Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What non-pharmacologic interventions or resources do you recommend for parents of patients with severe anxiety?
It depends on the type of anxiety, but a few things that I have found helpful over the years... Education about the physiology of anxiety, amygdala info, and the body’s response/cycle to anxiety is key. Help the patient understand that the goal cannot be to “get rid of” all anxiety; trying to contr...
For a hospitalized patient with depression and suicidal ideation who is refusing food, water, and medication, do you consider forced medication?
A depressed and acutely suicidal patient should be committed and made to take medication and food. That is the whole point of commitment laws. We are not told what other medical issues might be going on, which could affect the decision. For instance, if they are terminally ill, then what I am saying...
How do you transition patients between different long-acting injectable antipsychotics?
When it is time for the next dose of LAI #1, administer LAI #2 instead. Use an equivalent dose to produce equivalent dopamine receptor activity. To determine the equivalent dose, consider the maximum recommended dose of #1 to be equivalent to the maximum recommended dose of #2. With all the sophisti...
What interventions do you recommend for preschool-aged children exposed to severe trauma (ex. sexual assault) but not displaying any observable signs of PTSD?
I would be curious as to when the "assault" occurred in relation to the child being evaluated? When one says that there are no PTSD symptoms, are they using the under-6 criteria? PTSD symptoms are not the only response to an assault; children are more likely to demonstrate distress behaviorally, su...
What has your experience been counseling on and prescribing Cobenfy?
I have good results from it - but just like with any medication in psychiatry, there isn't "one size fits all". There is data that shows a more rapid titration to the highest dose (125-30) works the best. It goes 2 days with 50-20, then 5 days with 100-20, then transitions to 125-30. You have to mak...
When do you use guanfacine instead of stimulant medication for adults with ADHD?
The premise that guanfacine could simply replace stimulants due to its non-controlled status misrepresents the complexity of adult ADHD. ADHD is a heterogeneous neurodevelopmental disorder, and treatment must address distinct, often overlapping, neurobiological pathways. Stimulants and non-stimulant...
When do you decide to stop prescribing controlled substances in patients who are also using cannabis?
The only controlled substance I prescribe is stimulants. If patients are using cannabis more than at bedtime or recreationally on the weekends, I will wean them off stimulants, as their effects will be limited by the significant cannabis use. I will do the same with alcohol.
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
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 taper antipsychotics being used for autism spectrum disorder if behaviors have been stable?
With sustained stabilization of behaviors - i.e., stable for 1 year - I start to taper very slowly, depending on how long they have been on a particular medication. This decision also depends on how severe the behaviors were prior to starting the antipsychotics, and whether or not they have any SEs....