A physician of How I evaluate
I start every evaluation by listening to the whole story before I ask my own questions. Patients usually know what is wrong with their lives even when they cannot name the diagnosis, and the details they volunteer early, about sleep, about work, about what changed and when, are often the most useful information I will get. Then I fill in the rest systematically: the psychiatric history, including every medication tried and for how long; the medical history, because thyroid disease, sleep apnea, anemia and a dozen other conditions can look like depression or anxiety; family history; alcohol and other substances; and the circumstances of the person's life, including their work, their relationships and the beliefs they draw on.
I use standardized rating scales at the first visit and at every follow-up. A score is not a diagnosis, but it gives us both a number to compare against next time, which is more reliable than memory. I order laboratory tests when the picture warrants them and I review any recent results a patient brings.
How I decide on medication
I prescribe when there is a diagnosis that medication treats and when the likely benefit outweighs the risks for this particular patient. That sounds obvious, but it rules out a lot of prescribing: medication for a stressful situation that will resolve on its own, a second antidepressant added before the first has had a fair trial, a sedative continued for years because nobody reviewed it.
When medication is the right call, I choose it based on the symptom pattern, the patient's medical conditions, other medications they take, side effects they have had before and, frankly, what has worked for a close relative, since that is a reasonable clue. I start at a dose that is likely to be tolerated and I explain what the first two weeks typically feel like, because side effects usually arrive before benefits and patients who are warned about that stay the course. I give every medication a fair trial at an adequate dose before I conclude it has failed, and I follow a deliberate order when one does fail: optimize, then switch, then augment, then consider Spravato or other interventional options for depression that has resisted two or more trials.
Patients taking antipsychotic medication get a fixed monitoring schedule for weight, blood pressure, blood sugar and lipids. Patients taking lithium or certain anticonvulsants get the laboratory monitoring those drugs require. I would rather order a test that comes back normal than miss a problem that was preventable.
How I think about therapy
Medication changes the biology of a condition. It does not change a marriage, a job or a way of thinking that has become a trap. Every visit with me includes supportive therapy and practical problem-solving, and for many patients that is enough alongside medication. When a patient needs structured psychotherapy, such as cognitive behavioral therapy for anxiety or exposure-based work for panic and avoidance, I refer to a therapist and I stay in contact so that we are working toward the same goals. I think of therapy and medication as two tools that work better together than either does alone, and the evidence agrees.
Interventional options
The Boynton Beach office is a certified Spravato treatment site. For adults with treatment-resistant depression, esketamine nasal spray is an FDA-approved option that can work within days to weeks rather than months. It is not a first step, and I do not present it as one. It requires in-office administration, two hours of monitoring after each dose, blood pressure checks and a commitment to the induction schedule. When a patient has done the earlier steps properly and is still ill, it is a serious option and I will say so. Transcranial magnetic stimulation is available through Stedfast Psychiatry, and I refer patients for whom it is a better fit, including those who want to avoid further medication. For the most severe or urgent depression, I will discuss electroconvulsive therapy honestly, because it remains the most effective treatment we have for certain patients.
What a follow-up looks like
A follow-up visit is not a refill appointment. We review the rating scale, compare it with the last one, go through side effects, check adherence without judgment and look at what has changed in the patient's life since the last visit. Then we make a decision: hold the course, adjust the dose, change the medication or add something. I tell patients which of those we are doing and why, and I write down what would prompt us to change the plan before the next visit.
What I expect from patients
I expect honesty, including about missed doses, alcohol and whether the plan feels workable. I expect patients to tell me when something is not right rather than waiting for the next appointment. I expect them to take part in the decisions, because a plan a patient does not believe in is a plan that will not be followed. In return, I will explain my reasoning, I will not rush the visit and I will not keep anyone on a medication without a clear reason.
Telehealth
I see patients by video anywhere in Florida. Telehealth is well suited to medication follow-ups and to patients who live far from Boynton Beach or who cannot easily leave work. I ask the same questions, use the same scales and keep the same records as I do in the office. Some visits need to be in person: a first evaluation when I need to examine a patient, visits that involve laboratory work and every Spravato treatment. The office will tell you which applies when you schedule.
If you are in crisis, call or text 988 or go to the nearest emergency room.