Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients regarding risks of cannabis use?
I am in agreement with Dr. @Dr. First Last. Both alcohol and cannabis are legal in most states now, and use is not uncommon in patients of all ages. My stance: Rare/occasional use... probably not going to cause much problem (physical or mental) unless you are addiction prone, or if there is any fami...
What are your considerations when treating insomnia in perimenopausal patients with comorbid anxiety or mood disorders?
I would choose to first try nortriptyline for such a patient. While being an older medication, I find it to be excellent. It is generally well tolerated and helps with insomnia, anxiety, and depression. It isn’t studied much, because it’s been generic for so long, and oftentimes, clinicians are unfo...
How do you approach antidepressant selection in patients with prominent fatigue but minimal mood symptoms?
I'm puzzled by this question, in that prominent fatigue without mood symptoms warrants a proper medical workup before assuming it is depression related. This would include a full set of labs, a sleep study to rule out sleep apnea or other causes of fatigue (and with daytime MSLT to rule out narcolep...
How do you support recovery in patients with MDD and AUD experiencing anhedonia and social isolation after losing alcohol-based social networks?
Although the availability of possible sources of social contact varies with age and setting, I usually ask about prior personal experience, particularly in religious organizations that involve social connection. Anhedonia is a matter of degree. It may be possible to get people to chart during the da...
What are the best initial treatments for unprescribed stimulant use in patients who are using stimulants periodically to improve occupational or academic functioning?
This is such an important and increasingly common question—and I’m not sure there's a single "best" initial treatment, but I’ll share how I approach it. First, I think it’s worth pausing on the assumption that someone who uses unprescribed stimulants for performance must have a focus problem or ADHD...
What’s your approach when a parent declines mental health services for their child due to cultural stigma or fear of CPS involvement?
This is always challenging, but the most important part is establishing a relationship of trust with the family, exploring their concerns and reservations regarding the recommended treatment, and also emphasizing the rationale and risks associated with not following treatment recommendations. CPS ca...
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...
How do you counsel patients and caregivers on dietary interventions for autism?
Whole foods diet, e.g., Whole30.com. All the information on that website is free. I will remove common food allergens. Remove all synthetic food dyes. 100% organic to protect the microbiome. Consider a spore-based probiotic for a few months.
When do you decide to switch stimulants vs. continuing to maximize dosage in ADHD treatment?
I definitely agree with Dr. @Dr. First Last about the core concept that this question appears to be asking - "When do you know if a stimulant is just not working for your patients symptoms, and/or when do you decide to change to a different stimulant?" Before answering the second part of this core q...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...