Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you decide who to rechallenge clozapine after it was discontinued for a neutropenic episode?
The clozapine rechallenge of the patient previously treated with clozapine but having it discontinued due to clozapine induced neutropenia or absolute neutropenia now has a sizable evidence-based literature suggesting that it can be done safely and successfully. Selecting patients with previous disc...
Would you consider starting a stimulant in an inpatient or crisis setting for patients whose severe behavioral issues are due to untreated ADHD?
For an adult without an established diagnosis, I don't believe initiating stimulant therapy during an acute inpatient stay is appropriate. ADHD is a legitimate neurodevelopmental condition, but it shouldn't be used as a catch-all explanation for behavioral disruptions in a hospital setting. Starting...
How do you approach the psychiatric evaluation and disposition of adolescents presenting after an overdose that was not a suicide attempt?
There is much to learn. If previous history of SIB, OD-likely admit. Known psychiatric disorder - perhaps IOP/PHP. What triggered the OD? For instance, breakup, argument - perhaps IOP/PHP. Recent traumatic event - perhaps IOP/PHP Family functioning: Is the family supportive, dismissive, chaotic, or...
How do you approach effectively diagnosing ADHD within the time constraints of outpatient practice?
I approach diagnosing ADHD by asking a series of questions. Questions 1 - 3 are pretty straightforward, the others can be more nuanced depending on the case: 1) Do enough ADHD symptoms apply (6 symptoms in 1 category for kids, 5 symptoms in adults)? I ask about specific symptoms and encourage the pa...
What non-medication interventions or resources do you provide parents of children with oppositional behaviors?
Behavioral therapies, including parent management training, are the most evidence-based treatments. For children under 7, a well-respected intervention is PCIT (Parent-Child Interaction Therapy). There are also the Triple-P Positive Parenting Program, Incredible Years, and Coping Power Program. The ...
How do you formulate and diagnose patients with chronic psychosis that developed after methamphetamine use but persists after cessation of use?
It may ultimately become schizophrenia that’s been unmasked by the stimulant use. I believe you need six months or maybe three months for a schizophreniform diagnosis, and then after that, it becomes schizophrenia if it meets all the other criteria. I have to check the DSM on the timeline.
Do you avoid triptans in patients on SSRIs due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
When do you start pharmacotherapy for PTSD in children?
The only medications to be used are to address sleep disturbance and nightmares. Poor sleep has been shown to increase PTSS. So prazosin and, on occasion, clonidine should be used. And they should be used as early as possible. SSRIs are generally not that effective and should only be considered if t...
Do you include a specific risk assessment in your outpatient clinic notes?
I typically include a risk assessment in my outpatient notes. I address the risk of violence and self-harm. I try to approach violence and suicide risk in a manner analogous to the primary care approach to cardiovascular risk: continuous risk reduction. In most outpatients, there is no imminent risk...
How do you address/manage the recreational use of dextromethorphan (sometimes called "robo-tripping") that has risen to the level of use disorder?
This problem of "robo-tripping" has become an increasingly observed clinical issue, namely the misuse of dextromethorphan with cough medication (Robitussin). This is often in conjunction with alcohol misuse. We recently published a case report in The American Journal of Drug and Alcohol Abuse (Ledwo...