Why Your Mental Health Treatment Isn’t Working—Fix This First
Struggling with depression, anxiety, or insomnia despite medication and therapy tweaks? 🚑 The problem may not be the treatment—it’s the target. In this short lesson, consultant psychiatrist Dr Sanil Rege reveals the PACES framework (Perception, Activity, Cognition, Emotion/Reward, Sleep) and shows how clear, functional goals turn stalled care into real recovery.
#PsychiatrySimplified #MentalHealth #Depression #Anxiety #Therapy #Medication #PACES #TreatmentGoals
► Key takeaways
0:00 Why aimless treatment fails
1:01 Diagnosis ≠ Target: the biggest clinical blind spot
1:30 The 7 domains clinicians can actually modulate (PACES)
2:13 Short- vs long-term goals: stabilise first, then build
2:51 Matching meds & therapy to the right domain
4:10 One action step to start seeing progress today
► Why watch?
• Learn why antidepressants, mood stabilisers, or CBT can miss the mark
• Discover how to set specific functional goals that accelerate recovery
• Understand the “peel-the-onion” principle—improvement is feedback, not failure
• Get a practical roadmap you can discuss with your own clinician
👉 Resource: 3-hour masterclass at Academy.psychscene.com: https://www.academy.psychscene.com/courses/diagnostic-formulation-in-psychiatry/
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PACES Model: https://youtu.be/o-B4pnQwc_s?si=KNysGTl9wG9SXIvK
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29 Comments
Please Dr. What can I do I've been down with panic attacks, anxiety disorder in terms of social anxiety and this has distrupt my day to day life
Excellent information 👌 very well said
Saying that some people have for example treatment resistant depression
What a load of BS. Work on your diet. You are what you eat. Don't choose medications they're just to make money
For a medical student who is suffering from atypical depression , would you say therapy and antidepressants is the only solutuon to recovery ?
I feel like I listen you forever 😊
Hello doc . I live in Perth. How can I approach you? Please doc I need to badly
Thanks 🎉
Please make a video of somatoform disorder. So many people left untreated so many years . They are edge of collapse like me . Many doctors say somatoform disorder is not dangerous because symptoms r not physically but in my opinion symptoms are more worse than they thought. I know because i am suffering from somatoform disorder
This video was excellent. I'm at brand new mental health nurse practitioner. This explanation is a great foubdation to built my approach to treatment. Thank you
Brilliant video.
About 6 years too late for me and not helpful that the treatment I've received has not been effective at acknowledging the significant and real narcissistic abuse I've suffered or even stepped in to sufficiently advocate or defend me when these ill family members have even abused their role in society as physicians (one of them is a psychiatrist) in furtherance of that abuse.
Excellent video! As someone who is battling ADHD and depression, the thing I'm hoping to restore in my life is an overall sense of agency over my body. Many days I feel not in control. I'm stuck living in a body that will not listen to the commands of the mind. More of a somatic experience. Maybe not specific enough? But thanks to your videos I've found more therapeutic options that are slowly improving my sense of agency. Guanfacine has helped with my adhd, and Allegra D has helped with depression (No idea why the latter has been the most helpful? Can you speak more of this/mechanism of action?) Anyways, Thank you Doc!
I know someone who has narcolepsy type 1 but was misdiagnosed and diagnostically overshadowed with “psychotic depression,” because of the narcolepsy hallucinations.
Ssris saves lives never suffer in silence like I did in my late teens for over ten year until i finally seeked help best thing i ever did didnt previously because i was paniking incase they locked me up. Looking back I can laugh about it now but at the time I was very low. When I told the Dr he said others suffered the same symptoms I couldn't believe it I thought I was the only one as we didn't talk about these things back in the 90s and being male
I m aiming to reconnect people , to get back to work that is at stand still, raise energy levels and exercise and sound sleep.
As a psychotherapist this was so helpful to remind one to zero in on specific meanings and descriptions of patient symptoms and goals and what they want to “do.” My goal is to do more specific narrowing of patient’s descriptors and to zero in on goals more. Also, it was so helpful to see the needed foundation checks such as sleep as in the PACES. This helps me in my referral to specific medical specialist and psychiatrists for specific symptoms — to build that foundation upon which therapy can work more effectively. Thank you! ❤
Unfortunately in Canada doctors don’t care and just give you any medication they think is right for them and send you on your way .
Thanks Doc, another succinct video .
Your insights for those seeking help save wasted resource's of both client and consultants .❤💪🏻
We humans are such a melancholic species,and awfully hard on ourselves!!
Spot on with the points you make regards
Motivation planning and execution being key.
Oops , those are the fundamental features of the disability that's hampered my 60 + years of Dyspraxia (developmentally motor delayed human)
We know it all too well !
TIMESTAMPS & Summary (by VidSkipper AI ): Mental health treatment often fails because the goals are not clearly defined; it's crucial to set specific, functional goals and align treatment with those targets, focusing on how you want to act and relate to the world, not just on feeling better.
0:00 🎯 Defining Clear Treatment Targets
• 🎯 Treatment often fails due to unclear goals, not incorrect methods; defining specific goals is crucial for progress.
• 👤 Treatment should focus on the individual's specific issues, not just the diagnostic label; identify what isn't functioning well.
• 🛠️ Use the PACIS paradigm (Perception, Activity, Cognition, Emotion, and Sleep) to target specific domains for modulation.
1:03 🤔 Why Diagnosis Isn't Enough
• 🤔 When a patient says 'I have depression,' identify the specific area affected: sleep, cognition, pleasure, etc.
• ⚕️ Clinicians use the PACIS paradigm (Perception, Activity, Cognition, Emotion, Sleep) to modulate domains, not just address diagnostic codes.
• 🔗 Access a three-hour course on diagnostic formulation at academy.sene.com for practical application of the PACIS paradigm.
2:06 ⏱️ Setting Short-Term and Long-Term Goals
• ⏱️ Break down goals into short-term (reducing hyperarousal, stabilizing emotions, improving sleep) and long-term (reinstating routines, rebuilding confidence).
• 🚶 Recovery involves 'doing better,' which requires specific, actionable goals.
• 💡 Humans evolved for movement; recovery isn't just feeling better, it's about actively engaging with the world.
2:51 🧅 Medications and Therapy: The Right Tools
• 💊 Medications target specific constructs: Clonodine for nightmares, Lamotrogene for racing thoughts and mood dysregulation.
• 🧅 Treating psychiatric disorders is like peeling an onion; improving one domain may reveal underlying issues.
• 🛠️ Therapy is most effective when introduced at the right time; stabilize the patient first before deep psychotherapeutic work.
4:12 ❓ Getting Specific About Goals
• ❓ Instead of vague goals like 'I just want to feel better,' define specific actions: 'wake up earlier, go for walks, talk to people again.'
• 🎯 Target the functions that enable these actions; feelings emerge from how we act and relate to the world.
• ✅ If treatment hasn't worked, it might be targeting the wrong thing; align treatment with functional goals to move forward.
** Generated using ✨ VidSkipper AI Chrome Extension
De Rege i have a question please. How and What do you use or treating insonnia and better sleep restauring in adhd?
am on 45mg mirtazapine still depressed terrible. Tired of life. Extremely exhausted.
Para cargarme a gilipollas que usan esta mierda de trampantojo de control mental de pacotilla.
Do you know why? Because I am not mentally ill. They robbed me, blocked my bank account nearly for one year, ruined kicked me down the stairs, one women spilled drugs in my eye and nose and they are according doctor normal. I slept in cellar when second nanny let sleep baby at toilet, headmaster from kindergarten sat during Covid home, they fired me from work when I needed one day off because of back pain ect….I never ruined anyone's health, I am not alcoholic, I am not on drugs, living three years from my savings, had to pay even for ambulance, everyone has doctor for free in my country…. police, goverment nobody helped… Office clerk in Tábor the Czech republic can't speak English to sort out my stolen clothes luggage shoes….
What if you already know what to do, never expected medication to solve your problems but you fail to get out of self-destructive habits. How to get out of this trap when your own mind becomes a prison ?
This is going to be an enormous message, I apologize and understand if you, Dr Rege, do not have time to read and answer it. Anyone is welcome to share their experience or ideas.
Contextualisation : my psy-patient profile
I am followed monthly by a psychiatrist and have access to good healthcare.
Official diagnosis : I am autistic (on the higher functioning end of the spectrum) with ADHD. I am taking methylphenidate (1 year) and sertraline (3 years). The latter is scheduled for slow taper when I am doing better.
Not really diagnosed separately and probably intertwined with my autism and adhd but I still consider them big pieces of my puzzle :
1. Personnality
A. Obsessive-compulsive tendencies / Perfectly matching nearly all criterias for obsessive-compulsive personnality disorder
B. Cluster of extreme perfectionnism / procrastination / indecisiveness
2. Emotions
A. Complete absence of interpersonal emotional attachment, or to say it in a simpler way : inability to feel love or genuinely care for people / Perfectly matching nearly all criterias of Schizoid personality disorder
B. Lingering but manageable social anxiety
I've also been suffering from Post Acute Covid Infection Sequelae (long covid) for 7 months now with cognitive impairment as the main symptom ( = "brain fog" associated with a tension headache) showing very little sign of improvement lately. I would describe this impairment as life-ruining if I didn't have hope to recover. It acted as a catalyst for all the other issues and made these past few months the most painful in my life.
End of contextualisation
It's been many years now and I have kept reinforcing those toxic patterns of addiction, avoidance, indecisiveness, procrastination, perfectionnism… ever since I was a kid. I have grown into someone I hate while being more or less aware of it the whole time. My actions have always been in opposition to my goals and values as I have always fallen to the hedonistic temptation of internet addiction (first with consoles as a kid), food binges, then drugs (alcohol included) as an adult thankfully.
I have tried over and over and over again to take actions towards my goals and consistently relapsed after a few days of success… An unbreakable hope for change was keeping me from giving up. I've realized it was something already documented called avoidance coping with delusional beliefs about my ability to become anything and change at will to cope with the reality of my failures, avoiding painful events (such as exams after not studying) by just not going or painful tasks (like making an important decision) by just completely not thinking about them and procrastinating as long possible, giving up last minute either because of indecisiveness or fear of failure.
It feels like 2 distinct and opposite personnalities : the short-sighted compulsion-driven monkey and the one I want to be ALL THE TIME. It tends to be very binary, either junkie mindset or progress mindset at a given time.
I've been stuck in this cycle for now more than a decade. For the first time ever, I have silently given up with less and less attempts to work towards my goals and more long periods of complete hedonism, seeking whatever will make me feel better, distracted, insterested or high in the moment with no consideration for the future consequences, even as near as the following day.
I'm losing hope. How to break out of deeply rooted patterns destroying your life ? How to escape the jail in your mind ?
This is sooo good!!!
"Stabilize first – then build." How do I "stabilize"?
I know what I want, what my goals and dreams are. But all my psychiatrist has to say is, "just do it". Yet, "just doing it" clearly doesn't work the way it sounds, otherwise I wouldn't be in this messy situation. When I try to "just do it" and force myself into what I feel is expected of me, I burn out faster than a candle drenched in gasoline, and I end up feeling worse than before.
Dr Rege, I want to ask you some serious questions. And I am writing this to you with a lot of hope to be helped. I did not have any major mental health issues or probably the ones that could have been resolved on their own or probably with some therapy. But i have taken over 40+ Psych meds with over 4 docs in India. Then a final opinion concluded that so much treatment wasn't even required. Plus took the rtms treatment without a clear indication. On stopping fluoxetine, i lost sleep, weight and now memory problems. Reintroducing meds didn't work well. I still can't sleep and i have never had sleep issues ever. I take a melatonin 3mg that barely helps me sleep. I have changed my dr but case is somewhat not clear as to why so much issue with sleep and memory. The use of meds for no substantial reason can cause loss of brain cells that produce neurotransmitters? Is this the cause? Or the withdrawal is still lasting and brain struggling to regulate neurotransmittera production and balance? Receptors overwhelmed? Can i heal and recover from this? Career and life at stake. Request you to please help out. Your guidance will be obliged. Thanks
Fabulous clip. Fantastic doctor.
Do some patients do better with Jornay PM? Is it less potent than Vyvanse? Is it smoother?
If we can fix stupidity we'd be right