Dr. Subramanyan offers video appointments for patients across California using secure, HIPAA-compliant technology provided by Zoom. All you need to meet with him virtually from the convenience of your home or office is high-speed Internet, a webcam and a modern web
browser.
Dr. Subramanyan conducts psychiatric diagnostic evaluations over a 2-hour initial appointment with all patients. Patients are asked to complete a battery of validated screening instruments and ratings scales electronically prior to this appointment. In most instances,
these two processes give Dr. Subramanyan sufficient information to make preliminary determinations about relevant psychiatric diagnoses and a course of action for treatment planning.
If additional time is needed for more complicated clinical presentations, he will recommend a 2nd appointment to continue the diagnostic evaluation. Secure, HIPAA-compliant electronic mail exchange after the initial 2-hour appointment may be used to sort out
diagnostic ambiguities.
Dr. Subramanyan offers second opinion consultations for patients and clinician colleagues who are interested in having a fresh set of eyes review a case. This may be especially helpful in instances where there is diagnostic ambiguity or progress in treatment has
stalled with inadequate symptom relief.
Second opinion consultations are typically scheduled for a 2-hour diagnostic evaluation and all patients are asked to complete a battery of validated screening instruments and ratings scales electronically prior to this appointment. Additional time is often needed to
review medical records and previously obtained laboratory data.
Dr. Subramanyan provides consultations to families and spouses attempting to get an adult loved one with a mental disorder evaluated and treated. He can also provide education about relevant psychiatric disorders that may be at play and discuss motivational
interviewing techniques in non-crisis situations. For families dealing with an adult child in crisis, he can direct you to appropriate emergency services and subacute treatment programs such as residential treatment.
Dr. Subramanyan offers long-term psychotherapy for patients who may benefit from such a course of treatment. Such individuals may have chronic difficulties in forming and maintaining healthy interpersonal relationships and tolerating disappointment/frustration. They
may be prone to extreme emptiness, loneliness, debilitating shame and experience significant fluctuations in self-esteem. As well, they may experience chronic difficulties in the workplace.
In addition to the supportive function of psychotherapy, Dr. Subrmanyan believes that the interpersonal and emotional experience that is co-created by patient and therapist can lead over time to symptom reduction and improved functioning in many instances.
Some patients may not want long-term psychotherapy - nor need it for their problems. Dr. Subramanyan conducts Cognitive Behavioral Therapy (CBT) specifically for the treatment of depression. CBT is a short, time-limited psychotherapy that is highly structured and
can be used in conjunction with antidepressant medication or on its own, depending on the patient's preference and the clinical scenario. For patients with anxiety disorders and Attention-Deficit/Hyperactivity Disorder who desire CBT, Dr. Subramanyan gives referrals
to trusted psychotherapist colleagues in his network who have expertise in treating these conditions with CBT.
In cases of severe, treatment-resistant depression, bipolar disorder, depression with psychotic features, depression with concerning suicidality, catatonia and refractory psychosis, a referral for electroconvulsive therapy (ECT) may be necessary and life-saving.
Although the neurobiological mechanism by which ECT treats severe psychiatric disorders is not fully understood, the procedure elicits an electrical seizure in the brain while the body is paralyzed (to prevent convulsions). ECT can have rapid antidepressant effects,
sometimes after just 1-2 treatments. However, a full “index” course of ECT is usually 12 treatments, administered 3 days a week. Tapering off ECT, combined with maintenance antidepressant medications, may help reduce the risk of depressive relapse. ECT is considered a
medically safe and effective treatment, however it carries a significant risk for memory impairment.
When patients are in a situation where ECT is an appropriate consideration, Dr. Subramanyan refers them to psychiatrist colleagues at select local hospitals who perform the procedure.
Transcranial magnetic stimulation (TMS) is a non-invasive, neuromodulation (brain stimulation) technology that has been FDA-approved for the treatment of depression and Obsessive Compulsive Disorder (OCD) in the U.S. Typically, patients are referred to TMS when there
is some degree of treatment-resistance (lack of adequate relief after multiple medication trials or evidence-based psychotherapies) involved in their case. Approximately 50% of patients will respond to TMS for treatment-resistant depression. It can be thought of as an
"augmentation" therapy when medications, for example, do not provide full symptomatic relief from depression or OCD.
Traditionally-administered TMS has far fewer risks associated with it than ECT, but is generally felt to be less effective and slower to produce an antidepressant response. Newer modalities of TMS, such as the accelerated treatment program developed at Stanford,
called Stanford Neuromodulation Therapy (SNT), and accelerated deep TMS appear to rapidly reduce symptoms of depression, even in treatment-resistant cases. Moreover, they appear to be as effective or more effective than the standard protocol that was FDA-approved in
2008. Notably, when TMS does work for the treatment of depression, the treatment effect is usually more durable than that of ECT. Studies on the durability of accelerated TMS response are ongoing.
Deep TMS (transcranial magnetic stimulation) is a form of TMS that penetrates deeper into the brain than standard TMS. Two different protocols of deep TMS have been approved by the U.S. FDA, one for treatment-resistant depression, the other for treatment-resistant
Obsessive Compulsive Disorder (OCD). These protocols target different regions of the brain that are involved in the pathophysiology of each condition.
Deep Brain Stimulation (DBS) is an invasive procedure that requires neurosurgery to implant an electrode (or electrodes) into specific regions of the brain involved in the neural circuitry of OCD or depression. It is usually a treatment of last resort and is employed
when there is significant distress or functional impairment from OCD and the individual has not responded to other treatment modalities (e.g. various medications, CBT, deep TMS, etc.)
A new form of deep brain stimulation, called closed loop deep brain stimulation, is being studied for treatment-resistant depression in the Department of Psychiatry at UCSF currently.
The professional literature suggests that intravenous administration of ketamine may be more effective than intranasal and oral administration. The bioavailability of ketamine introduced intravenously is 100%. Moreover, the administration can be carefully controlled
over a defined period of time - usually 40 minutes.
This is considered an "off label" treatment for treatment-resistant depression (TRD), primarily, although has been studied in other treatment-resistant psychiatric disorders. Various clinics in the greater San Francisco Bay Area offer intravenous ketamine therapy for
patients with treatment-resistant conditions.
There are instances when standard psychotherapies and FDA-approved treatments do not produce a clinically significant response in the treatment of depression, bipolar disorder, anxiety disorders, OCD and PTSD. In these cases, it may be worth it to an individual to
consider participation in a clinical trial of an investigational agent (i.e. an agent not currently FDA-approved for the given indication).
Dr. Subramanyan stays informed of clinical trials of investigational agents and modalities at UCSF, Stanford and other academic centers and makes appropriate referrals when indicated. Participation in a clinical trial often involves a randomization process, hence
there is no guarantee that the individual will be offered the active treatment being investigated. In other words, patients may end up in the "placebo arm" of the trial or the "sham arm" (for device-based treatments).
Dr. Subramanyan has provided advisory services to digital mental health startups in the early stages of their journey, including Kip Health, Spring Health and Kintsugi Mindful Wellness, three venture-backed companies in the digital mental health space. He keeps
informed of developments in this space and can provide founders without a background in mental health or mental health care delivery about relevant matters that they would need to consider to launch a product or service.
San Francisco Psychiatrists, Inc. is a full fee-for-service practice and is not paneled with any insurance providers. Thus, Dr. Subramanyan's services would be considered "out-of-network" with all insurers. As well, he has opted out of Medicare.