POSTING RULES:

PHQ-9: Mood Check, No Cap

In the past two weeks, how often have these been hitting different?

Not vibing with stuff you normally love?

☐ Nah, I’m chill

☐ Eh, sometimes

☐ Fr tho, a lot

☐ Deadass, nonstop

Feeling like a whole sad playlist IRL?

☐ Nah, I’m good

☐ Lowkey, yeah

☐ Big feels, for real

☐ Every day, I can’t

Sleep schedule wrecked? Can’t sleep, or snoozing like it’s a sport?

☐ Nope, I’m solid

☐ Kinda sometimes

☐ Yeah, it’s bad

☐ All day or no sleep

Energy on E? Like, zero motivation to do anything? Battery stuck at 1%?

☐ Nah, I’m fine

☐ Meh, sometimes

☐ Yeah, I’m dragging

☐ 24/7 tired vibes

Eating weird? Either forgetting to eat or munching on everything?

☐ All good here

☐ Once in a while

☐ Pretty often

☐ Constant struggle

Feeling like the worst, like you’re failing or a letdown?

☐ Nope, I’m cool

☐ Occasionally

☐ Yeah, that’s me

☐ All day, every day

Brain lagging? Focus just not focusing?

☐ Nah, I’m sharp

☐ Sometimes distracted

☐ My brain’s on airplane mode

☐ Straight-up buffering all the time

Moving in slow-mo or zooming around like you're on 3 energy drinks?

☐ Nah, I’m steady

☐ Occasionally

☐ People notice, fr

☐ Constantly one or the other

Dark thoughts? Like “What’s even the point?” or worse?

☐ Nope, I’m good

☐ Kinda here and there

☐ Yeah, it’s a thing

☐ Way too often

If any of this applies, how much is it messing up your life?

☐ Not at all

☐ A lil bit

☐ A lot, ngl

☐ Total chaos

⊽

^^(disclaimer: ^^not ^^scientifically ^^validated ^^in ^^the ^^least ^^bit)

I am interested in psychiatry but feel like I am struggling with my rotation and don't know how to improve.

I am supposed to talk to patients before their appointments and go through a PHQ 9 and fill out a mental status exam. I have no EHR access at all, just names and contact info if they're not in person. My preceptor has told me to get more history but has not given me any further information as to how or what kind of questions to ask. He also is not available to ask questions usually and the office staff can't help. He has told me to be pushier with questions. That makes me a bit nervous because I don't know which patients will take pushing and which won't because I don't know anything about them when I talk to them.

When I try to ask patients why they're seeing the doctor when did their issue start, what kind of problems they have, they get confused or frustrated with me because it should be already known or in their chart. Or they don't really have insight and I don't really know how to ask follow up questions.

I guess I am just struggling with how to ask questions and be better at this rotation and would like advice please.

This thread is for all questions about medical school, psychiatric training, and careers in psychiatry For further info on applying to psychiatric residency programs, click to view our wiki.

I see it way too often. Patients will get quetiapine first line for insomnia with no mental health comorbidities. From what I recall, somnolence effects of quetiapine stem from H2 antagonism of norquetiapine, essentially first generation antihistamine activity. In my opinion, this therapy puts patients at unnecessary risk of EPS, TD, dyslipidemia, and sexual disfunction. In my mind the benefits do not outweigh the risk, am I missing something? Why not try doxylamine or diphenhydramine first?

I am reading this text and several times I've had to stop and say out loud that these are some wild treatment approaches.

The book describes an approach to family therapy for patients with "schizophrenic transaction." If I understand it correctly, the authors believe that psychosis (very loosely defined here) arises from the patient as a way to propagate or correct the family structure, to one that is less threatening.

Has anyone read this book before, can anyone share their thoughts?

Hi guys,

As a resident in psychiatry in The Netherlands, I’m planning on organising a recurring film night for colleagues, which aim is to meet each other in a more casual setting. I’m curious to hear if you guys have any suggestions.

We’d like to explore how mental health is portrayed in film, although mental health does not necessarily need to be the main theme of the movie. I have been to more psychodynamically oriented film nights in the past (so discussions were more centred around intrapsychic conflicts protagonists were experiencing), which I also really enjoyed. Bottom line, the film needs to evoke enough to have some interesting discussions afterwards, and needs to be accessible for people that aren’t hardcore cinephiles as well. I was thinking direction Lighthouse (Robert Eggers), Mommy (Xavier Dolan), Cmon cmon (Mike Mills).

Wondering what those with more experience have to say regarding this. Starting residency this summer in psych and want to be aware of the biggest pitfalls with the DSM yall have noticed. I do think it’s helpful to have some criteria and a certain framework to base our practice in, but by no means do I think it’s a perfect book or system that totally captures the scope of psychopathology. What are yalls thoughts?

Hi everyone, I’ve been working in psychiatry for four years, and during this time, especially by the last 2 years, I’ve encountered cases where patients falsely claim to have conditions like Autism Spectrum Disorder, Dissociative Identity Disorder (DID), or Tourette Syndrome.

This raises a lot of questions for me, such as 1)What might motivate someone to misrepresent these diagnoses? 2)How can we, as mental health professionals, navigate such situations without dismissing genuine concerns? 3)Have you observed any impact of social media on the increasing misrepresentation of these disorders?

I’m curious to hear from others in the field. Have you come across similar situations? How do you approach them, and what strategies have worked for you? Individuals falsely claiming conditions like Autism, DID, or Tourette not only complicate the diagnostic process but also harm those genuinely affected. Their actions make it harder to accurately diagnose and support real patients. This ultimately creates unnecessary barriers for those truly living with these challenges.

Hi all,

PGY-4 here, I recently diagnosed a patient with PMDD and was hoping to ask r/psychiatry for their input regarding treatment.

Patient being treated for PTSD, MDD and GAD with venlafaxine 300mg daily, mood symptoms overall well-controlled up until recently when she began noticing increased irritability and low mood leading up to the beginning of menses at which times her symptoms almost immediately improve. (She’s also taking prazosin 4mg in the evenings.)

I’m familiar with luteal-phase dosing of SSRIs/SNRIs but unsure how that would work on a patient already taking a therapeutic dose of one of these medications. Would there still be utility in adding an alternative medication during her luteal phase, and if so what would you recommend for a patient otherwise doing quite well on venlafaxine?

Any suggestions would be very much appreciated!

And what strategies or resources have you found effective throughout your clinical experience to ease the transition?

MS3 here so bare with my knowledge gap.

I've seen a lot of PCPs use psych meds with H1 blockade as sleep drugs, particularly in low doses. My understanding is that functionally these medications are acting as antihistamines at "insomnia doses". So why not just use an antihistamine? I understand if there's another comorbidity such as migraines, but is there another mechanism that aids in sleep besides the H1 action? Also does trazodone have this same mechanism? And since we know chronic antihistamine use is bad for cognitive function, sleep quality, and dementia risk, so should we even be using these medications as sleep aids?

Thanks y'all

Hi, I'm a psych PGY1 expecting to do child psych fellowship. I'm looking for resources (textbooks, podcasts, books/audiobooks, etc.) by child psychiatry related experts (especially evidence based content) that can help me both as a future CAP fellow and as an expecting father.

Despite being an introvert, I still think I have good people skills. But I’m not going to lie, after a full week of talking to patients, I’m often running on fumes and need my alone time on the weekend to recharge.

I’m good with my partner and family still though, but ever since I moved recently, the idea of making friends is exhausting. I just feel like all my people skills and ability to be funny and hold good conversations doesn’t come back until Sunday, when my battery is recharged.

How the heck am I gonna make friends if I’m useless on most Fridays and Saturdays when it comes to conversation? How do you handle it? I can feel how boring I am when I am recharging.

For context, my dad was formally diagnosed with NPD when I was a child, and multiple therapists over the years have told me my mom fits the criteria for BPD. For the sake of discussion, let’s assume this is accurate—it’s been an important part of my healing to frame their behavior through accepting their diagnoses, and I’m not looking to debate whether that’s right or wrong.

I’m a newly formally diagnosed autistic ADHDer and was hospitalized for MDD in the past. Psychiatry has had a profound impact on my life—my psychiatrists saved me, and this field feels like my calling.

Recently, on my psych rotation, I shared some observations about my mom’s behavior during a discussion about BPD and NPD with an intern. I thought this was a chance to deepen my understanding by connecting the material to what I’ve experienced. However, the intern didn’t take it well. They accused me of "diagnosing my parents" and implied that my background with these disorders might make me a bad fit for psychiatry. They even said, "Do you even know any psychiatrists with ASD?"—suggesting people like me can’t succeed in this field.

I’m torn about whether this comment was discriminatory or a fair observation. Some psychiatry skills, like mirroring body language and speech to build rapport, are harder for autistic individuals and could lead to burnout if approached rigidly. But is it possible to find a balance between being authentically yourself and still connecting empathetically with patients?

I’ve done years of therapy to process my trauma, and my goal is to use my experiences to relate to patients, not let them interfere with my care. So far, I’ve managed dynamics with BPD patients well on rotation, and I’m eager to learn more.

Can any psychiatrists with ASD weigh in on navigating burnout and finding this balance? Also, does anyone have advice about reconciling personal experience with professional practice? Is my history a potential asset, or does it create too much risk?

How can we make “masking” and “unmasking” more conceptually robust, reliable/valid concepts? Or does anyone have an approach to systematically assessing these phenomena? I don’t deny that these processes exist, but at times it seems they can be used in empty/self-serving formulations. “Oh yeah I was masking all my life, that’s why no-one’s seen any of my symptoms until middle age.” Why would masking uniquely apply to neurodevelopmental disorders? No one talks about eg masking their personality disorder

If you did a psychiatry residency?

Hey everyone. I went to medical school during the age of Anki, where we used spaced repetition flashcards to learn everything. I don’t necessarily think this was the absolute best way to learn, but I can attest that it was definitely helpful to memorize a bunch of facts, and also helpful for more broad concepts that really only made sense after I saw them a lot of times

I’ve noticed that in psych residency we often use reference texts (DSM, Stahl’s, Maudsley) but there’s not any clear spaced repetition flash card deck to help us memorize diagnostic criteria, psychopharmacology stuff, treatments, etc

I want to create an Anki deck (digital flashcards that use a spaced repetition algorithm to help with learning) for psychiatry residents. Ideally this would be useful for both wards + boards. I know this isn’t the only way to learn, or even the “best” way to learn, but it’s one product that seems to be missing and has some demand

So…

• What would you include in such a deck? For example, I think such a deck should definitely include DSM diagnostic criteria for different diagnoses and psychopharmacology (drugs, mechanisms of action, indications, major side effects, drug drug interactions, monitoring, etc)

• What resources should I base this deck off? Obviously DSM has the important diagnostic criteria, but what about pharmacology and other concepts?

Thanks, I appreciate your input.

Stimulants can increase the productivity of people without ADHD. So what is the harm in having easier access to stimulants? The patient will follow up regularly with the prescriber and be monitored the way they would if they were using any other medication.

I think this question was asked before on this sub, and someone referred to what happened in the 1950s with housewives. Is there any evidence for that anecdotal claim?

Obvious caveat: the contraindications of bipolar disorder, psychosis, addiction, diversion, and certain heart conditions should be kept in mind.

EDIT: Based on the comments and the linked studies, these are some of the potential risks of more widespread use of stimulants: risk of psychosis, mania, and addiction in patients who initially seemed unlikely to develop these conditions.

Basically, there are many people without ADHD who would benefit from stimulants. However, it's hard to determine who those people are versus those who will become manic, psychotic, or addicts.

Could you please help me figure out what stats for psychiatry are good enough? How many publications, months of USCE and LoRs, and extracurricular work (like voluntary work) does someone need to be quite sure to get a spot in any residency program?
What is considered the minimum/good/excellent score in STEP 2 for psychiatry?

I am asking as IMG, who is about to graduate within a few months. I would like to know what I should improve, considering I'm still at uni and have a few possibilities more than when I will be outside uni.

Thank You so much in advance, guys, for your time, help and effort. Have a great day, best wishes.

#residency #usa #img #match #thankyou #helpneeded

Common thought is that SSRIs are a trigger for reversible cerebral vasoconstriction syndrome and that SSRIs should be indefinitely held after a angiographically proven episode. I have seen a few neurologists in town re-prescribing SSRIs with verapamil to post-RCVS patients once the vasospasm has cleared with the belief that the two drugs cancel the recurrence risk. Any psychiatrists comfortable with this or have an opinion/experience restarting SSRIs after a resolved RCVS episode?

Hello, I'm an OMS-3 who was recently on his cardio rotation.

One of the patients I was following was a very sick patient who had two occurrences of dofetilide-induced torsades arrest after initially coming into the hospital for A.fib w/ RVR and was treated with dofetilide. This patient had a complicated and long ICU course consisting of multiple intubations over a span of about 2 weeks.

I was following the pt on the general floor, and one of the consistent recommendations we kept making as the cardiology service was that 2/2 recent arrest, we would prefer to avoid ANY low risk or significant QTc prolonging agent because we needed to treat the patient chronically with amio due to the afib rvr as well, so they were existing at around ~490 QTc just as is on cardiac meds.

This patient developed some form of in-hospital delirium or post-ICU encephalopathy, and the IM team elected to initially treat with seroquel which we noted and shot down almost immediately because of the high QTc prolongation risk. After that, I believe the patient was switched to zyprexa. The attending asked me to literature review to find risk of QTc prolongation for different psych medications because we were unsure as to the exact risk of it for Zyprexa.

We consulted psychiatry for recommendations who ended up switching the pt from zyprexa to ativan, but it ended up being an ineffective control med for the pt's delirium. Shortly after this, the significant other elected to place the patient on hospice and we stopped having involvement in terms of med management.

I haven't had my psych rotation yet, but I had a really difficult time answering whether olanzapine causes QTc prolongation, with some literature saying yes vs others no. Generally my understanding was that it was pretty low-risk, but we wanted to even avoid low-risk in this patient.

What is your approach to inpatient delirium if I specifically want to avoid any risk of QTc prolongation but ativan isn't effective? I have no idea what we could have done next to help the patient's delirium outside of r/o further medical causes.

This year I lost one of my patients to suicide. I only recently inherited them and worked with them for 1 month before I found out they had passed. They were very high risk (elderly, male, divorced, 2 recent attempts/plans, narcissistic traits). They had made 2 efforts to commit suicide, making a plan, before I inherited them but was hospitalized before attempting after their therapist and family found out each time. The pattern was 1 admission each month prior to coming onto my panel. They were referred to and completed an IOP after the second admission. They consistently endorsed severe depression with anxious distress without any improvement throughout the entire treatment course despite multiple heavy hitting medications and the higher levels of care. In fact they expressed that in-patient and IOP made them feel worse about themselves. By the time I assumed care they were taking an SSRI, SGA, and clonazepam. Other SSRI's and SGA's had been trialed up to that point. I moved this patient to my limited private/therapy panel so that I could meet with them for an hour each week. We were in the process of referring to a private residential mental health program due to lack of progress when I was notified of their death. Family had been involved throughout the entire process, including attending some of the last visits I had with them. At our last visit he did not meet IVC criteria and both the patient and family maintained he would not benefit from and did not need another admission.

I'm relatively at peace with this sad outcome, but it's making me think more about all of my other high risk patients and whether or not I should be more aggressive in demanding/requiring in-patient treatment whenever things seem they are going poorly. This is probably a dumb question and an over reaction, but is there a point/number of patient deaths where you aren't allowed to practice anymore? I know that suicide is rare and difficult to predict even in the psychiatric population but i'm just feeling very shaky about my ability to identify the signs of it now.

Primary care psych

Hi all!

I’m in primary care and wanted to get some thoughts on how you as a psychiatrist would proceed in these situations.

1. 30-40 y/o patients, get diagnosed with major depression, I usually loop them with counselor and start them on SSRI. I have a one month follow up where they say nothing changed, so my advice at that point, wait for a few more weeks to have the full effect of the med. then at 3 month follow up, I hear the same thing that “nothing changed, I still feel depressed and anxious” at this point, specifically in terms of pharmacotherapy, what is the next best course of action? Would you switch them to another SSRI? Or augment the therapy with a second agent? If so, what would you augment it with?

2. Patients with multiple psych conditions bipolar, schizophrenia, depression, anxiety, personality disorder, somatoform disorder on poly pharmacy. I have been referring out this patient population to psych with my hope being they can downgrade or discontinue some of the medications. At what point would you advise the PCPs to refer patients out to psych?

Thanks for your time!

honestly im super tired of worrying about interviews and sending LOI's. Currently sitting on 6 IV (25x/USMD/no red flags) and not feeling good but I feel like ive been stressing for so long that i am stress-numb now?? I could definitely send more LOI but everyone keeps saying they are very low yield and at this point I am just super discouraged. I do well in interviews and actually enjoy them but don't have enough to feel comfortable... Any words of wisdom are welcome:/

I am treating a 20 something year old psychotherapist with history of recurrent MDD and probable BPD. Has Hx inpatient for SI when in undergrad but had been pretty stable since then. Has been slowly spiraling for past year (combo of family issues, disillusionment with career choice, move across states, relationship breakup. Election tipped pt over the edge). Presented to therapist (I mainly do meds and pt sees separate therapist) asking for inpatient psych due to increasing si. Pt is seeking an inpt unit that specializes in treatment of helping professionals. Any of my US colleagues know of such a place?

Hello All, I’m a current PGY-3 in the western US and I’m trying to find supervision in CBT for psychosis. I know this is a long shot, but does anybody have any leads on where I could look to find something like this? I’ve looked in my region (eastern Washington) without much success. Any help would be appreciated.

A major insurer in the Pacific Northwest is now requiring that all paneled providers attest to having “Network Security and Privacy Insurance”. Does anyone have recommendations for companies who offer this as a standalone product? Most companies I’ve spoken with want me to buy general liability from them too, but I already have that type of coverage with Brexi.

I do neuropsych testing for a variety of reasons and have to deal with insurance rejections and often opt for peer-to-peer. There's a psychiatrist in my hospital that handles TMS and she deals with rejections quite frequently too.

We've noticed a change to this appeal process for multiple insurance recently where our first "peer to peer" call is just a meeting from a nurse that basically reads us InterQual criteria and state how this is the "up to date treatment guidelines." When we explain how our patient meet criteria (often having to cite information from patient's chart) or explain how criteria is out of date the nurse usually just gets flustered and say they can't do anything, they just follow guidelines, and will "escalate" to a physician if we wanted them to do that. Then we get the actually "peer to peer" which is often someone outside of psychiatry anyway.

Is this the new norm? Are insurance just adding an extra appointment before actual peer to peer to waste even more of our time or encourage us to give up?

Background, Female 20 years old, PTSD, new onset Bipolar last year when her PCP started her on zoloft, which brought her to my office. Had mixed results with SSRI + 2nd gen until in a mixed episode she attempted to OD, and ended up in Inpatient for a week. Pt moved across the country back with her parents where her home psych started Wellbutrin 150 + Abilify 15. I started seeing her again 2 months ago and she is *fairly stable with bipolar, but has new onset Anorexia symptoms that she never disclosed before (less than 400 calories daily, major obsession of body image, withholding/fasting).

I feel like a dumbass for not catching this sooner. Explained the seizure risks to pt, ordering labs, started a tentative 2 week tapper off wellbutrin with plans to start Mirtazapine or an SSRI in 1 week. Consulting with my supervising doc about this tomorrow, looking for insight. Should I stop the Wellbutrin faster and/or start a new Med immediately?

Edit: I view the vast majority of my DXs as provisional or working. I'd been more confident of a bipolar dx in this pt based on: Psychologist in our integrated practice same dx, as well as the dx from her psychiatrist at home. Multiple very classic presentations of: No sleep for 3+days with extremely high energy witnessed by her roommates, risky decision making, got engaged to a BF of 1 month, increased self harm, rapid speech in office, flight of ideas, mild delusions.

Edit 2: Thank you all for feedback/suggestions. Reevaluating both DX and best medications is likely necessary here. I'm sure my supervising doc will have similar thoughts tomorrow.