Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to using clonidine for anxiety?
It definitely helps in patients with autism with anxiety, 0.1 mg po bid but not my first line because of the blood pressure drop or rebound. I don’t use it as a first line for anxiety, as I haven’t seen any improvement if it’s just used for anxiety. Strattera has some evidence for anxiety in autism,...
What is your experience in the efficacy of vortioxetine for treating anxiety disorders?
Although vortioxetine (currently branded as Trintellix in the USA) is only FDA-approved for the treatment of Major Depressive Disorder, many of the SSRI medications can be used off-label for anxiety disorders, panic disorder, or OCD. Clinical studies often have mixed results, though. Because it has ...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
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 manage atomoxetine-related fatigue?
Fatigue is a common side effect of atomoxetine, especially during the early part of treatment. Fatigue associated with usage wanes over time for many users (one to three weeks usually; if it still persists for up to six weeks, fatigue is less likely to resolve on its own), but if not addressed, it c...
When do you consider using modafinil as an adjunctive treatment for depression?
While modafinil is off-label for depression, I frequently add it in if patients have persistent low-energy states despite other treatments, or if they can not tolerate bupropion. The biggest holdup in its use is often insurance barriers, which frequently prevent psychiatrists who are not sleep-certi...
How do you incorporate rating scales such as the PHQ-9 into your treatment of major depressive disorder?
My practice has evolved (more therapy now), but for 20+ years, I administered the PHQ-9 and the GAD-7 at every visit for every patient. During those years, everyone was on some form of medication, and it felt relevant to see how they were responding. Also, occasionally someone would have worse numbe...
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.
Which cognitive screening tools do you use when evaluating older adults with suspected dementia?
In keeping with Alexander Luria's (paraphrased) maxim that knowing what a patient gets wrong on cognitive screening is incomplete until you know why/how they erred, I'd say the tool used is less important than interpreting it. So, I don't worry too much about MMSE vs MoCA vs SLUMS (as long as the MM...