Since the 2004 FDA black-box warning on all antidepressants for pediatric use, controversy continues over the use of SSRIs and SNRIs in children and adolescents. Both classes of medication are still commonly used for pediatric depressive disorders, anxiety disorders, and obsessive-compulsive disorder.

Ketamine has become increasingly popular as an off-label medication for rapid onset treatment of refractory depression. Recently, the American Psychiatric Association convened a task force to review the data and come up with some recommendations.

Evaluating a first episode of psychosis in college students is challenging—it’s not clear from the outset if the episode will represent a one-time occurrence or the start of a lifelong illness. The differential diagnosis is large and includes depression with psychotic features, bipolar disorder, a primary psychotic disorder like schizophrenia or schizoaffective disorder, drug-induced psychosis, and transient psychotic episodes.

If a kid without psychosis says Freddy Krueger’s in the closet and his parents assure him that no one is in there, he will eventually settle down and fall asleep. A psychotic child will not be able to fall asleep and will persist in his belief no matter how much reassurance he receives. Another important clue is if the child has these fears during the day or at school.

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How do you start a new patient on antidepressant treatment? We do this countless times in our practices, and reviewing the topic may feel a bit like returning to residency. However, it’s important to revisit our standard operating procedures from time to time to ensure we’re thinking carefully about our decisions during our busy days.

You’ve tried different SSRIs and then some, but your patient either can’t tolerate what you’ve prescribed or simply hasn’t experienced a lift in mood. Now what? Dr. Gitlin has some ideas.

Your patient has now failed four antidepressant medications, both alone and as cocktails. What else can you pull out of your bag of tricks? Dr. Becker suggests considering transcranial magnetic stimulation (TMS), which he maintains is underutilized. “Many of my colleagues right down the hall from me still don’t think of TMS for treatment or don’t know who to refer for it,” he says. “I think it should be more readily considered for a lot of patients out there.”

For a look at how TMS works, how effective it is, how it compares with electroconvulsive therapy (ECT), whether some brands of TMS machines are better than others, and what you have to do to make sure your patient’s health insurance plan picks up the tab, we spoke with Dr. Becker, who prescribes this treatment for some of his patients.

NeuroStar just announced that the FDA has cleared an updated version of its TMS system. Called the NeuroStar Advanced Therapy System, its primary claim to fame is that patients can receive a full TMS treatment in only 19 minutes, as opposed to the 40 minutes required with NeuroStar’s original system.