Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage withdrawal symptoms of SNRIs that exist even after slow taper?
Another strategy is to do a custom ultra-slow taper. You need to be able to trust the patient can follow through with the instructions. The venlafaxine XR capsule can be opened and sprinkled on food. You can decrease by very small amounts (<1 mg) by taking fewer and fewer beads over time (e.g., remo...
How do you cross-taper when switching from an SSRI to an SNRI?
It depends on which SSRI and SNRI are involved, as well as the dose of the SSRI. If switching from a low-dose SSRI, a cross-taper is not typically necessary given that both SSRIs and SNRIs increase serotonergic transmission and therefore a withdrawal effect will likely not be felt. If switching from...
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
When do you recommend acamprosate vs. naltrexone for medication-assisted therapy in alcohol use disorder?
I would suggest starting naltrexone for about a week and then transitioning to Vivitrol shots. Continue Vivitrol every four weeks as a maintenance treatment regardless of drinking levels. I would also recommend at the start of the treatment, getting some baseline labs to include a CBC, comprehensive...
In what cases do you recommend the use of gabapentin for off-label use in alcohol use disorder?
Often patients with AUD who decline first-line medication treatments, i.e., naltrexone or acamprosate, are more open to gabapentin when advised of its potential benefits for anxiety, mood, and sleep, as these are common issues that drive alcohol cravings and use. Flexible dose titrations starting wi...
What medications have you found to be effective for childhood-onset speech fluency disorder?
I believe that speech therapy is needed for this and not a problem that medications will help, or I would not recommend it for this condition. There are no FDA-approved medications.
How do you differentiate cognitive inflexibility due to autism from similar patterns in anxiety or OCD?
This is a nuanced and often confused area. In ASD, behavioral rigidity is typically automatic and ego-syntonic. While often distressing to others, an individual with ASD is not bothered by their inflexible thinking. In OCD and other anxiety disorders, compulsive behaviors or mental acts are more vol...
What medications have you found helpful in the treatment of stimulant use disorder?
There are no accepted pharmacotherapies for stimulant use disorder and the most important component of an integrated pharmacopsychosocial approach is the psychosocial part. Two medications that are probably the best in my hands (but certainly not evidence-based) are ADHD medications and mood-stabili...
How do you manage obsessive-compulsive disorder refractory to high-dose SSRI and cognitive behavioral therapy?
In general, I follow a decision tree based on refractoriness and comorbid conditions. Let us first assume that we have already provided an adequate dose of an SSRI for an adequate duration of 12 weeks. I use the following doses as general targets for SSRI treatment: Fluoxetine 80 mg/d Escitalopram ...
How do you approach stimulant-related insomnia for pediatric patients who are otherwise good responses to low-dose stimulant treatment for ADHD?
Clonidine 0.1 mg qhs is my first choice if I have to use something. However, first consider decreasing the stimulant dose or changing to a shorter-acting stimulant. Or go with Strattera so you can use a lower dose of stimulant. Or go with guanfacine so you can also use a lower dose of stimulant. Sti...