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Practice Details

What conditions do you treat?

In theory, any mental health complaint. That being said, a solo telepsychiatry practice is better equipped to handle some conditions more than others. Also, I have high standards of evidence, and refuse to throw medications at problems that will likely not benefit from them. You might hope that all doctors would do so, but all the incentives in medicine cut against this. I recommend Atul Gawande’s popular press article on this (https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande). The main failure mode of modern medicine is that doctors feel the need to “do something” even when there’s no reason to believe that the risks of intervention outweigh the benefits. This should not be misinterpreted to mean that I am overly cautious about using psychiatric medications when indicated, just that I understand them to be tools, as invaluable for one job as they may be useless or even harmful for the next. With the caveat that nothing below is medical advice, or a promise for a particular medication to be prescribed to you, let me summarize my main treatment approach for every common chief complaint:

Depression: The notion that depression is inherently pathological is an impoverished view of the human condition. Our griefs and our pains make us who we are. “Despair is the price one pays for self-awareness. Look deeply into life, and you’ll always find despair.” (Yalom) Reducing human emotions to serotonin and neuron voltage channels is both wrong and harmful. We all must learn to adapt to the limitations and absurdities of human life. This usually involves either finding a faith in God or developing a philosophical framework to cope with our mortality. Kierkegaard said we will either find peace in the pain of resignation, or we will find joy in the hope of the absurd. That is, we will either cope with the idea that we are apes on a rock in space, with no afterlife or any transcendent meaning, or we will, as he preferred, find God and work out our faith with fear and trembling. Either process will involve angst.

Having said that, there is no doubt that our biology impacts our mood, and that medications can have a positive impact on our biology. Some depressed people are really anemic, and can be cured with an iron supplement. Some depressed people have thyroid problems that can also be fixed with a simple oral medication. In principle, there is nothing wrong with the hypothesis that some people are depressed because their neurons do not release enough serotonin, and a simple SSRI can fix this organic problem. Unfortunately, humans are diverse and these straightforward stories only describe a small minority of cases that we now label “Major Depressive Disorder.” A depressed person may or may not benefit from any given medication, given our primitive understanding of what, if anything, is “wrong” in the depressed brain. Each medication is like pulling the arm of a different slot machine, of an unknown payout schedule.

The good news, and the reason I am willing to provide pharmaceutical treatment for depression, is that many of our medications remain untried even in “treatment resistant” depression cases. Most doctors are far too concerned about safety, which they can be held liable for, and they forget to worry about efficacy, about which they have no skin in the game. A patient being tried on their 4th SSRI is like a person pulling the same lever on a losing slot machine, while an entire section of the casino remains dusty and unused, and perhaps “due for” a win. Some medications that I may try for depression include imipramine (or other tricyclic antidepressants), Seroquel (quetiapine), alprazolam (Xanax), magnesium glycinate, Adderall, lithium, tranylcypromine (or other MAOIs), pramipexole, zinc, modafinil or even Suboxone / buprenorphine.

Anxiety: The management of anxiety, along with panic attacks and OCD, is where psychiatry really shines. We have an armamentarium of barbituates and benzodiazepines, along with other agents, that are truly effective. While therapy and coping skills are helpful for anxiety, the modern world lays such a cognitive burden on most people that even the well adjusted among us often have persistent psychic tension. I believe that anxiety is fundamentally maladaptive in a way that sadness is not. We react to business deadlines and bank statements as though they were lions or escaping prey. In the absence of a physical threat, anxiety is often a pure “bug” in the human software, whereas depression is an unpleasant but necessary “feature” of our design. I should warn you that most effective treatments for anxiety run the risk of producing dependence, and if “being dependent” on a medication is a deal-breaker for you there will be limited options available, as even non sedative options like venlafaxine or paroxetine have a discontinuation effect (similar to withdrawal, in layman’s terms).

ADHD / inattention: Human beings probably weren’t meant to sit down and focus on a specific task for multiple hours in a row, and insofar as ADHD is fundamentally a imbalance between available mental focus and environmental need to focus, modern society has created a massive ADHD epidemic that is generally undertreated. I actually don’t like to treat uncomplicated ADHD, as it is a waste of my subspecialist training, but I am certainly willing to do so. The various amphetamine formulations are the pillar of any reasonable treatment of ADHD, with all other medications aside from methylphenidate (and maybe modafinil) relegated to an auxiliary role only. I like treating more complicated cases, using second and third line agents, and my ideal ADHD patient would be on modafinil or memantine or desipramine in addition to a stimulant. However, I know some people with ADHD struggle to find someone willing to prescribe stimulants, so I am willing to see uncomplicated stimulant refills if no other doctor is available.

Bipolar Disorder: Mood stabilization is one of the great success stories of modern psychopharmacology, although unfortunately one still beset by controversy about the ideal treatment approach for “maintenance” medications (that is, the best way to prevent mood episodes during the time that the patient is not acutely depressed or manic). I am happy to see patients with bipolar disorder or mood instability complaints.

Please Just Continue My Meds: Psychiatric medications are highly variable in terms of individual response, and this makes life difficult for people on the tail ends of the normal distribution. Doctors are trained to treat the average patient, and our tendency to discount every data point more than one standard deviation from the mean leads to poor outcomes for people who are outliers. If you are doing well on a given medication combination I will likely continue it no matter what it is.

Substance Abuse: Most serious substance abuse disorders require a team treatment approach and intensive therapy commitments. Medications are sometimes helpful, but there is no advanced art of psychopharmacology, no second or third line polypharmacy regimens, just a need to commit to individual or group therapy and make other psychosocial changes. I am not really equipped to treat substance use disorders over telepsych and feel I have little to offer beyond the standard Medication Assisted Treatment (MAT) or anti-craving medications that anyone could prescribe.

Eating Disorders: Most serious eating disorders require a team treatment approach and intensive therapy commitments. Medications are sometimes helpful, but there is no advanced art of psychopharmacology, no second or third line polypharmacy regimens, just a need to commit to individual or group therapy and make other psychosocial changes. I am not really equipped to treat eating disorders over telepsych and feel I have little to offer beyond the few standard FDA approved medications for binge eating. Note that the seemingly obvious strategy of prescribing medications that cause weight gain, like olanzapine, to anorexia nervosa patients simply does not work.

Schizophrenia or psychosis: Most serious schizophrenia spectrum or other psychotic disorders require a team treatment approach (such as an ACT team) and intensive therapy commitments and community resources, and often access to long acting injectable medications. I am not really equipped to treat psychosis over telepsych and feel I have little to offer compared to a community mental health clinic. A good case manager is the key to handling these complex patients, and there is very little a private practice psychiatrist can do to address housing and financial issues, or lack of insight and medication non-adherence.

Do you see children?

I am trained in Child and Adolescent Psychiatry, with my board exam scheduled in the fall of 2021. That said, I believe child psychiatry is largely a failed project. With the noteworthy exception of ADHD, intellectual disabilities and other developmental disorders, I would never recommend that a child I cared about go to see a child psychiatrist. Of course good child psychiatrists exist, and I know many of them, but the field as a whole is far too nonchalant about prescribing powerful psychotropic medications to children with little evidence of efficacy and a clear risk of harm. Unruly or misbehaving children and teens are falsely labeled as bipolar to justify putting them on medications that rarely change their behavior but often cause significant side effects, including weight gain that as is in many cases permanent. The normal anxiety and angst of the teen years is pathologized and medicated without benefit, and without a serious understanding of direct risks, to say nothing of second order effects. The SSRI medications, treated as though benign by too many physicians, can cause an impulsive or hypomanic-like state, and I’ve seen a case of a young man who will be haunted his entire life by the legal consequences of a fistfight he started at school, which was out of character for him and likely due to fluoxetine (Prozac) related impulsivity.

You may wonder who I think I am, a young psychiatrist from Toledo, Ohio, to be such a sharp critic of my field. Everything I am saying is well known to my colleagues, on an academic level, but most doctors don’t appreciate placebo or regression to the mean effects, and because most mental health conditions are either self-limited or episodic in nature, and most serious side effects are either rare or hard to identify as medication reactions, over the course of a career a doctor becomes more and more confident in their own practices, in a process independent of whether their particular treatments are helping their patients. This is the tragedy of medicine for centuries: if I apply leeches to a patient and they recover, that proves that leeches work, and if I apply leeches and the patient dies, that just proves how severe the underlying condition was. Treatments cannot fail, only be failed. This is why every culture has a shamanic or other traditional healing profession full of strange or even harmful practices.

Google “Paxil lawsuit teenagers” and “Risperdal lawsuit teenagers” for a sense of how dramatically the child and adolescent psychiatry project can fail. The paroxetine trial “Study 329” is so infamous it has its own Wikipedia page. These were not small failures, and they involved people very high up on the academic ladder, including Harvard faculty. Unfortunately, these major scandals had little impact on actual clinical practice. A British Medical Journal (BMJ) op ed a few years after the lawsuits was appropriately titled “No correction, no retraction, no apology, no comment: paroxetine trial reanalysis raises questions about institutional responsibility.” [See https://www.bmj.com/content/351/bmj.h4629 ]

Even setting aside major corruption / data hiding scandals, the mundane evidence base for many child and adolescent medications is just not impressive. Consider the simple example of using Prozac (fluoxetine) for depression in teenagers. The 2007 study “Treatment for Adolescents With Depression Study” by Dr March at Duke University is a landmark paper, studying both Prozac alone, therapy alone and their combination and famously concluding: “Taking benefits and harms into account, combined treatment [Prozac plus therapy] appears superior to either monotherapy as a treatment for major depression in adolescents.”

How could an evidence based psychiatrist ignore such results? It seems so clear that I have heard it argued that prescribing Prozac is standard of care, meaning that a doctor could face serious liability if they failed to prescribe Prozac to a depressed teen. But let’s look at the numbers in more detail. The study used a quantified measure of depression called the CDRS-R (Children’s Depression Rating Scale-Revised), which measures depression symptoms on a 17 to 113 scale, with 17 being minimal depression. The average depression score of the patients in the study was 60 at the beginning, and at week 12 it had fallen to 33.6 in the combined treatment group. This sounds good, but therapy alone reduced the score to 40.3, and I wouldn’t personally want a teenager I cared about being exposed to the risks of Prozac for a less than 7 point difference on a scale that goes up to 113. By week 24 the therapy alone group and the combined treatment group were indistinguishable at 31.2 and 29.9 respectively. Also, the CDRS-R includes questions about physical symptoms like appetite and fatigue / sleep quality, and it is plausible that any benefits that Prozac has are due to appetite or energy level related effects rather than to mood benefits per se. Have a look at the list of side effects on Prozac’s drug label, including the black box warning, and tell me whether you would trade them for these temporary benefits.

I am happy to treat teenagers, but most complaints would be better addressed by a good therapist. Psychiatric medications have the most to offer in cases involving anxiety spectrum and ADHD / learning disorders.

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