When a patient isn't getting better, it's natural to ask, “What's the next medication we should try?” But before making another change, I think it's worth stepping back and asking a different question: Have we fully understood why the current approach isn't working? This topic was suggested by our community member Shai Nico, who wanted to learn more about treatment-resistant depression. I appreciate questions like this because they give us an opportunity to explore the clinical reasoning behind the treatment decisions we make every day. Treatment-resistant depression requires more than cycling through medications. It calls for a closer look at the diagnosis, the adequacy of previous treatment trials, the patient's response, and the factors that may be complicating recovery. 🧠 Start with the basics. Was the dose appropriate? Was the medication taken consistently? Was there enough time to evaluate the response? 🔎 Revisit the diagnosis. Bipolar spectrum symptoms, anxiety, trauma, substance use, sleep problems, and medical conditions may all affect the clinical picture. 🩺 Match the next step to the response. Optimizing treatment, switching medications, and considering augmentation are different strategies. The right choice depends on the patient's history, tolerability, and goals. 💡 Know when to broaden the conversation. Psychotherapy, TMS, ECT, and ketamine-based treatments may be appropriate for selected patients, depending on the clinical situation. ❤️ Don't lose sight of the person behind the diagnosis. Symptom scores matter, but so do relationships, daily functioning, and the ability to participate in life again. Treatment resistance doesn't mean a patient is untreatable. It means we need to reassess carefully, think critically, and build the next step around the individual. Thank you, Shai, for bringing this topic to our community. Your question may also help other clinicians who are navigating similar cases. For my fellow clinicians: What do you reassess first when a patient isn't responding as expected?

Starting an SSRI is not just about choosing a medication. It’s about understanding the patient in front of you, the symptoms you’re treating, and how to balance therapeutic benefit with tolerability. For nurse practitioners working in psychiatric care, knowing the common starting doses of medications like sertraline and fluoxetine is important. Just as important is knowing when to start lower, titrate gradually, and reassess before making the next adjustment. 1. Sertraline (Zoloft) Sertraline is commonly used to treat depression and several anxiety-related conditions. - Adults: A common starting dose is 50 mg daily for major depressive disorder and some other indications. - Lower starting doses: Depending on the indication, symptoms, and tolerability, a clinician may start at 25 mg daily before increasing the dose. - Adolescents: When appropriate for the patient's age and diagnosis, treatment may begin at a lower dose. Pediatric use and dosing should follow current, indication-specific prescribing guidance. Starting at a lower dose may be helpful when a patient is particularly sensitive to medication effects or experiences significant anxiety-related symptoms. The goal is to find a therapeutic dose while minimizing avoidable adverse effects. 2. Fluoxetine (Prozac) Fluoxetine is another commonly prescribed SSRI used for depression and other conditions, depending on the patient's age and diagnosis. - Adults: A common starting dose for major depressive disorder is 20 mg daily, although the appropriate initial dose can vary by indication and patient factors. - Lower starting doses: Some patients may benefit from beginning at 10 mg daily, followed by gradual titration when clinically appropriate. - Children and adolescents: Initial dosing depends on age, diagnosis, and the applicable prescribing guidance. A lower starting dose may be appropriate for some patients. Fluoxetine has a long half-life, which is an important consideration when evaluating medication effects, adverse reactions, and changes made during treatment.

When a patient presents with psychotic symptoms for the first time, one of the most important questions isn't simply, “Which medication should I start?” It's this: What is causing the psychosis? The differential diagnosis may include: • Primary psychotic disorders, including schizophrenia-spectrum disorders • Bipolar disorder with psychotic features • Major depressive disorder with psychotic features • Substance- or medication-induced psychosis • Medical or neurological conditions The challenge is that psychotic symptoms can look similar across different conditions, but the underlying causes and treatment approaches may differ significantly. Before settling on a diagnosis, consider the full clinical picture: 🔎 Timeline: When did the symptoms begin, and how have they progressed? 🧠 Mood symptoms: Are there signs of mania or major depression? 💊 Substance and medication exposure: Could a substance, prescribed medication, or withdrawal be contributing? 🏥 Medical and neurological factors: Is further evaluation needed to investigate another cause? 📉 Functioning: Has there been a change in cognition, behavior, self-care, or daily functioning? First-episode psychosis warrants prompt assessment, including consideration of medical causes. A careful diagnostic evaluation helps guide appropriate treatment and avoid premature conclusions. 💡 Clinical pearl: Don't just ask, “What medication should I use?” Ask, “What diagnosis am I treating, and what evidence supports it?” 🎓 Want to strengthen your diagnostic reasoning and psychopharmacology skills? The Psychiatry Masterclass with Dr. Mena offers structured, clinically focused education to help psychiatric clinicians build confidence in psychiatric assessment, diagnosis, and medication management. PREMIUM | $199/month or $1,500/year ✅ All 14 course modules ✅ Video lessons and course materials ✅ Downloadable slides and handouts VIP | $500/month or $3,500/year Everything in Premium, plus: ✅ One-on-one mentorship with Dr. Mena focused on business, branding, and clinical practice