A physician of How I evaluate
I start every new evaluation with a full hour, and I use it. Before we talk about medication I want to know what the problem is costing you: the job you are struggling to hold, the mornings you cannot get out of bed, the relationship that is wearing thin. Symptoms matter, but function is what we are trying to restore, so I write down two or three concrete functional goals at the first visit and we measure against them from then on.
Alongside the history I use structured instruments, the PHQ-9 for depression and the GAD-7 for anxiety among them, and I ask about sleep, alcohol, caffeine, stimulants, thyroid disease and the medications other physicians have prescribed. A surprising number of referrals for treatment-resistant depression turn out to be something else: untreated sleep apnea, a bipolar spectrum illness that was never recognized, a medical cause nobody checked. I would rather spend the first hour ruling those out than spend six months treating the wrong diagnosis.
How I decide on medication
I prescribe when the evidence says medication is likely to help and when the patient, having heard the trade-offs, wants it. For a first episode of moderate depression or anxiety, that usually means a single SSRI or SNRI at an adequate dose for an adequate time, which is eight to twelve weeks, not three. Most medication failures I see are trials that were stopped too early or never reached a therapeutic dose.
When a first medication does not work, I do not simply reach for the next one on the list. I check adherence and side effects, I reconsider the diagnosis, and then I choose between switching, augmenting and adding psychotherapy based on the specific pattern of what did and did not improve. I tell patients what I am expecting to happen and by when, so that we both know whether a trial has failed rather than arguing about it.
I am conservative with benzodiazepines and stimulants, not because they have no place but because their place is narrow and their long-term costs are real. If I decline to prescribe something, I will explain why and offer an alternative.
How I think about therapy
Medication changes the biology; therapy changes what you do with it. For anxiety disorders in particular, cognitive behavioral therapy has an evidence base that rivals medication, and the combination outperforms either alone for many patients. I do not provide weekly psychotherapy myself, but I will tell you plainly when I think you need it, and the practice has therapists I can connect you with. I keep in touch with the therapist when you give me permission, because two clinicians working from different pictures of the same patient is a recipe for drift.
Interventional options
I lead the Deep TMS and Spravato programs at Stedfast Psychiatry, and I think about both earlier than many psychiatrists do. The STAR*D trial showed that the odds of remission fall with each failed antidepressant, and that after two adequate trials the next medication offers a modest return. That is the point at which I raise FDA-cleared Deep TMS, delivered at our Palm Beach Gardens center, and FDA-approved Spravato, which we administer under monitoring in the office. Neither is a last resort in my practice. They are tools with defined indications, and I will tell you where you stand against those indications rather than letting the decision drift.
I also know their limits. Deep TMS asks for 36 sessions over several months. Spravato requires two hours of observation after each dose and someone to drive you home. Both work for many patients and not for all. I will give you the response and remission rates from the trials, not a sales pitch.
What a follow-up looks like
Follow-ups are shorter and more frequent early in treatment, usually every two to four weeks until you are stable, then every one to three months. Each one begins with the same scores we took at the first visit and the functional goals we wrote down. If the numbers have not moved by the time I said they should, we change something at that visit. I do not renew a plan that is not working just because the appointment was on the calendar.
What I expect from patients
Honesty about what you are actually taking, including alcohol and anything bought without a prescription. Completing the rating scales before each visit. Telling me about side effects before you stop a medication on your own, because stopping abruptly causes problems I can usually help you avoid. And patience with the timeline I give you, which I will have explained in advance.
In return you can expect me to explain every decision, to tell you the evidence behind it, and to say so when I do not know.
Telehealth
I see patients by secure video across Florida. Telehealth works well for medication follow-ups and for anxiety and depression care generally. It does not work for everything: Deep TMS and Spravato require in-person visits, some evaluations are better done in the room, and I will ask you to come in when I think it matters. New patients can start by video if they prefer, as long as they are physically in Florida at the time of the visit.
If you are in crisis, call or text 988 or go to the nearest emergency room.