Tampa Neuropsyciatry is now offering the recently FDA-approved treatment, Esketamine (Spravato). Esketamine is a molecule that is the mirror image of the better known ketamine. Ketamine was initially FDA-approved as an anesthestic to be used during surgical procedures. In the early 2000’s, ketamine was studied for the treatment of depression. Interestingly, ketamine was found to be fast-acting with antidepressant effects noticed within hours of injection. While it was also found to be short-lived, the antidepressant effect lasted for several days. Importantly, another potential benefit is the decrease in suicidal thoughts.

Apart from its remarkable effects on depression, ketamine became a particularly interesting treatment for depression due to its novel mechanism of action. It doesn’t work like any other antidepressant, rather it is theorized that ketamine’s effects on depression are caused by an increase in the production of brain growth factors called neurotrophins.

Due to the fact that Ketamine does not absorb effectively when taken orally,  the clinical trials were conducted with intravenous (IV) administration. This, however, made the wide-spread usage of ketamine for depression less accessible to all patients.

As a result, the pharmaceutical branch of the Johnson and Johnson company then began testing ketamine’s mirror image, esketamine, in an intranasal formulation (nasal spray). After rigorous testing, the FDA approved esketamine in March of 2019 for the treatment of major depressive disorder. More specifically, it was approved for treatment-resistant depression (TRD) which is considered depression that has not improved with traditional antidepressants.

The clinical trial results found esketamine to be very effective in both response (over 50% improvement of depression) and remission (over 90% improvement of depression). It was also found to be effective in keeping depression at bay once it improved or resolved. One crucial finding in these clinical trials was that people who had tried more antidepressants actually had a higher likelihood of getting better with esketamine. This is of particular importance because practically all treatments for depression have been found to be the opposite – the more medications you have tried, the less likely you are to get better. This is true of traditional antidepressants, transcranial magnetic stimulation (TMS), and also electroconvulsive therapy (ECT).

In the esketamine clinical trials, safety was looked at in detail. The participants who were given esketamine were much more likely than those given placebo to have the following symptoms: disassociation, sedation (feeling tired), dizziness, nausea, tingling sensations, dry mouth, and increased blood pressure. Of the side effects, the most unusual for an antidepressant was the dissociation. Dissociation includes the following descriptions: feeling weird, spacey, loopy, floating, visual disturbances, trouble speaking, confusion, numbness. The good news was that in the vast majority of cases, these side effects resolved within two hours. Because of these side effects, the FDA decided that esketamine should be given only in doctor’s offices or hospital settings where they would require a two-hour monitoring period after administration of esketamine. It was also required that after receiving esketamine, people should not drive until the following day.

The FDA outlined the following treatment regimen: Two treatments per week for the first month, then one treatment per week for the second month, and one treatment every two weeks for month three and beyond.

Although the treatment process is cumbersome, those with depression will tend to agree that it is worth it to finally achieve relief. In my psychiatry practice, it is very common for me to see folks with depression that has lasted for years and not improved with traditional antidepressants. Esketamine has been long-awaited by psychiatrists nation-wide. My patients and I are grateful that a novel, effective, and safe treatment is now available and ready for use.


What is neuropsychiatry?

Neuropsychiatry is the field of medicine that studies and manages diseases of the brain that affect emotion, behavior, or cognition. This can mean either managing primary psychiatric disorders like major depressive disorder or bipolar disorder with an emphasis on their biological aspects, or managing emotional, behavioral, or cognitive problems that are very common with primary neurological disorders like parkinson's disease or multiple sclerosis.

One major aspect of neuropsychiatry is the study and management of dementia, which seems to lay at the intersection of psychiatry and neurology. This is a particular interest in neuropsychiatry as symptoms are a clear consequence of specific areas of the brain which are degenerating.

In fact, much of our knowledge of brain function has come from the study of dementias, as specific dementias target specific brain regions.

Who practices neuropsychiatry?

Both psychiatrists and neurologists can practice neuropsychiatry. The term 'neuropsychiatrist' can actually be used by any psychiatrist or neurologist, depending on their scope of practice. A neuropsychiatrist will traditionally spend a significant amount of their practice either studying or treating diseases which involve injury having occurred to the brain. This can mean either traumatic brain injury, stroke, parkinson's disease, multiple sclerosis, Alzheimer's dementia, frontotemporal dementia, and many others.

The United Council of Neurological Subspecialties now requires either psychiatrists or neurologists to complete a one to two year fellowship (training program) in order to qualify for board certification in neuropsychiatry.

How do I find a neuropsychiatrist?

To be blunt, there aren't a lot of us. Most are working at larger hospital systems or university hospitals. Unfortunately, the best way to find someone is to do a google search for your town/city/state. One great resource is the website of the United Council of Neurological Subspecialties, where you can find a list of physicians who are board certified in neuropsychiatry and behavioral neurology. Another resource is your state's Brain Injury Association, which may have a list of physicians that practice neuropsychiatry. Lastly, a neuropsychologist in your town/city will most likely know which psychiatrists or neurologists in your area have this type of expertise.




What is a traumatic brain injury versus concussion?

What is Traumatic Brain Injury (TBI)?

TBI occurs when physical trauma to the head results in injury to the underlying brain. A concussion is a mild severity TBI. As an example, a person who is playing football can hit their head on the field but have no injury to the brain. Although this is a head injury, it is not a TBI. A more severe injury of the same type can injure nerve cells within the brain, which we would call a TBI.

We deduce that injury to nerve cells has occurred if any number of neurological symptoms are present immediately after the injury. This includes confusion, loss of consciousness, or memory impairment. Brain imaging techniques like CT or MRI can be helpful in grading the severity of the injury.

What are the consequences of Traumatic Brain Injury (TBI)?

The symptoms that people commonly encounter include headache, dizziness, poor concentration, fatigue, insomnia, depression, anxiety, and impulsivity. About 80 to 90 percent of mild TBI / concussion symptoms resolve within three months of the injury.

It is common for emotional or behavioral problems (such as depression, anxiety, irritability, impulsivity, apathy) to persist despite the resolution of neurological symptoms (headache, dizziness, visual problems. The emotional and behavioral problems that occur with TBI are the result of disrupted brain circuits. These symptoms can mimic traditional psychiatric disorders like major depression, bipolar disorder, and schizophrenia.

Another major problem that occurs after TBI is cognitive impairment, which we can describe as problems with processing information. There are a number of different ways in which we process information including storing memories,  pulling memories from their storage sites, organizing/sequencing/executing tasks, focusing on tasks, and shifting attention from task to task, amongst others.

How do you treat the consequences of Traumatic Brain Injury (TBI)?

As will all neuropsychiatric disturbances, the basis of treatment starts with a diagnosis. An understanding of brain circuits is necessary to understand how TBI can result in certain clusters of either emotional, behavioral, or cognitive symptoms.

In traditional psychiatry, a person who has decreased interest in pursuing their usual activities will be thought to have depression. Whereas, in the absence of other features of clinical depression, a neuropsychiatrist may recognize this to be an apathy syndrome due to a specific area of the brain that has been injured.

Similary, traditional psychiatry may view someone with mood swings and aggression to have bipolar disorder, in the absence of other features of bipolar disorder, a neuropsychiatrist may recognize this to be a dysexecutive syndrome due to certain areas of the brain that have been injured.

It is also important to note that neuropsychiatric symptoms in the context of traumatic brain injuries can result in hormonal imbalances, sleep disorders, seizure activity, or even disturbance of brain areas involving vision.

Cognitive impairment can be difficult to diagnose without formal evaluation and testing. As mentioned for other neuropsychiatric problems, the basis of treatment starts with a diagnosis. Once we know which cognitive domains are impaired, we will know which treatments will be most helpful.

Overall, treatment of TBI is through medication, psychotherapy, rehabilitation psychology, cognitive rehabilitation through speech/language therapy, occupational therapy, physical therapy, and vision therapy.





What is depression?

There are several criteria that psychiatrists use to make a diagnosis of depression. The most important are when some has depressed, sad, or low mood for the majority of each day and nearly every day of the week. A person with depression also has difficulty feeling joy. Things that used to bring them joy, for example hobbies, or even the small pleasures of every day life like conversations with friends, having a nice breakfast or lunch, no longer do it for them.

When this persists, and is accompanied by a number of other symptoms, for weeks at a time, and interfere with a person's normal daily functioning, we are likely to make a diagnosis of 'major depressive disorder.'

What needs to be made clear is that depression can be debilitating. It is hard to understand without having experienced it, and this is one of the reasons why people tend to keep it to themselves. Depression affects all realms of one's being, from their work life, social life, family life, and even spiritual life. It drains them, and can get to the point where all one sees is hopelessness. It is common for depression to lead to suicidal thoughts or suicide attempts.

What causes depression?

The simple answer is that there are numerous causes. We can break them down into two broad categories: genetic and environmental. Depression, like other psychiatric problems, commonly runs in families, but the majority of cases do not have a strong genetic component. As such, we tend to think of depression as being the consequence of vulnerability factors, like genetic predisposition, and precipitating factors, like stressful life events.

Neuropsychiatry involves the study of brain functioning as it relates to psychiatric disorders. Our view on things is a bit different from the field of psychiatry at large. We tend to see depression as being the consequence of abnormal brain functioning, which has been well documented in scientific studies in which functional brain imaging reveals abnormal brain functioning being alleviated by both biological and psychological therapies.

The question remains, what causes abnormal brain function? A plethora of causes have been found: dysfunctional neural circuitry, hormone imbalances, vitamin deficiencies, traumatic brain injury, stroke, stress response, medication side effect, psychological abnormalities, etc.

How do you treat depression?

Firstly, treatment is only effective if you have a proper evaluation which leads to a diagnosis. As there are numerous causes of depression, there are also numerous treatments. Without a thorough evaluation, depression tends to be reflexively treated with either antidepressants or psychotherapy. Although this can be effective in a large number of cases, it does not help everyone. It is necessary to address all of the factors that are contributing to the depression.


Publications in Peer-Reviewed Journals

Program of Enhanced Psychiatric (PEP) Services for Patients with Brain Injury & Neuropsychiatric Disturbances (NPD): A Proposed
Model of Care

Faizi Ahmed, M.D., Kathleen Bechtold, Ph.D., Gwenn Smith, Ph.D., Durga Roy, M.D., Anita Everett, M.D., Vani Rao, M.D.


Neuropsychiatric disturbances associated with brain injury occur frequently and are a common cause of poor quality of life and caregiver burden. These disturbances can disrupt rehabilitation therapies and contribute to functional impairment if they are not appropriately treated. Although some patients can be treated adequately in an outpatient brain injury clinic or rehabilitation clinic, others need a more specialized structured program. Behavioral problems in particular are challenging and often lead to discharge of patients from traditional rehabilitation programs because their behaviors can be disruptive and/or harmful to themselves and others. These patients are often admitted to inpatient general psychiatric units, where they do not receive the comprehensive care they need. In an effort to prevent unnecessary hospitalizations and to provide comprehensive treatment, a community-based, multidisciplinary program was developed to address the physical, cognitive, and psychiatric needs of patients with brain injury. The program is highlighted with two case presentations: (a) a 31-year-old man with severe traumatic brain injury with subsequent cognitive and behavioral symptoms who had improvement in symptoms and quality of life, and (b) a 38-year-old woman with cognitive and mood symptoms after left temporal lobe resection due to medication-refractory epilepsy who had improved mood symptoms and daily life functioning. Brain injury is commonly associated with a host of neuropsychiatric symptoms that wax and wane. There is an urgent need to develop comprehensive programs that can address the multiple needs of this patient population in a community setting.


Faizi Ahmed, M.D., Kathleen Bechtold, Ph.D., Gwenn Smith, Ph.D., Durga Roy, M.D., Anita Everett, M.D., Vani Rao, M.D.. Program of Enhanced Psychiatric Services for Patients With Brain Injury and Neuropsychiatric Disturbances: A Proposed Model of Care." The Journal of Neuropsychiatry and Clinical Neurosciences 28.2 (2016): 147-152.


Neuropsychiatric disturbances associated with traumatic brain injury: a practical approach to evaluation and management

Vani Rao M.D., Vassilis Koliatsos, M.D., Faizi Ahmed M.D., Constantine Lyketsos M.D., Kathleen Kortte, PhD.

Traumatic brain injury (TBI) causes a wide variety of neuropsychiatric disturbances associated with great functional impairments and low quality of life. These disturbances include disorders of mood, behavior, and cognition, and changes in personality. The diagnosis of specific neuropsychiatric disturbances can be difficult because there is significant symptom overlap. Systematic clinical evaluations are necessary to make the diagnosis and formulate a treatment plan that often requires a multipronged approach. Management of TBI-associated neuropsychiatric disorders should always include nonpharmacological interventions, including education, family involvement, supportive and behavioral psychotherapies, and cognitive rehabilitation. Pharmacological treatments include antidepressants, anticonvulsants, antipsychotics, dopaminergic agents, and cholinesterase inhibitors. However, evidence-based treatments are extremely limited, and management relies on clinical empiricism and resemblance of TBI neuropsychiatric symptom profiles with those of idiopathic psychiatric disorders. Although the understanding of TBI-associated neuropsychiatric disorders has improved in the last decade, further research is needed including prospective, longitudinal studies to explore biomarkers that will assist with management and prognosis as well as randomized-controlled studies to validate pharmacological and nonpharmacological treatments. The current review summarizes the available literature in support of a structured, systematic evaluation approach and treatment options as well as recommendations for further research directions.

Vani Rao M.D., Vassilis Koliatsos, M.D., Faizi Ahmed M.D., Constantine Lyketsos M.D., Kathleen Kortte, PhD.Neuropsychiatric Disturbances Associated with Traumatic Brain Injury: A Practical Approach to Evaluation & Management. Seminars in Neurology. 2015 February, 35(1):64-82