Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you believe that buspirone is ineffective in patients who are previously treated with benzodiazepines?
I've found buspirone helpful for patients who don't want to taper their benzo unless they have another medication on board. I wait until the buspirone is at a stable dose (typically at least 15 mg BID) before tapering the benzo. I specifically avoid cross-tapering/titration as I worry they will asso...
When do you consider pharmacogenetic testing to assist in the selection of antipsychotic medications?
I don't usually consider it, as the evidence of clinical use isn't warranted unless the patient is on heroic dosing or has side effects to every medication. I usually will get plasma levels, and you can get plasma levels for pretty much any antipsychotic - it's a cheaper GeneSight. For example, if I...
Do you routinely prescribe an anticholinergic agent for EPS prophylaxis when starting or continuing antipsychotics or do you prefer to use it only as needed (PRN) if/when symptoms develop?
In the setting of starting long-term treatment with antipsychotics, anticholinergics should not be started automatically for prophylaxis of EPS. Anticholinergics have numerous significant side effects and often are continued indefinitely without ever clarifying if patients actually have EPS.Antichol...
What is your approach to using stimulants in treating children with both ADHD and autism?
I think the most important thing to understand is that stimulants can be helpful but perhaps less frequently helpful and often with more side effects than in children with ADHD only. So low expectations with awareness of and preparation for the potential of significant worsening is key. A few other ...
What strategies have you used to facilitate insurance approval of off-label psychiatric medications for children and adolescents?
Off-label (i.e., non-FDA-approved) medications are frequently used to treat psychiatric disorders in children and adolescents. One reason for this is that even FDA-approved medications that have been shown to be effective for child and adolescent psychiatric issues don't always work with every patie...
What is your treatment algorithm for excoriation disorder?
Neurotic excoriation, also known as skin-picking disorder or excoriation disorder, is part of the obsessive–compulsive spectrum. There is no FDA-approved pharmacological treatment. The gold standard, evidence-based therapy is Habit Reversal Therapy (HRT), a form of cognitive behavioral therapy that ...
Are there any potentially successful pharmacologic interventions (instead of CBT or behavioral interventions alone) for Schizoid personality disorder?
This is a tricky question to answer in part because people with schizoid personality disorder do not typically present for treatment. If they do, it is often due to co-morbid symptoms such as mood or anxiety symptoms. Therefore, these symptoms are often what are targeted pharmacologically. People wi...
What antidepressants are recommended for management of depression or anxiety in patients with spinal cord injuries?
Some general considerations first: Acute or chronic injury? Associated TBI? Is uncomplicated depression/anxiety the main feature or significant anger and agitation? Is some cognitive rehabilitation needed? Is some motor system rehabilitation needed? On a vent? Difficult to wean? Acute? Think about a...
When do you consider using multiple antipsychotic medications for chronic management of psychosis?
I've used multiple antipsychotics in three different types of scenarios: Finding a good benefit when you're in the middle of a cross-titration (e.g., cross-titrated olanzapine to ziprasidone due to sedation and weight gain; ziprasidone monotherapy was less effective, but adding back 5 mg olanzapine...
What medications have you had success with for patients with high functioning ASD and co-morbid ADHD and anxiety?
First, separating the problem and likely cause of the presenting symptoms or symptoms that you want to treat will be important for such patients. ASD kids will have stereotypic behaviors that may look like OCD or anxiety but may not be. Separating this is particularly important because regular presc...