Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What adjustments do you make for ADHD medications during puberty?
I do not make anticipatory changes specifically related to puberty, as each individual is unique. Rather, I regularly meet with parents and tweens during medication reviews to discuss what target symptoms we are treating and how the medication is helping. I provide general guidance that as kids grow...
What is your preferred antipsychotic for augmenting treatment of major depressive disorder?
Over the years, the overpromotion of antipsychotics as augmenting agents was largely initiated by experts with industry ties, often underemphasizing their significant neurological and metabolic side-effect burden. Today, the trend I see is that their primary use has shifted toward primary care physi...
How often do you repeat a formal suicide risk screen at follow-up visits?
Patient safety and suicide, in my practice, is always my number one priority. However, that does not translate into plastering every patient encounter with a formal suicide risk assessment. Once I come to know my patient's history, stability, and life situation, for most ongoing patients in my outpa...
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
What are the main confounding variables you ask about and monitor in patients with depression and anxiety?
It is critical to rule out bipolarity, which is often missed. The other major issue is to investigate the possibility of medical comorbidities, which may be causing or contributing to the mood disorder and anxiety. Check labs and other issues, including imaging. Review all past records you can find....
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
In your clinical experience, has T3 augmentation been effective for treatment-resistant depression?
I have used T3 as Cytomel for this purpose, after hearing Dr. Lee Cohen describe his research on the subject. However, over time I have found that simply using thyroxine, which I think is a mix of T3 and T4, for augmentation works about as well. The response, as I recall, to either one has been mean...
After a medication overdose, do you restart that same medication if the patient reports it had been effective?
This is a good question, because intuitively it doesn't make sense to resume it (also, you would look really bad if your patient OD'd on the same medication that you prescribed). Truth is, patients can OD on anything. Generally, in my experience, people OD on meds that make them sleepy because they ...