Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When and how do you approach prescribing viloxazine for patients with ADHD?
Viloxazine is a potent inhibitor of CYP1A2 and a weak inhibitor of CYP2D6 and CYP3A4. It should never be used within 2 weeks of an MAOI. I use significant caution when prescribing it with other psychotropic medications, as it can raise the levels of multiple other agents, including aripiprazole, dex...
How do you address parental concern about children becoming addicted to stimulants for ADHD treatment?
In the current environment with an epidemic of fatalities from opiates, the question about addiction to stimulants is timely. I present the parents with the data, which shows that controlled dosing leads to a steady level of dopamine and does not produce a high. Further, studies find that treated ki...
How do you approach treatment of obsessive behavior in patients with autism spectrum disorder?
This is such a rich topic, which comes up frequently in my practice, and the diagnostic distinction has real treatment implications. I think it’s helpful to start with some definitions, in which the key is function, not topography. OCD obsessions/compulsions: ego-dystonic, anxiety-driven, patient re...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
What medications do you consider for patients with premenstrual dysphoric disorder who do not respond to SSRIs?
In addition to emphasizing how helpful self-care can be (a little more sleep than usual, exercise, healthy nutrition, including limiting carbs, mindfulness), calcium carbonate 600 mg BID, judicious benzodiazepines, and gabapentin 100-300 mg hs can be helpful. Continuous OCPs can also be very useful....
How do you counsel patients about the risks and benefits of mood stabilizers (e.g., lithium, lamotrigine) during pregnancy?
Great question! The risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and discontinuation of medications increases the risk of relapse during pregnancy and postpartum. The majority of women who stop mood stabilizers for p...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
How do you manage acute agitation or psychosis in patients who are already taking aripiprazole (oral or long-acting injectable)?
Episodes of acute agitation are considered a psychiatric emergency, and considering treatment with dual antipsychotics (which will only be temporary) should have a lower threshold of consideration. Dual antipsychotic treatment is controversial, but there are promising results as well however (Ortiz-...
How do you formulate and diagnose patients with chronic psychosis that developed after methamphetamine use but persists after cessation of use?
It may ultimately become schizophrenia that’s been unmasked by the stimulant use. I believe you need six months or maybe three months for a schizophreniform diagnosis, and then after that, it becomes schizophrenia if it meets all the other criteria. I have to check the DSM on the timeline.
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Clinical ...