Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
Would you use bupropion for mood disorder or substance use in an adult patient with previous childhood seizures that resolved?
The short answer is maybe, though it would not be my first choice. Bupropion is known to lower the seizure threshold, thus the basis of the question. Selection of an antidepressant depends on multiple factors including response to prior medications, side-effect profile, cost, presence of comorbid sy...
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...