Shrinks In Sneakers

SSRIs Aren’t The Villain or The Hero

I’ve narrowed my use of escitalopram, sertraline, and fluoxetine to specific situations. Not because they don’t work, but because they work best in the right context.

While SSRIs are often underwhelming for depression alone, they can be extremely effective when severe anxiety disorders are part of the picture.

In this short video, I explain: • When SSRIs actually help • Why anxiety changes medication choice • A real case where fluoxetine was the best option for comorbid bulimia

Not anti-medication. Just pro–thoughtful prescribing.

It’s Time to Bring MAOIs Back

Stop sleeping on MAOIs. These meds are not “scary,” “dangerous,” or “old school.” They’re some of the most effective antidepressants ever made — and modern guidelines show exactly how to use them safely.

✨ Why we should use them MORE: • They shine in true treatment-resistant depression • They work in melancholic + anxious presentations • They succeed where 5–7 previous meds failed • Patients often say it’s the first time they’ve felt like themselves again

✨ Why they’re SAFE (when used correctly): • Tyramine risk is low with today’s food standards • BP changes are predictable + manageable • Tons of augmentations ARE safe (lithium, bupropion, modafinil, TCAs) • Most surgeries don’t require stopping them • Clear rules = clear safety

MAOIs aren’t the problem. Fear and outdated training are.

It’s time to bring them back. This is Psychiatry Unfiltered.

Why Public Psychiatry Is Failing https://youtu.be/Kx30MoQJEKU?si=OY6zinYatckE9p-S via @YouTube 

💤 Why Trazodone Works So Well for Depression Related Insomnia

Have you ever wondered why trazodone became the go-to medication for insomnia associated with depression?

It’s not just because it helps people fall asleep plenty of medications do that. The key difference is how trazodone changes the architecture of sleep.

Unlike sedatives that merely increase total sleep time (often leaving people feeling groggy or unrefreshed), trazodone specifically enhances stage N3 — deep, restorative sleep. This is the phase where your body and brain truly recover.

Patients often describe feeling more refreshed and clear-headed, even if their total sleep time isn’t dramatically longer. That improvement in sleep quality may also play a role in lifting mood and reducing depressive symptoms.

🧠 It’s a reminder that not all sleep aids are created equal — and that understanding how a drug affects sleep stages can make all the difference.

What people get wrong about using prazosin 🧠💊

Prazosin is one of the few medications that consistently helps with PTSD-related nightmares and autonomic arousal from trauma — but it’s also one of the most misused.

Unlike doxazosin, prazosin actually works for trauma-related sleep disturbance. The key is understanding how to dose it safely and effectively.

Too many clinicians start at 1 mg at bedtime (which is correct) but never move beyond 1–2 mg/day. At that level, most patients will see little to no benefit. 👉 The real-world effective range can go up to 40 mg/day, depending on tolerance and symptom response.

The most common mistake? Fear of titration — leaving patients underdosed and still suffering from nightmares that could have been treated.

Rethinking Clozapine Monitoring

New Video: Rethinking Clozapine Monitoring

Clozapine remains psychiatry’s most effective antipsychotic—but its use is often limited by fear and confusion around blood monitoring.

The truth is this: 🩸 Agranulocytosis risk peaks during the first six months and then drops substantially—but never reaches zero. 📉 The FDA recently rescinded the REMS, but left the package insert requirements intact, leaving clinicians uncertain about best practices.

In this video, I review the new pragmatic monitoring recommendations

Weekly ANCs for 18 weeks, then

Monthly until two years, and

Consider discontinuing routine monitoring after two years if no abnormalities.

Weekly ANCs for 18 weeks, then

Monthly until two years, and

Consider discontinuing routine monitoring after two years if no abnormalities.

The key is shared decision-making—document your rationale and educate patients about early warning signs like fever or sore throat. And don’t forget: an annual CBC remains essential for catching smoldering dyscrasias.

Dissociative Identity Disorder in Real Life: My First Convincing Case

🚨 New Case Files from the Ward – Episode 2 🚨

For most of my career, I didn’t believe in Dissociative Identity Disorder (DID). I thought it was overdiagnosed, exaggerated, maybe even a myth.

That changed when I met a patient whose history and presentation completely shifted my perspective. This is the first convincing case of DID I’ve encountered — and I’m breaking it down in detail.

In this video, you’ll learn: 🔹 Why DID is often missed or misdiagnosed 🔹 The trauma connection & neuroscience behind dissociation 🔹 Evidence-based treatments (and why there’s no quick fix) 🔹 How this case challenged my own clinical bias

🎥 Watch here: https://youtu.be/pORsuZVE27c

Facing the Fear Why Avoidance Makes Anxiety Worse

Many psychiatrists will tell you that without DBT, you can’t treat BPD.

They’re wrong.

If you work in underserved communities, “expensive and fancy” isn't in the vocabulary. But honesty, structure, and belief in the patient? That’s more than enough.

Here’s how I treat BPD without boutique therapy or polypharmacy:

✅ Give the diagnosis—directly, nonjudgmentally

✅ Shift the focus from symptoms to building a life

✅ Track mood daily—pen, paper, or app, just do it

✅ Don’t panic in crisis—model calm, not chaos

✅ Teach distress tolerance—don’t reinforce escape

✅ Avoid polypharmacy—no “borderline cocktail”

✅ Never cosign helplessness or catastrophizing

✅ Reinforce patient agency—they have a role in recovery

Most patients with BPD do get better over time. But not because of some idealized therapist or magic med combo—because they do the work.

Your job? Be consistent. Be honest. Be steady.

Brexpiprazole + Sertraline A New Hope for PTSD Treatment

PTSD Is Hard to Treat. This Combo Might Actually Help.

We’ve had SSRIs as the “standard” for PTSD for decades. Most of us know they often don’t work well enough.

Now, a new Phase 3 RCT tested brexpiprazole + sertraline in over 550 adults—and the results were surprisingly strong:

✅ 68.5% of patients had ≥30% symptom reduction ✅ 5.6-point greater drop on CAPS‑5 vs sertraline alone ✅ Gains in psychosocial functioning, mood, and resilience ✅ Stable effects with no relapse through 12 weeks ✅ Discontinuation due to AEs: just 3.9%

We may finally have something to offer patients stuck in the cycle of trauma and ineffective treatment.

FDA decision expected 

Understanding Psychiatry Navigating Skepticism and Science

🧠 Why do people distrust psychiatry—and what can we do about it?

Proud to share my latest article in Psychiatric Times: "Understanding Psychiatry: Navigating Skepticism and Science" 👉 https://www.psychiatrictimes.com/view/understanding-psychiatry-navigating-skepticism-and-science

We’re living in an era of deep mistrust in institutions—including medicine. Psychiatry often gets the harshest judgment. In this piece, I tackle the roots of that skepticism and explore how we can bridge the gap between scientific progress and public perception.

If you're a clinician, patient, or just someone curious about mental health—this one's for you.

🧠 “Psychiatry is a scam.” “Big Pharma controls your brain.” “Mental illness isn’t real.”

🤨 You’ve heard the takes. Now here’s the truth.

🔴 In my new article for Psychiatric Times, I dive headfirst into the controversy:

👉 Understanding Psychiatry: Navigating Skepticism and Science

🔥 I don’t dodge the hard questions—about overmedication, broken trust, and bad science—but I also push back against lazy anti-psychiatry takes that ignore the very real suffering of patients.

Mirtazapine: A unique tool in the antidepressant toolbox

Mirtazapine isn’t your typical SSRI—and that’s exactly why it can be useful in the right context.

✅ When to consider mirtazapine:

Depression with insomnia

Poor appetite or weight loss

Concern about sexual side effects

Patients struggling with GI intolerance to SSRIs

⚠️ When to avoid it:

Obesity or metabolic syndrome

Risk of daytime sedation

Orthostatic hypotension history

Mechanistically, it’s a noradrenergic and specific serotonergic antidepressant (NaSSA). It works via alpha-2 autoreceptor blockade, enhancing 5-HT1A transmission while avoiding 5-HT2/3 activity—translating to fewer GI and sexual side effects.

💡 Pro tip: Sedation is dose-dependent and paradoxical: Lower doses (7.5–15 mg) = more sedation Higher doses (30–45 mg) = less sedation

In short, mirtazapine shines in cases where sleep, appetite, or tolerability limit other antidepressants—but use it strategically.

Amantadine A versatile but underused tool in managing antipsychotic side...

Amantadine: A versatile but underused tool in managing antipsychotic side effects

Though not first-line, amantadine is a second-line option for antipsychotic-induced Parkinsonism, with some unique advantages:

🔹 Comparable efficacy to anticholinergics—without the cognitive side effects 🔹 May help with antipsychotic-induced weight gain 🔹 Can reduce prolactin levels 🔹 Also considered a second-line treatment for tardive dyskinesia

Mechanism? Still unclear—likely dopaminergic. But it’s not without risks:

⚠️ Tolerance can develop within weeks ⚠️ May worsen psychosis or trigger mania in vulnerable patients

Dosing: Start at 100 mg daily → increase to 100 mg BID if needed after 5–7 days Max dose: 300 mg/day (divided)

Amantadine isn’t for everyone—but for the right patient, it can be a valuable part of your psychopharmacology toolkit.

Anticholinergic medications work fast—and that changes how we use them

Unlike many psychotropics, anticholinergics don’t require time to build up in the system. Their effects are often rapid, which means:

🔹 You can be flexible with dosing 🔹 In some cases, they can even be used on an as-needed basis 🔹 There’s no need for prolonged daily use if symptoms don’t persist

💡 Always tailor the approach to the patient—but don’t forget: not every medication needs a standing daily dose.

You’ve lowered the dose You’ve switched the antipsychotic But the EPS ...

You’ve lowered the dose. You’ve switched the antipsychotic. But the EPS is still there—now what?

At this point, an anticholinergic may be necessary. But here’s the key:

🔹 Use the lowest effective dose 🔹 Tailor it to the individual 🔹 Regularly reassess the need for continuation

These medications can help, but they’re not risk-free—especially when used long-term. Cognitive side effects, anticholinergic burden, and systemic issues can accumulate over time.

Antipsychotic-induced Parkinsonism: Common, often overlooked, and sometimes mishandled.

🧠 It’s a real issue—and one every clinician needs to know how to manage. But here’s the catch:

🔹 Don’t reflexively reach for anticholinergics. Too often, they’re started without a clear diagnosis—and left on board far too long, exposing patients to cognitive and systemic side effects.

📌 Know your risk profiles: ➡️ Risperidone and paliperidone are most likely to cause Parkinsonism ➡️ Lurasidone and olanzapine can also contribute, especially at higher doses