending on which one to pick, the patient will need to have labs done, as well as how responsible the patient is. If we are talking lithium, we want to make sure GFR is okay, as it tends to decline...