It hasn’t even been a week and I have another patient lying to me to get more benzodiazepines. I think it’s a combination of having a lot of anxiety about patient safety, and also having had a life-long pet peeve around people lying. I keep trying to remind myself that lying is a symptom of addiction, but that only gets me so far. I see so many patients talk about being “treated like criminals,” but I don’t know how someone can stay trusting in this role. It also makes me really hesitate to want to use benzodiazepines at all even in short term situations because I recently had a different patient try to manipulate me into giving him more beyond what we agreed on. At the same time, I don’t want to become that way. I think there are some people who can benefit from having a few PRNs per month. Looking for some sage advice here.

One of the units I cover is a detox unit and we get some treatment resistant cases of alcohol withdrawal.

A patient can be on 10-12 mg of Ativan during one day and still have elevated CIWAs.

In these cases the RNs ask me to prescribe Librium because the last doctor who worked there would do so but oftentimes their liver enzymes are in the mid 200s and I only have one lab draw to go off of.

If their CIWAs are still elevated would you give Librium.in cases where liver enzymes are 200 plus or would you hold off due to risk of liver toxicity?

I'm a master's-level therapist, and in my jurisdiction, diagnosis is restricted to psychiatrists and doctoral-level psychologists (probably for the best, lol). I've noticed that psychiatrists I've worked with seem fairly divided on whether to disclose diagnoses of ASPD or NPD.

Some feel that transparency is important and that patients have a right to understand their diagnoses. Others have told me they avoid disclosing these diagnoses or documenting them in the chart because there are few robust, evidence-based treatments available, and they worry that disclosure could damage the therapeutic relationship without offering much practical benefit. So they simply focus on treating symptoms.

I recognize that there is some evidence supporting approaches such as TFP, schema therapy, and MBT for NPD, but my understanding is that the evidence base remains limited, and these treatments are inaccessible to most patients anyway.

I'm genuinely curious how other clinicians approach this. Do you disclose these diagnoses routinely, selectively, or not at all? How do you weigh transparency and patient autonomy against potential stigma, effects on the therapeutic alliance, and the practical implications for treatment?

I can see arguments on both sides and would be interested in hearing how others navigate this.

Hi all. Not sure what I’m looking for here. I’m a PGY2, and hate everything I think. Just got berated again on the inpatient unit for the 50th time, almost cried. I’m so sick of this. I’m so jaded towards the patients now. I don’t think I’d like outpatient either because it seems so boring and I don’t want to just feel like I’m handing out pills. I don’t see myself doing child or the other psych fellowships. And it feels too late to switch to another specialty. So at this point I don’t even know what to do. Does anyone here have experience doing a second residency? Is that feasible? That’s the only option that gives me hope at this point

Hey there! I am a third-year medical student exploring different specialties, and psychiatry is one that has really caught my interest. I’m hoping to get some perspective from practicing psychiatrists and residents about what the specialty is actually like beyond what we experience during medical school.

I have a few questions:

1. What makes someone a good psychiatrist? Are there certain personality traits, skills, or qualities that you think separate a good psychiatrist from a great one?

2.How satisfied are you with your career? Are you happy with your compensation, work-life balance, and overall quality of life? Has the specialty met your expectations?

3. What are the biggest downsides of psychiatry? What aspects of the job frustrate you, and what do you wish you had known before entering residency?

4. What do you find most rewarding about psychiatry? What keeps you interested and motivated in your work?

5. Would you choose psychiatry again? If you could go back to medical school, would you make the same decision? Why or why not?

6. What advice would you give a medical student considering psychiatry?

I’m trying to understand both the positives and negatives before making a career decision. I’m particularly interested in the long-term career satisfaction of psychiatrists and how the specialty compares with what you initially expected.

I’d really appreciate hearing your experiences and perspectives. Thanks in advance!

Outpatient attending here. Have had an influx of adults in their 40s/50s coming to clinic with an outside ADHD diagnosis. Usually from an LPC or therapist in the community that did a couple diagnostic sessions, sometimes without even getting collateral info or childhood records.

Patient waltzes into clinic with their diagnosis paperwork. Asks for stimulants. They know exactly what to answer during my ADHD assessment. They don’t meet criteria for other disorders. Use all the TikTok buzzwords like “rejection sensitive dysphoria” and “executive dysfunction”

They all mysteriously have the same flavor of ADHD… “I was a well behaved child, good student, good grades” and have a college degree and did just fine in their career until now. Suddenly they’re struggling and it MUST be ADHD.

What do you do with these patients?

This piece was inspired by residents, especially those who have reached out asking more about this topic. Just some thoughts on how to think about language and use it in your formulations.

https://affectbeforediagnosis.substack.com/p/salem-needed-a-mental-status-exam?r=1pr2tf&utm_campaign=post-expanded-share&utm_medium=web

Accepted to an MD program in the northeast (Tier 1 Research via USNews)

I have a strong research background in neuromodulation and am developing contacts in academic psychiatry in Boston, NYC, and SF

I am specifying this because I am interested in pursuing a private cash-pay practice that offers interventional services, with some days telepsych and room to scale the practice over time

I also want to involve myself in industry. Whether through hosting trials, biotech consulting, or equity, I am undecided

Practically speaking, what is the realistically attainable upper-end income on a model like this, after overhead is taken into account? I understand that initial time investment would be high

Separately, how drastically might the landscape change 10 years from now, in terms of therapies?

I expect personalized medicine and new stimulation protocols, but I was wondering if standardized treatment options could also be adopted in that timeframe (ie. transcranial ultrasound, psilocybin, etc.) like how TMS and esketamine are now

And as neuromodulation/circuit-based models progress, where is the line drawn between neurology and psych?

I have considered neuro and functional neurosurgery, but I prioritize work-life balance

I'd appreciate perspectives on any of these questions, especially from people combining clinical practice, neuromodulation, and industry work

As practitioners in psychiatry, we consistently work to combat mental health stigma and anti-psychiatry sentiments. However, inadequate training among mental health nurse practitioners contribute to poor diagnostic skills and medication management, which will ultimately cause negative patient experiences. I can’t see how these experiences would not further reinforce existing stigma and undermine trust in the field. There are great nurse practitioners but the current amount of inadequately trained nurse practitioners, especially PMHNPs, is concerning to say the least to the field of psychiatry.

I've consistently heard that Headway has been able to get rates better than folks who try to contract with insurance directly. But I have yet to see what rates Headway actually offers. I reached out but haven't heard back from them yet. Google says this... and just wondering if this is accurate to what folks have been able to get with them. TIA!

Recently, a supervisor recommended me this book on the subject of Paraphilias and its treatment. Can anybody tell me if this is a good book on the subject or not ?

Hello everyone, I'm a psychiatry resident moving between sites and I'm currently at a site that recommends weekly troponin I and CRP labs to evaluate for myocarditis development in patients started on clozapine in addition to the standard CBC with diff for ANC levels.

Now don't get me wrong I fully believe clozapine induced myocarditis is real, and I fully intend to follow the policies of the hospital I am in. However every single part of my IM and EM training from medschool and residency is screaming at me to not check these labs in asymptomatic patients due to high risk of false positives. I've known cardiologist who i'm pretty sure would kill me for checking it in an asymptomatic patient in the ED. I've tried looking up the guidelines on APA, pubmed, and from the FDA and while they all note the risk of myocarditis they only recommend checking troponin I and CRP after symptoms actually develop instead of pre-emptively in asymptomatic patients.

My current site recommends immediate clozapine cessation in anyone with a bump in troponin or CRP due to risk of myocarditis but I feel like these labs can have such low specificity in asymptomatic patients that we're risking kicking off a bunch of people who could otherwise benefit significantly from it.

I was wondering what everyones thoughts on this practice were.

I am a medical student trying to understand where the seizure risk from bupropion comes from in restricting patients with anorexia nervosa. I know bupropion is contraindicated in bulimia and anorexia due to seizure risk. I was taught the electrolyte imbalances from purging in bulimia combined with the activation from bupropion lower the seizure threshold together. The only study I can ever find about bupropion and eating disorders is this one, which does not include subjects with anorexia, only bulimia. Is the seizure risk from bupropion still there in anorexia, even in the restricting subtype without binging/purging?

I'm currently looking for a second part-time gig and would like to get a better sense of the market compensation. I'm in an East Coast VHCOL area. For those working on an hourly basis at an outpatient clinic, how much are you paid? I've recently spoken with recruiters for 2 different clinics in the area, both offering what seemed like rather low pay ($150/hr as a 1099 contractor, no RVUs, no benefits, 20 hours a week). Is this typical or are these lowball rates?

I'm a PGY-1 psychiatry resident at a large, old psychiatric hospital. The program is 5 years, the formal teaching is poor, and most of my attendings have limited experience. I have no other program to move to, so this is where I'll train.

Some context on the setting:

I have a lot of autonomy. I can spend as much time as I want with patients and make my own decisions about their medications.

Many of our patients are chronic, with histories going back to 1980.

There's no ER, no OPD, and no consultation-liaison service, so my exposure is almost entirely inpatients.

I've been a self-learner since med school, and I'm willing to study everything on my own. My plan is to build a structured curriculum around deliberate interview practice, in-depth psychopathology, and systematic psychopharmacology from textbooks, guidelines, and primary literature.

My questions:

Is it realistic to become a good psychiatrist this way, given the gaps in my setting?

How would I fill those gaps?

What would you prioritize in year 1, and which resources would you use?

Thanks!

mine is that although I appreciate his podcast, I find David Puder so irrationally annoying🫣

I have a patient and I really want to help him in this areas , but after nearly 6 weeks he is still unfazed and in the same place when it comes to Negative symptomes
Any thoughts ?

Edit: to clarify, yes I meant PhD Dr

And also I do prelim/final Dx on a lot of Pts regularly, mostly due to Psychiatrists availability. I did this before I was signed off 🫣 at the start “Acute stress reaction” was my diagnosis for every case but the more I was exposed, the more confident and better I got. Case conference with MDT obviously before discharge…

In saying that; I’m the expectation the rule, most MH clinicians in my team - those especially with social work background, should not be diagnosing or even implying Dx to MDTs…. I have nothing against social workers, in fact, they have a really important role to play but staying in our lane is really hard when your rural & APS has made it extremely hard for psych undergrads to work in the field/learn.

Learning from the psychiatrists has been good for medication, diagnostic differentials, but I wouldn’t go to any of them for CBT… maybe ACT but that’s an expensive ACT session(s)

Like most tho, some good, some not so good, some really bad - like most fields.

Have a good weekend y’all

Officially became a psychologist recently! Long journey, but made it.

I work alongside some brilliant psychiatrists in a community mental health team & I’ve found all of the more seasoned ones, extremely respectful of my profession & turn to me for advice on “therapy” but I have heard notions that some might consider psychologists “not real doctors”

As an FYI- I’m Australian so I don’t need to be a doctor to be a psychologist but I have spent 7 years studying/interning

I work in public health for now but I’ll likely split 50/50 soon because fuck, the burnout is real my friends.

I’m curious how others are approaching the endless ADHD assessments, especially when the reported symptoms described by the patient do seem to meet criteria, but the overall clinical picture leaves some uncertainty. I saw that now 25% of adults think they have ADHD, and perhaps it could be true, or due to social media, or the difficult capitalist society we live in.

I know cross-setting impairment and childhood symptom onset have been to key to look for. I spend multiple sessions and incorporate different screening tools, such as the Wender Utah, BAARS, ASRS. I ask about potential OSA as well, have recommend sleep studies to some. Despite all this, over the past few months, I’ve noticed more and more patients during the assessment are providing multiple examples of their symptoms in childhood than I ever experienced earlier in my practice. I sometimes wonder if this is because the public has learned through tik tok or other outlets that childhood onset is necessary to mention “to get diagnosed”. For this reason, I am concerned about potential over diagnosis.

A recent Danish study found that two psychiatrists agreed on any DSM-5 diagnosis only 55% of the time, which speaks to the challenges with diagnostic reliability. There’s also so much variability in prescribing practices, I see so many different things in the large group I work in; from stimulants in patients with moderately elevated BP without any cardiac clearance, some clinicians chosing to diagnose/prescribe to patients using cannabis, no age restrictions/guidelines when it comes to older adults.
With the ongoing demand for stimulants, I’m finding both new evaluations and requests to continue prescriptions from previous providers increasingly challenging because of this.

Should I continue to just take what i hear face value, or is there more I could be doing to properly diagnose/rule out exaggerated responses? Am I over thinking this more than necessary? My overall panel is varying between 17-20% total patients having an ADHD diagnosis, which is more than it has ever has been over the years I’ve been in the field…

let’s say one of these patients with 900 vague and disconnected symptoms (and various self diagnoses) lands in your lap — with a full panel of negative medical testing. how do you manage them?

I have recently seen people saying behavioural activation doesn't work / needs to be modified for ASD because (purportedly, not that I agree) ASD works differently to other conditions of low energy / amotivation (again not that I agree autism is one of these conditions). I have seen this both in professional spaces and personal spaces where the term 'spoons' is used. The alternative to behavioural activation tends to be environmental modification and a slower life to suit the disability.

Related, I have also heard the stories of those who have gotten autism diagnoses and then 'realised' that they were pushing themselves too hard all along towards a road of autistic burnout and since then have begun to listen to their body and reduce their workload. I say relatedly because this seems like 'behavioural de-activation' if there ever was such a term and frankly it seems like their life is worse and less functional but supposedly they are happier than ever.

At the same time I am aware there are indeed some syndromes where the mainstay is not behavioural activation but just lots of rest when needed.

Thoughts?

Has anyone quit a job earlier than what was indicated by their contract. Job is an inpatient child psychiatrist role. The job is fairly demanding and was initially described as "cush." They deliberately held interviews during a lower census month. On call for 7 days straight 2 weeks a month. Only one other covering provider, no PTO. Have to be available for consults for multiple hospitals in the ED or the medical floor in addition to the unit which may or may not lead to a demand for full consultation. Was described as initially covering for 2 hospitals and 2 potentially 3 EDs, this expanded to other EDs with incorporation of late night same day care coordination meetings.

I've spoken with a lawyer but the contract specifies that the earliest for termination without cause is 24 months. That's with notice given 6 months prior end date. Otherwise potential of being sued unless there's a breach of contract. Which short staffing the role doesn't count as a breach.... Even if there's something that they're not doing well they have 30 days to rectify the problem. Any recommendations?

Just wanted thoughts before I potentially go back to the lawyer as the fees add up and I don't have another job waiting in the wings. After $1500, they've told me little I didn't already know so I don't want to go back to them unless a) we're reworking the contract for an earlier termination (not sure this is likely) or b) I'm being sued.

to be clear the lawyer told me I should ask for accommodations like time out on my "shifts." must of my days off I'm still recovering or catching up on notes and or notes being asked to attend monthly census meetings.

Omg did anyone else just get the biggest jump scare of their life with that ABPN email today?? 💀 my smart watch showed my heart rate instantly jumped to 110...

I just started a job as an attending and I wanted to renew my APA membership and it will cost me around $1000 to activate the membership. I was shocked of how expensive it is especially that I’m not an active participant in caucuses or present yearly. I primarily need for the monthly journal.

Is APA membership actually worth it, how can you justify such fees

FYI: Iam in HQOL city so there are mandatory extra fees included

Hi guys! I'm a current MS3 struggling to decide my specialty. I am thinking to open up my own private practice and eventually try to be more on the business side.

I was very interested in ophtho since MS1 because I just found the eye to be very fascinating and whenever I get a chance to see it through slit lamp it just looks very cool (almost like planets and everyone's is different). It also has great lifestyle and good pay. However I feel like my stats are pretty bad applying to ophtho and might need to duo apply.

On the other hand, I really enjoy talking to different people and socialize with them, which is why I think psychiatry is my #2 specialty that I want to go to. However, I am very invested in ophtho at this moment and did not start looking that in depth regarding psych. I just know when comparing salary wise optho is definitely higher, but I'm not sure how the private/business aspect looks. I also endorse the idea that psych can be done hybrid/full-telehealth so I don't need to deal with the horrific LA traffic and spend more time gardening and doing my yard work.

I haven't done either surgery or psych rotation yet, so things might change and there is always time for me to switch my mind. But I would very appreciate if there is any insights, especially to the private practice side of things like lifestyle & take home salary, etc. Thank you guys!!