NYC Psychiatry & Primary Medical Adult ADHD / ADD (Attention Deficit Hyperactivity Disorder)

Updated by NatanSchleider, M.D. on January 10th, 2021

DOCTOR IN THE FAMILY NYC Psychiatry & Primary Medical Care Doctors specialize in Adult ADHD /ADD Attention Deficit Hyperactivity Disorder Diagnosis and Treatment.

Psychiatric ADHD diagnosis in NYC in based on DSM V (Diagnostic Statistical Manual) criteria which require:

1. Childhood history of suspect or diagnosed ADHD
2. Ensuring that no organic or physical ailment like a thyroid condition or a metabolic issue us causing mental health issue (which is why general practice doctors see all our psychiatry patients)
3. Symptoms present in two settings (for example work and school)

To further confuse the diagnosis, ADHD is divided into subtypes (which from a psychopharmacologic perspective means little since medical treatment is the same across subtypes):

ADHD INATTENTIVE SUBTYPE OR ADHD-I REQUIRES:

Most or all of the following symptoms, excluding situations where these symptoms are better explained by another psychiatric or medical condition:

• Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• Have difficulty maintaining focus on one task
• Become bored with a task after only a few minutes, unless doing something they find enjoyable
• Have difficulty focusing attention on organizing or completing a task
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• Appear not to be listening when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions
• Have trouble understanding details; overlooks details

ADHD HYPERACTIVE-IMPULSIVE SUBTYPE OR ADHD-HI REQUIRES:

Most or all of the following symptoms, excluding situations where these symptoms are better explained by another psychiatric or medical condition:

• Fidget or squirm a great deal;
• Talk nonstop;
• Dash around, touching or playing with anything and everything in sight;
• Have trouble sitting still during dinner, school, and while doing homework;
• Be constantly in motion;
• Have difficulty performing quiet tasks or activities;
• Be impatient;
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences;
• Have difficulty waiting for things they want or waiting their turn in games;
• Often interrupt conversations or others’ activities;

ADHD COMBINED SUBTYPE OR ADHD-C REQUIRES A MIX OF ADHD-I AND ADHD-HI

MANY ADHD PATIENTS SUFFER FROM REACTIVE ATTACHMENT DISORDER AND MAY SUFFER LEARNING AND MOOD DISORDERS.

DIAGNOSIS OF ADHD

No simple diagnostic test is available for ADHD although the FDA has approved Quantitative Electroencephelograms (QEEG) for diagnosis. These are performed by neuropsychologists (rarely covered by insurance).

Written diagnostics tests (IE Conners) and Computer Based Tests are also available (IE Test of Variable Attention or TOVA).

More common and accessible (and affordable) are screening ADHD exams like ASRS Version 1.1 [www.doctorinthefamily.nyc/forms/Adult-ADHD-Screening-Test-Version-1.1] and the Vanderbilt ADHD Diagnostic Rating Scale (VADRS)

[www.doctorinthefamily.nyc/forms/Vanderbilt-ADHD-Diagnostic-Rating Scale-VADRS] are options.

Some recent studies show that certain markers in blood and urine are different in patients with ADHD:

• platelet monoamine oxidase expression,
• urinary norepinephrine,
• urinary MHPG,
• urinary phenethylamine levels,
• blood plasma phenethylamine concentrations (are lower in ADHD individuals relative to controls (and the two most commonly prescribed drugs for ADHD, amphetamine and methylphenidate, increase phenethylamine biosynthesis in treatment-responsive individuals with ADHD).

ADULT ADHD TREATMENTS

Behavioral and talk therapies show no good evidence in helping Adult ADHD (they do help Childhood ADHD).

Exercise seems to help Adult ADHD slightly.

‘THE FACT THE TALK THERAPY IS NOT EFFECTIVE FOR ADULT ADHD MAKES IT UNIQUE. I ALWAYS PREFER TRIALING NON-MEDICAL TREATMENT BEFORE A PRESCRIPTION FOR MOST ILLNESSES BUT UNFORTUNATELY, MEDICAL TREATMENT WITH PRESCRIPTION STIMULANTS ARE THE FIRST LINE OF TREATMENT IN ADULT ADHD.’ NATAN SCHLEIDER, M.D.

A plethora of medicines are available for Adult ADHD, some short acting, some long acting. Methylphenidate (Ritalin) is the oldest and best known among non-physicians follow by mixed amphetamine-dextroamphetamine (Adderall). Others I commonly prescribe include Vyvanse , Focalin, Concerta, and methamphetamine. These tend to be less speedy; however, every patient reacts differently to these medicines.

Please contact DOCTOR IN THE FAMILY psychiatrists in NYC if you are seeking diagnosis, second opinion, and/or treatment options for ADHD / ADD by calling or texting 646-957-5444.

DOCTOR IN THE FAMILY’S Center for Anxiety: Evaluation, Therapy, Treatment, in NYC

DOCTOR IN THE FAMILY psychiatrists and primary care physicians focus on anxiety therapy and treatments in NYC.

After a medical evaluation to confirm no organic or physical cause of anxiety like an overactive thyroid (rare but we catch this about 5% of the time), a psychiatric evaluation of anxiety is started.

Anxiety is a natural emotion people experience during particularly stressful times. We all feel stress and anxiety. Anxiety disorders are the most common and pervasive mental disorders in the United States.

When anxiety is uncontrollable and frequently a clinical anxiety disorder is diagnosed.

Anxiety disorders are a psychiatric condition with medical concern that can affect your health and wellbeing (IE increased risk of heart attack, insomnia, and high blood pressure).

While it is normal to have anxiety about work stressors and project deadlines, people with anxiety disorder may feel anxiousness, fear and worry that they cannot control.

The symptoms of anxiety disorder include:

• feeling worried, fearful or panicked
• difficulty falling or staying asleep
• feeling tired
• heart palpitations
• nausea
• sweating
• tight muscles
• feeling shaky
• worrying more days than not
• trouble focusing
• losing ability to function socially, with friends, family or at work

DOCTOR IN THE FAMILY psychiatrists manages anxiety disorders in NYC comprehensively. We are New Yorkers.

We understand anxiety and stress in ways a remote telehealth provider in other states do not.

To best treat anxiety we do our homework via thorough mental and physical evaluation.

We get to the root of the anxiety and find the proper diagnosis by doing the following:

First, an entire medical history and a full work up is done to see if other health factors may be contributing to your anxiety. Common conditions that may affect anxiety levels include but are not limited to:

• hormone imbalances
• thyroid imbalances
• nutrient deficiencies
• sleep disorders
• specific phobias
• Obsessive Compulsive disorder
• trauma
• Other mood disorder like depression and PTSD

Second, we advise talk therapy (if this has not been tried already) to alleviate anxiety.

Third, we advise exercise daily and certain herbal medicines/natural supplements like kava, kava kava, valerian, and melatonin for insomnia.

Fourth and last, if the above has been tried and failed we discuss medication treatment options which may include:

1. If needed non-habit forming prescription medicines FDA approved for anxiety (or insomnia if you have insomnia too)
2. Daily non-habit forming prescription medicines that kick in quickly (IE buspirone aka Buspar)
3. Daily longer acting medicines in the SSRI or SNRI family FDA approved for treatment of anxiety.
4. Benzodaizapenes (IE clonazepam or Klonopin) on an if needed basis to be used sparingly as these can be habit forming / our bodies get tolerant to them if taken with regularity.

DOCTOR IN THE FAMILY psychiatrists and general practitioners are available to address anxiety by contacting out office by text or call at 646-957-5444.

NYC PSYCHIATRY & PRIMARY CARE PHYSICIANS: Alcoholism & Opiod, Opiate, Painkiller Addiction Treatment in NYC

DOCTOR IN THE FAMILY Addiction Medicine doctors are experienced in treating many Substance Use Disorders:

• Alcoholism and alcohol abuse disorder using accamrposate (Campral), naltrexone, disulfiram (Antabuse), or Vivitrol

• Alcohol withdrawal using chlordiazepoxide (Librium)

• Opiod Use Disorder: Narcotic (opioid, opiate) and Painkiller Abuse addiction, narcotic withdrawal—treatments include buprenorphine, Subutex, Suboxone, Zubsolv, naltrexone, and Vivitrol

• Tobacco abuse treated with Nicotine Replacement Therapies like the Nicotine Patch and medicines like varenciline (Chantix) and buproprion (Zyban or Wellbutrin).

Treatment of alcohol abuse and drug misuse or abuse entails the highest level of confidentiality and support.

Natan Schleider, M.D., is licensed by SAMHSA for the prescription of buprenorphine (Suboxone, Zubsolv) in the treatment of narcotic (opioid, opiate) addiction and dependence and is currently accepting patients.

Dr. Natan Schleider is a member of the American Society of Addiction Medicine and is Board Certified in Addiction Medicine. Suboxone induction, Suboxone stabilization, and Suboxone maintenance can all be managed in our Manhattan NYC office and via telemedicine in your home (in select cases).

Fellowship groups like Alcoholics Anonymous, Narcotics Anonymous, and Al-Anon are all recommended and are FREE.

Please see Our Links page for more resources.

DOCTOR IN THE FAMILY Addiction Psychiatrists and General Practice Phsyicians are available to help obtain and maintain sobriety by calling or texting 646-957-5444. Please contact us to schedule an appointment.

NYC Psychiatry & Primary Medical:Bipolar Disorder evaluation and treatment in Manhattan NYC.

Updated by Natan Schleider, M.D. on January 12^th, 2021

DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctorsspecialize in Bipolar Disorder evaluation and treatment in Manhattan NYC from our Manhattan Office or via Telepsychiatry.

Our NYC Psychiatrists follow DSM V(Diagnostic Statistical Manual) criteria in confirming a diagnosis of Bipolar Disorder.

NOTE THIS IS OFTEN DIFFICULT AND TAKES TIME SINCE BIPOLAR PATIENTS MAY PRESENT ONLY WITH SYMPTOMS OF DEPRESSION FOR WEEKS OR YEARS BEFORE HAVING A MANIC OR HYPOMANIC EPISODE.

What Is Bipolar Disorder?

Bipolar disorder is characterized by shifts in mood, and those who have it can experience high energy, euphoria, and become overactive. This is known as mania, and it can also include irritability, and some people can become easily agitated in a manic state. Manic episodes also associated with risk-taking behaviors and increased impulsivity

On the other end of the spectrum, people with bipolar disorder can have very low moods, and this is the depressive side of the condition. Just like with major depression, bipolar sufferers who are having a depressive episode can feel down on themselves, have low energy and motivation, and think about death and suicide.

Nonetheless, these mood swings are not typically short and temporary. Instead, these episodes must last at least a week for mania and two weeks for depression for the person to have Bipolar I disorder. This is not only important for diagnosing bipolar disorder, in general, but it can also determine what type a person has, which you will learn more about in the next section.

Types Of Bipolar Disorder

There are different types of Bipolar Disorder:

• Bipolar I Disorder: consists of manic episodes that last for a minimum of seven days and occur for most of the day, or when the symptoms require hospital care due to their severity. People with Bipolar I will experience depressive episodes lasting two weeks or longer; then they will have periods of normal mood.

• Bipolar II Disorder: characterized by depressive and hypomanic episodes. The symptoms of mania are not as severe or long-lasting as with Bipolar I.

• Cyclothymic Disorder: hypomanic and depressive symptoms that are persistent but not intense enough or do not last long enough to qualify as hypomanic or depressive episodes. These symptoms can last for at least two years in adults, and for one year in kids and adolescents.

• Other Specified and Unspecified Bipolar and Related Disorders: this category includes bipolar disorder symptoms that do not match any of the types previously mentioned

However, the DSM bipolar section goes into greater detail as to what constitutes a manic, hypomanic, or depressive episode, which will be covered next.

According to the DSM-5 by the American Psychiatric Association, here is, verbatim, the specifications for each type of episode:

For Manic Episodes

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary)

Note: In the bipolar disorder DSM-5 versus DSM-IV, Criterion A is revised to include increased energy/activity as a core symptom

1. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

(1) Inflated self-esteem or grandiosity

(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) More talkative than usual or pressure to keep talking

(4) Flight of ideas or subjective experience that thoughts are racing

(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)

(7) Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

1. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
2. The episode is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medication

At least one-lifetime manic episode is required for a diagnosis of bipolar I disorder

For Hypomanic Episodes

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least four consecutive days and present most of the day, nearly every day.
2. During the period of mood disturbance and increased energy and activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:

(1) Inflated self-esteem or grandiosity

(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) More talkative than usual or pressure to keep talking

(4) Flight of ideas or subjective experience that thoughts are racing

(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7) Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

1. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
2. The disturbance in mood and the change in functioning are observable by others.
3. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic symptoms, the episode is, by definition, manic.
4. The episode is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medication.

Hypomanic episodes are common in bipolar I disorder but are not required for a diagnosis of bipolar I disorder. Criteria for a past or current hypomanic episode and a past or current major depressive episode are required for diagnosis of bipolar II disorder.

For Depressive Episodes

Five or more of the following A Criteria (at least one includes A1 or A2)

(A1) Depressed mood-indicated by subjective report or observation by others (in children and adolescents, can be irritable mood).

(A2) Loss of interest or pleasure in almost all activities-indicated by subjective report or observation by others.

(A3) Significant (more than 5 percent in a month) unintentional weight loss/gain or decrease/increase in appetite (in children, failure to make expected weight gains).

(A4) Sleep disturbance (insomnia or hypersomnia).

Source: unsplash.com

(A5) Psychomotor changes (agitation or retardation) severe enough to be observable by others.

(A6) Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed.

(A7) A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick).

(A8) Impaired ability to think, concentrate, or make decisions-indicated by subjective report or observation by others.

(A9) Recurrent thoughts of death (not just fear of dying), suicidal ideation, or suicide attempts.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, a prescribed medication’s side effects) or a medical condition (e.g., hypothyroidism).

The symptoms do not meet criteria for a mixed episode. A mixed episode is characterized by the symptoms of both a major depressive episode and a manic episode occurring almost daily for at least 1 week. This exclusion does not include episodes that are substance-induced (e.g., caffeine) or the side effects of medication.

There has never been a manic episode or hypomanic episode.

MDE is not better explained by schizophrenia spectrum or other psychotic disorders.

The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation). This differentiation requires clinical judgment based on cultural norms and the individual’s history.

The DSM V bipolar chapter also states that it is important to note that each symptom must either be new or must have worsened compared with the person’s pre-episode status and must persist most of the day, daily, for at least two weeks in a row. Exclude symptoms that are clearly due to a general medical condition, mood-incongruent delusions, or mood-incongruent hallucinations. Additionally, symptoms must persist most of the day, daily, for at least two weeks in a row, excluding A3 and A9.

Conclusion

By knowing what each episode entails from the DSM 5 bipolar disorder listing, a doctor can determine which variant of the condition a patient has. For example, if he or she sees that someone has exhibited depressive symptoms and hypomania a diagnosis for Bipolar II can be made. If no manic or hypomanic symptoms were present at all, it would more than likely indicate major depression disorder, instead of bipolar.

Treatment for Bipolar Disorder

Most of our patient have tried talk therapy and various over the counter or prescription antidepressants before consulting us. If these work, terrific; however, antidepressants INCREASE the risk of inducing a manic episode and we use these with caution.

Mood stabilizers are our primary medical treatment choice and include medicines form different families.

For example, my favorite is lamotrigine (Lamictal) which is an anti-seizure medicine FDA approved for mood stabilization. I like it since it has few side effects and dosing is once daily. Depakote is another favorite in the anti-seizure family.

Many other medicines for Bipolar Disorder exist. All must be taken daily. Some are in the ‘anti-psychotic’ family and include Abilify, Seroquel, and Geodon. These tend to work fast and be stronger so patients MUST be watched closely to ensure they are not overmedicated and ‘feeling like zombies.’

Lithium is the oldest of the Bipolar medicines. It has advantages like it has been around for 40 plus years and therefore is not known to cause any brain damage although levels must be checked in the blood periodically to make sure they are therapeutic and not toxic.

Please contact DOCTOR IN THE FAMILY psychiatrists and primary care doctos in NYC if you are seeking diagnosis, second opinion, and/or treatment options for Bipolar Disorder by calling or texting 646-957-5444.

NYC Psychiatry & Primary Medical:Depression Treatment in NYC

Updated by Natan Schleider, M.D. on January 10^th, 2021

DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctorsspecialize in Depression Treatment in NYC from our Manhattan Office or via Telemedicine.

Our NYC Psychiatrists follow DSM V(Diagnostic Statistical Manual) criteria in confirming a diagnosis of Depression, the fancy medical term for depression.

Depression is an ‘umbrella term’ as there are many subtypes of depression:

Some forms of depression are slightly different, or they may develop under unique circumstances, such as:

• Persistent depressive disorder (also called dysthymia)is a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered persistent depressive disorder.
• Postpartum depression is much more serious than the “baby blues” (relatively mild depressive and anxiety symptoms that typically clear within two weeks after delivery) that many women experience after giving birth. Women with postpartum depression experience full-blown major depression during pregnancy or after delivery (postpartum depression). The feelings of extreme sadness, anxiety, and exhaustion that accompany postpartum depression may make it difficult for these new mothers to complete daily care activities for themselves and/or for their babies.
• Psychotic depression occurs when a person has severe depression plus some form of psychosis, such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations). The psychotic symptoms typically have a depressive “theme,” such as delusions of guilt, poverty, or illness.
• Seasonal affective disorderis characterized by the onset of depression during the winter months, when there is less natural sunlight. This depression generally lifts during spring and summer. Winter depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably returns every year in seasonal affective disorder.
• Bipolar disorderis different from depression, but it is included in this list is because someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression (called “bipolar depression”). But a person with bipolar disorder also experiences extreme high – euphoric or irritable – moods called “mania” or a less severe form called “hypomania.”

Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-5 include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder (PMDD).

Criteria for Diagnosis of Depression:

If you have been experiencing some of the following signs and symptoms most of the day, nearly every day, for at least two weeks, you may be suffering from depression:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, or pessimism
• Irritability
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy or fatigue
• Moving or talking more slowly
• Feeling restless or having trouble sitting still
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide, or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Treatment and Therapies

Depression, even the most severe cases, can be treated.

The earlier that treatment can begin, the more effective it is.

Our NYC psychiatrists prefer NOT to medicate unnecessarily. Ideally talk therapy, exercise, and herbal medicines like St. John’s Wort could be tried before starting an antidepressant medicine.

That said, depression is ideally treated with a combination of medications and psychotherapy.

Note: No two people are affected the same way by depression and there is no “one-size-fits-all” for treatment. It may take some trial and error to find the treatment that works best for you. There are some blood tests that help DOCTOR IN THE FAMILY Psychiatrists chose a medicine but these are not precise and not usually covered by insurance.

Medications

Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has manageable side effects. A medication that has helped you or a close family member in the past will often be considered.

Antidepressants take time – usually 2 to 4 weeks – to work, and often, symptoms such as sleep, appetite, and concentration problems improve before mood lifts, so it is important to give medication a chance before reaching a conclusion about its effectiveness.

Please Note: In some cases, children, teenagers, and young adults under 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. This warning from the U.S. Food and Drug Administration (FDA) also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

Some final tips on managing depression:

Here are other tips that may help you or a loved one during treatment for depression:

• Try to be active and exercise.
• Set realistic goals for yourself.
• Try to spend time with other people and confide in a trusted friend or relative.
• Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately.
• Postpone important decisions, such as getting married or divorced, or changing jobs until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Continue to educate yourself about depression.

Please contact DOCTOR IN THE FAMILY psychiatrists in NYC if you are seeking diagnosis, second opinion, and/or treatment options for PTSD by calling or texting 646-957-5444.

NYC Psychiatry & Primary Medical:Insomnia & Sleep Disorder evaluation and treatment in Manhattan NYC.

Updated by NatanSchleider, M.D. on January 11^th, 2021

DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctorsspecialize in Insomnia & Sleep Disorder evaluation and treatment in Manhattan NYC from our Manhattan Office or via Telepsychiatry.

Our NYC Psychiatrists follow DSM V(Diagnostic Statistical Manual) criteria in confirming a diagnosis of insomnia.

Symptoms MUST be present at least 3 nights weekly for 3 months DESPITE adequate opportunity to sleep.

Insomnia is an ‘umbrella term’ as there are many subtypes of insomnia but requires ONE of the following form Part 1 AND one from Part 2:

1. NIGHTIME: Dissatisfaction with sleep quantity or quality, with one or more of the following symptoms: Difficulty initiating sleep; Difficulty maintaining sleep, characterized by frequent awakenings or trouble returning to sleep after awakenings
2. Daytime: The sleep disturbance causes clinically significant distress or impairment in daytime functioning, as evidenced by at least ONE or more of the following:

• Fatigue or low energy
• Daytime sleepiness
• Impaired attention, concentration, or memory
• Mood disturbance
• Behavioral difficulties
• Impaired occupational or academic function
• Impaired interpersonal or social function
• Negative effect on caregiver or family functioning

Insomnia can be divided for the sake of medical treatment into two groups:

1. Primary insomnia—These patients present to our office saying ‘Doc, life is great, work is good, I am happy and healthy, I just can’t sleep and I don’t know why. I have ben to a sleep specialist for an overnight sleep study which was negative or inconclusive. Medical treatment for primary insomnia can be started with over the counter medicines like melatonin or diphenhydramine or Zequel; however, most patients have already tried and failed these. We are therefore left with medicines FDA approved for primary insomnia like zolpidem (Ambien), zolpidem CR (Ambien CR—which is approved for chronic insomnia), zalepolon (Sonata), and Lunesta.
2. Secondary insomnia—These patients present to our NYC psychiatrists or primary care doctors saying ‘Doc, life is bad, I am stressed, my health good be better, I am unhappy at home or at work, my mind races as I try to sleep.’ These patients have insomnia SECONDARY to underlying problems. These underlying problems must be treated for sleep to improve. Many medicines are available for secondary insomnia. While the benzodiazapenes like alprazolam (Xanax), triazolam (Halcion), diazepam (Valium), etc are good choices for SHORT TERM treatment of secondary insomnia, they can be habit forming if used for months on end. We therefore may prescribe a benzodiazapene to ensure our new patient gets some sleep (as they are often too tired to focus on the consult). After, other medicines can be tried.

Please contact DOCTOR IN THE FAMILY psychiatrists and primary care doctors in NYC if you are seeking diagnosis, second opinion, and/or treatment options for insomnia by calling or texting 646-957-5444.

NYC Psychiatry & Primary Medical: Ketamine IV & Spravato Depression Treatment in NYC

Updated by Natan Schleider, M.D. on January 10th, 2021

DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctors offer ketamin IV and Spravato Nasal Spray Eskestamine Treatment for Severe Depression in out Manhattan NYC.

What is Ketamine?

Ketamine is an anesthetic medication that blocks the NMDA receptor. More recently, ketamine has been discovered as a safe and effective treatment for depression, and randomized controlled trials have shown rapid improvement in mood as well as reduction in suicidality compared to people who receive a placebo or another drug.

Is ketamine right for me?

Adults age 18 and over who suffer from moderate-severe depression and have not had success with traditional treatments for depression are eligible for ketamine treatment. Our comprehensive evaluation will include a medical history and basic lab results to ensure ketamine is safe for you.

Does ketamine really work?

Several randomized controlled trials demonstrate that ketamine has made a significant improvement in depressive symptoms and suicidality over the course of the first 2 weeks. In fact, if ketamine does not work for you after 2 sessions, the data suggest it is unlikely to work at all. KETAMINE IS NOT FDA APPROVED FOR TREATMENT OF DEPRESSION AS OF THE TIME I WRITE THIS (1.10.2021) BUT ESKETAMINE AKA SPRAVATO, A SISTER DRUG TO KETAMINE IS FDA APPROVED FOR DEPRESSION TREATMENT.

What are the risks?

For depression, the doses of ketamine used are much lower than the dose for anesthesia, making it relatively safe. That said, ketamine does carry the risk of changing (especially increasing) blood pressure and heart rate. Hence it must be administered in a health care facility to ensure safety and appropriate monitoring. Longer term risks include urinary symptoms, cognitive impairment (with prolonged use), and substance use disorders. We will monitor for these symptoms throughout the treatment.

What is the process to receive a ketamine treatment for depression?

1. Schedule an appointment. Call 646-957-5444 or schedule a consult online [www.zocdoc.com/professional/natan-schleider-md-103585]
2. Our physicians and psychiatrists with expertise in treatment-resistant depression to determine if ketamine (or another treatment) is the best treatment for you.
3. Evaluation of basic lab results to ensure ketamine is safe for you.
4. The initial administration of the ketamine treatment.
5. Twice weekly ketamine administration for 2 weeks with follow-up treatments as recommended by psychiatrist. A typical case would be 8-12 treatments over 4-6 weeks.
6. Follow-up care as recommended by NYC DOCTOR IN THE FAMILY Psychiatrists and Primary Care Physicians.

How much does ketamine cost?

Intransal Ketamine: The cost for the service of administering intranasal esketamine in our offices is covered by your insurance plans we work with [www.doctorinthefamily.nyc/fees]. All office consults are $750 to $1,500 as stated Our Fees page. Please note this cost does NOT include the cost of the drug itself. The only FDA approved formulation of ketamine is intranasal esketamine, also known as SpravatoTM. This medication is brand-only. Your insurance may cover the cost of the medication itself, or you may need prior authorization, which DOCTOE IN THE FAMILY Office Staff will help with.

IV Ketamine: The FDA has not approved the use of IV ketamine for treatment-resistant depression, which means this is an off-label use of the medication. As such, ketamine treatment may not be covered by insurance and will cost $750 per infusion.

Does it matter if ketamine is administered via IV or nasal spray?

Esketamine aka Spravato is a form of ketamine that can be used via a nasal spray that was FDA-approved to treat treatment-resistant depression in 2019. While esketamine aka Spravato does not require an infusion, it must be administered in a health care setting where patients can be monitored for up to two hours.

Please contact DOCTOR IN THE FAMILY psychiatrists in NYC if you are seeking information on ketamine and or esketamine aka Spravato depression treatment by calling or texting 646-957-5444.

NYC Psychiatry & Primary Medical: Adult Post Traumatic Stress Disorder Treatment or PTSD

Updated by Natan Schleider, M.D. on January 10th, 2021

DOCTOR IN THE FAMILY: NYC Psychiatry & Primary Medical Care Doctors specialize in Adult PTSD Post Traumatic Stress Disorder Treatment from our Manhattan Office or via Telemedicine.

Our Psychiatrists follow DSM V (Diagnostic Statistical Manual) criteria in confirming a diagnosis of PTSD. This requires the following criteria are met:

Criterion A: stressor (one required)

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

• Direct exposure
• Witnessing the trauma
• Learning that a relative or close friend was exposed to a trauma
• Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

Criterion B: intrusion symptoms (one required)

The traumatic event is persistently re-experienced in the following way(s):

• Unwanted upsetting memories
• Nightmares
• Flashbacks
• Emotional distress after exposure to traumatic reminders
• Physical reactivity after exposure to traumatic reminders

Criterion C: avoidance (one required)

Avoidance of trauma-related stimuli after the trauma, in the following way(s):

• Trauma-related thoughts or feelings
• Trauma-related external reminders

Criterion D: negative alterations in cognitions and mood (two required)

Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect

Criterion E: alterations in arousal and reactivity

Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

• Irritability or aggression
• Risky or destructive behavior
• Hypervigilance
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping

Criterion F: duration (required)

Symptoms last for more than 1 month.

Criterion G: functional significance (required)

Symptoms create distress or functional impairment (e.g., social, occupational).

The traumatic event is persistently re-experienced in the following way(s):

• Unwanted upsetting memories
• Nightmares
• Flashbacks
• Emotional distress after exposure to traumatic reminders
• Physical reactivity after exposure to traumatic reminders

Symptoms are not due to medication, substance use, or other illness.

FINAL CRITERIA: THERE ARE TWO ADDITIONAL PTSD CRITERIA CALLED DISSOCIATIVE SPECIFICATIONS AND THE PATIENT MUST HAVE ONE:

• Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
• Derealization. Experience of unreality, distance, or distortion (e.g., “things are not real”).

• Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

DOCTOR IN THE FAMILY: PSYCHIATRISTS AND PRIMARY CARE DOCTORS APPROACH TO PTSD TREATMENT (FOLLOW AMERICAN PSYCHOLOGIC ASSOCIATION GUIDELINES)

• Our Primary Care Doctors will make sure PTSD symptoms are not caused or worsened by an underlying health or medical or substance abuse condition.

1. Psychotherapy will be offered or provided to the patient; however, MOST of our patient have already had and failed OR are looking to supplement with medical treatment options.
2. Medicines currently FDA approved for PTSD include sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor). Each has benefits and risks which are reviewed in detail. None are addicting. You can stop taper off these medicines if you decide you don’t like them at any time.
3. In New York State Medical Marijuana is approved for the treatment of PTSD. For those patient who do not like pills, this is a viable alternative or a supplement. We can get you a New York State Medical Marijuana Card for PTSD.

Please contact DOCTOR IN THE FAMILY psychiatrists in NYC if you are seeking diagnosis, second opinion, and/or treatment options for PTSD by calling or texting 646-957-5444.