Conditions We Treat

WHEN TREATMENT HASN’T BEEN ENOUGH

People rarely come to CNY Psychiatry simply because they have a diagnosis. More often, they come because something isn’t working.

Depression has persisted despite treatment. Symptoms have returned. Medications have helped only partially or caused unacceptable side effects. A diagnosis no longer seems to explain the entire clinical picture. Or a patient and treatment team are wondering whether another approach should be considered.

CNY Psychiatry specializes in the evaluation and treatment of psychiatric conditions that have been difficult to treat.

Our starting point is not a procedure. It is understanding the patient and the illness we are trying to treat.

WHEN THE DIAGNOSIS ISN’T CLEAR

Treatment resistance should sometimes prompt us to reconsider the diagnosis itself.

When several reasonable treatments have failed, the answer is not always another medication.

Is the original diagnosis correct? Are there features of bipolar illness that have been overlooked? Are anxiety, trauma, obsessive symptoms, sleep problems, substance use, medical illness, or other factors contributing? Did previous treatments truly fail, or were they limited by dose, duration, tolerability, adherence, or other circumstances?

What is preventing this person from getting better? You do not need to arrive knowing your diagnosis or which treatment you need. Helping determine that is part of our job.

DEPRESSION & TREATMENT-RESISTANT DEPRESSION

Depression can affect motivation, energy, concentration, sleep, appetite, relationships, work, interests, and the ability to imagine a meaningful future.

Treatment-resistant depression generally refers to major depressive disorder that has not responded adequately to appropriate antidepressant treatment, commonly after inadequate response to two or more adequate antidepressant trials. But counting medications tells only part of the story.

Sometimes the illness is genuinely resistant to treatment. Sometimes the treatment strategy needs reconsideration.

Treatment options may include psychiatric evaluation and ongoing treatment, TMS, accelerated TMS, Spravato, IV ketamine, or selected combined strategies.

The treatment can be selected for the patient rather than the patient selected for the treatment.

What happens after improvement also matters. The objective is not simply to achieve response. It is to build a durable recovery.

BIPOLAR DEPRESSION

Depression occurring within bipolar disorder requires particular diagnostic and treatment consideration.

A person with bipolar disorder has experienced, or has the biological vulnerability to experience, episodes of mania or hypomania in addition to depression. That broader pattern can significantly change how depression should be treated.

Why bipolar depression can be missed: people often seek treatment during depression, while hypomanic periods may not initially feel like illness. Careful history should consider sleep, energy, activation, impulsivity, irritability, family history, and previous medication responses.

When treatment repeatedly fails, diagnostic certainty should not automatically increase. Sometimes it should decrease.

Treatment may include medications with established roles in bipolar disorder, psychotherapy, attention to sleep and circadian stability, and selected interventional treatments. TMS has been studied in bipolar depression and may be considered for selected patients, although the evidence base is smaller than for major depressive disorder.

Ketamine has also been studied in bipolar depression and may produce rapid antidepressant improvement in some patients, but evidence is less extensive than for unipolar TRD. IV ketamine is off-label for bipolar depression.

Spravato does not have a specific FDA-approved indication for bipolar depression.

In bipolar disorder, getting better and remaining stable have to be considered together.

OBSESSIVE-COMPULSIVE DISORDER

OCD is not simply being organized, particular, or perfectionistic. It is characterized by obsessions, compulsions, or both that can profoundly disrupt daily life.

Symptoms can involve contamination and washing, checking, harm fears, intrusive violent/sexual/religious thoughts, reassurance seeking, counting, symmetry, mental rituals, scrupulosity, catastrophic doubt, and avoidance.

Exposure and Response Prevention (ERP) is a core evidence-based treatment. Medication, particularly serotonergic treatment, can also play an important role.

CNY Psychiatry does not provide ERP internally but strongly encourages appropriate evidence-based psychotherapy and collaboration with OCD therapists.

For selected patients with persistent symptoms despite appropriate care, CNY Psychiatry offers rTMS for OCD. We provide rTMS, not dTMS. Our rTMS approach is off-label.

Our goal is not to replace proven OCD treatment with technology. It is to determine when technology can thoughtfully add to it.

POST-TRAUMATIC STRESS DISORDER

PTSD can affect mood, sleep, relationships, concentration, emotional regulation, memory, and a person’s sense of safety long after danger has ended.

Trauma-focused psychotherapy is central to treatment for many patients. Avoidance can provide short-term relief while allowing PTSD to persist.

Written Exposure Therapy is a brief, structured, evidence-based trauma-focused psychotherapy for PTSD. CNY Psychiatry does not provide WET internally. We collaborate with WET-trained community therapists.

The patient’s therapist remains the therapist.

Ketamine has been studied independently as a potential treatment for PTSD, but IV ketamine is not FDA-approved for PTSD and the evidence base is smaller than for unipolar TRD.

CNY Psychiatry’s Ketamine + WET program coordinates IV ketamine treatment with WET sessions for selected patients. WET itself is established; the specific combined strategy remains evolving.

The goal is not to erase the past. It is to restore freedom in the present.

ANXIETY DISORDERS

Anxiety becomes an illness when fear, worry, physical symptoms, or avoidance become persistent enough to interfere with daily life.

Anxiety is not one disorder. Symptoms may occur in generalized anxiety disorder, panic disorder, social anxiety disorder, phobias, PTSD, OCD, depression, bipolar disorder, substance-related conditions, sleep disorders, medical illness, or as medication effects.

A symptom is not always a diagnosis.

Evidence-based psychotherapy is central for many anxiety disorders. Medication can also play an important role. Benzodiazepines may have appropriate clinical uses but require thoughtful prescribing because of tolerance, dependence, withdrawal, sedation, cognitive effects, and interaction risks.

TMS, ketamine, and Spravato are not routine treatments for primary anxiety disorders simply because CNY Psychiatry offers them.

We do not recommend an advanced treatment simply because we happen to offer it.

The goal is not necessarily to eliminate anxiety. It is to reduce anxiety’s authority over your life.

TINNITUS

Chronic tinnitus can significantly affect sleep, concentration, mood, anxiety, and overall quality of life.

Because tinnitus can have many causes, appropriate medical and audiologic evaluation should come before consideration of TMS. For selected patients with persistent, bothersome tinnitus, CNY Psychiatry offers off-label rTMS. Research has produced mixed results, and response cannot be predicted.

Learn About TMS for Tinnitus.

A DIAGNOSIS DOES NOT DETERMINE A TREATMENT

Two people can have the same diagnosis and need very different treatment.

Depression does not automatically mean TMS. Treatment-resistant depression does not automatically mean ketamine. OCD does not automatically mean rTMS. PTSD does not automatically mean ketamine.

Sometimes the most appropriate recommendation is a treatment we provide. Sometimes it isn’t.

Good psychiatric care requires being willing to say both.