POSTING RULES:

Here is the scenario -

I have a patient who's husband traveled a lot for work.

I sent her rx's in electronically. Always to a Walmart, always in our state, always from me (duh).

But usually a different walmart each month.

I am on the phone with the pharmacist of the most recent Walmart and she is telling me this pattern is a "Red Flag" and she will not fill the most recent rx.

Is using different pharmacies still need to be considered a red flag in the setting of the PMP?

In the setting of electronic rx? With me on the phone ready to verify any element of what has been going on?

.

I was recently informed by another psychiatrist that in regards to the Clozapine/Luvox combo, the strength of Luvox doesn't matter much. That if the Luvox dose is decreased it won't affect the Clozapine level much because Luvox's enzyme interactions with Clozapine's reaches a point of saturation. So as far as Luvox dose, it wouldn't matter if the person was on Luvox 100 mg or 25 mg (but the Luvox also addresses depressive symptoms so in that regard it does matter).

I'm unable to find any studies confirming this and was hoping someone could guide me to where I can find some.

specific examples would be great

So I am a medical doctor finishing my residency in psychiatry in a small wealthy country in Europe. After 5 first years of residency that was honnestly traumatic-- I started off in the field passionated about mental health, psychology and neuroscience and I ended up being disgruntled but the reality or I saw In my daily practice. I guess I had an idealized view of psychiatry.

Anyways; now finishing my residency I received so many offers it's not decent. Out of all these offers, I retained mostly two of them claiming to not be as a shit environment as I and most resident are used to: shit hours; being exploited; doing things we never did before; rigid hierarchies..etc and I just can't choose. I also got diagnosed with adult adhd and got medicated-- that might explain my hardships in the past.

Job setting 1: the pay will be depending on my workload and I'll be receiving 50% of the net income I make, meaning the owner of this little center only receives 20 %, and I receive the rest. This means I will make from 150 to 300 k depending on my workload. As a resident in my country we usually make a stable salary of 100 to 120 k so it will be a very serious pay raise,two to three times increase. I met this guy and seem like a very nice person, the center is small and he gives me full flexibility to practice however I want. The clients are mostly working, richer clients.

Job setting 2: I haven't met her but, she basically has a lot of things with me in common. She has a bigger center and employs many people. We talked for hours on the phone. She offer similar paysetting as kobsetting 1, meaning a significant paybump from previous jobs. She does research, is very experimental, and seems to be very broadly competent and does many interesting approaches-- zootherapy, psychedelic assisted psychotherapy. She also seem to be very engaged and progressist. Works with many type of clients/patients but also underserved people. She seems to be more of a pionneer in her field and is very passionated. She tries to convince me forcefully on the phone arguing that her job setting is the best. Red-flag--or green flag: She also says that I seem like the perfect worker for her because I went through a lot lol-- I come from a wartorn little country and that I had to show a lot of resilience. On paper, she really seems like an incredible boss. The potential issue might be that she might be exploitative and push residents to do things they are not competent to do. Atleast in my experience, very empathetic and passionated people tend to have a dark manipulative side or can overwork their employees. This might be a reach though. Because I have bad experience with bigger center and social dynamics in bigger structures; same for female bosses as a male; I'm a little apprehensive and biased. Maybe I should embrace my fear of female bosses lol.

Thoughts? Which job setting would you choose? The comfortable/flexible one OR A comfortable, diverse potentially challenging and experimental one. Both pay good and can be partime if necessary. First one is more of a chill city practice type of seeting while second seem to be more of a learning experience.

Dear all I have recently received the wonderful assignment of individual supervision of some new psychologist.

I have offered supervision before to experienced therapists, and thought this wouldn't be much different. However after a couple of sessions I feel like I am missing the mark - I haven't been able to offer them the right level of supervision that they need as completely new to psychotherapy. Also, the patients they see are quite difficult. All the new psychologist seem really talented, and I have no doubt that they will become excellent therapists in time.

I am looking for advice, suggestions and maybe some literature on working with, supervising and teaching people psychotherapy from scratch.

Curious to see what others are seeing for moonlighting rates locally for weekend inpatient coverage. Adult or child-adolescent. Anyone willing to share how much and what the coverage situation looks like?

I treat a lot of ADHD. For the majority of my ADHD intakes, I actually do agree they have ADHD. In fact, it’s possible that I over-diagnose in favor of avoiding missed diagnoses.

But if I disagree that ADHD seems likely, I have never seen people who distrust my professional judgment more than people who have convinced themselves that they have ADHD based on something they researched online. And I have never gotten more severely negative online reviews than from patients for whom I did not agree to prescribe (what I consider to be) abuse-level doses of Adderall, or Adderall to treat (what they blatantly admit to be most likely) THC-induced cognitive dysfunction, or from people who claim to have had no interest in a particular treatment, but who seem very upset with me when I disagree that ADHD seems likely. At this point these people are tarnishing my professional reputation online with extremely negative reviews, and there is nothing I can say in response due to HIPAA laws. They have deliberately misquoted me, and have done so in a manner that is obviously (to me) retaliatory in nature (but they make no mention of the fact that I have declined to prescribe Adderall in their review). I have tried to convey my clinical reasoning with compassion and without judgment, but it turns out that those factors do not matter. What seems to matter most is whether or not I agreed to prescribe Adderall.

For that reason, I’m discontinuing accepting new ADHD patients. Don’t misunderstand me; I get a lot of satisfaction from treating what I understand to be a potentially disabling condition. For my current patients who do have ADHD I have no problem continuing treatment. But the minute I see an intake who is prescribed a stimulant or is seeking an ADHD diagnosis I will absolutely call them and inform them of my policy against seeing new patients who have those conditions or are seeking those diagnoses.

Change my mind.

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How do you all navigate the almost transactional relationship of a new patient paying cash and expecting you to refill their stimulant/diagnose them with ADHD if that's what they're seeking?

I've refused a few times in these situations in which patients did not meet clinical criteria based on their symptoms (or lack thereof), which led to the patients flipping out screaming at me saying they wasted their money and wanting a refund. I always say they're paying for my assessment, not for the diagnosis/selling a prescription. It is still a very uncomfortable experience.

Similarly, I've referred patients, who I was fairly confident did not have ADHD, for neuropsych testing, and they 100% always come back with an ADHD diagnosis. Most assessments don't even ask about co-morbid drug abuse. I wonder if these assessments from psychologists are also influenced because the patients are cash-paying, and for customer satisfaction.

Have not seen anything in the research about this and am not convinced that fluoxetine is truly the best AD to pair with it since they’re both Eli Lilly drugs (would be quite the coincidence if so).

What is your experience? Have you seen any studies on this?

Studies that suggest long term out comes for people who taper are poor.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376663/

But this study (and most like it) require tapers of 12wks and 52wks is considered a long taper.

I think 52 weeks is a fast taper based on what I see. I think tapers that are successful take years, like at least 3. But I don't see studies that allow for tapers that long.

I have colleagues that use these studies to argue against recommending tapers of methadone/bupe.

Obviously pts have to be "stable" or "stable-ish" before a taper can be started. But I also think discharge planing begins on the day of admission?

If you want to stay on your MAT for life, and you are well informed and resolute in your choice, I am ok with that. I just see people who are on it long term and have not really been educated about the options. That's not ok with me.

What to you all think about this, how do you practice?

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I've always heard beat the boards for licensing exam, but not sure if I want to do that a year out. I'd like an affordable question bank with or without review materials that may be a lead up for Beat the Boards if that makes sense.

I probably won't do beat the boards until time of licensing exam, like 4 months out. I want some questions to go through now and reviews that may be applicable to residency/PRITE. I did Rosh last year. My understanding is to focus more on boards and less than PRITE in 4th year. What's a qbank I can start now to try and finish up by New Year before transitioning to beat the boards?

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Or any other deals I should look into. Not interested in group buys unless currently active.

One of the reasons given for why addiction treatment has to be so hard to access and so rigid in it's implementation is that if it's not, the DEA will swoop down and arrest everyone involved.

And yet, this is the typical case of who the DEA goes after....

https://www.dea.gov/press-releases/2024/01/19/doctor-convicted-trial-unlawfully-dispensing-controlled-substances

Watch this documentry, in the second half of the season they are trying to take down a pill mill which was operating much like the example above. Took them like a year to shut it down.

https://www.rottentomatoes.com/tv/the_pharmacist

And then the recent Supreme Court ruling. Even the guys who need to be shut down are not at that much risk it seems.

https://www.ormanagement.net/Feature/Article/07-22/Landmark-Supreme-Court-Ruling-Recognizes-Opioid-Prescriber-Good-Faith-Defense/67650#:~:text=The%20U.S.%20Supreme%20Court%20has,medicine%20for%20years%20to%20come.

I am not speaking to what might happen if you have a bad outcome and you get sued. That is a different issue for sure.

I am not saying you should not or could not practice in a way you feel safe/comfortable. Take the precautions, have the boundaries.

Just don't blame your practice on the DEA.

Or am I wrong?

Hello, does anyone know the law on issues pertaining to youths and pronouns? If the parents state “you must refer to my child as their birth name and pronouns” does the law bind you into misgendering the child? Even when it is demonstrably damaging to their mental health? How are other providers handling this increasingly common scenario? What, if any, resources can be supplied to families whose political or religious views do not align to support their children’s identity or orientation? I feel very worried, and honestly distressed, for my pediatric patients in this position. Thanks all.

Is there any research on whether or not short-term (2-4 weeks) and low dose benzodiazepine use increases or decreases stress tolerance?

I am working with a patient presenting with panic disorder, agoraphobia, and hypochondriasis who is resistant to antidepressants. While I know benzodiazepines should not be used during exposure, I'm wondering about post-exposure to assist with increased functioning at home as they return from exposure feeling highly anxious and are struggling to function.

Would a short-term script presumably help build up a reasonable distress tolerance before ceasing them (e.g. 2 weeks of 0.5mg lorazepam in morning post-exposure, 0.5mg in afternoon, 0.5mg in evening)? I know that chronic, long-term use of benzodiazepines, particularly with increasing tolerances has been shown to backfire, but there doesn't seem to be much about short-term use.

In the outpatient setting (OBOT more than OTP).

Most patient will tell you when they relapse or even slip.

Most patients stop coming when they relapse. If they are in your office the pretest probability is way down.

Drug screens are not very accurate, drug test are expensive.

Drug screens are intrusive. Shaming. They impair the relationship.

There are often many other signs a person is using, and not using.

Drug screens undermine the patients ownership of their recovery. What are they doing in tx if they are still willing to use and lie about it?

Please try not to go off the deep end please. I am interested in a discussion. I stand by my statement, but I know it is not mainstream. I am open to the idea that I could be "wrong." Are you?

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Had a pretty frustrating phone call with a patient's parent today - basically a 20 something year old with autism who lives with their parents was brought into our psych ED for behaviors that were in large part the direct result of how their parents communicate with and discipline them - two minutes into our conversation it was pretty clear the parents are a big reason they act out, and it was pretty much confirmed by how angry the mom was on the phone about how the patient never listens to their unreasonable demands. I tried to talk to her about parenting styles, approaching their condition with understanding, family therapy, etc. but it was like water off a duck. I realize the odds of making a meaningful difference in a family's dynamic with a fifteen minute phone call are pretty low, but how do you handle counseling family in these situations where the patient isn't the root of the problem?

Hi all,

I'm a psychologist in private practice. My policy for my practice has always been that I will only initiate services if a patient is willing to have unrestricted sharing with their other treaters (typically a psychiatrist or NP/PA; sometimes, there are couples therapists or group therapists). Recently a question came up on a professional list serve I am part of and I was admonished somewhat that the patient has a "right" to more restrictive/selective sharing. I guess I feel super uncomfortable with, e.g., knowing a patient is drinking heavily and the psychiatrist is prescribing or that the patient is at high risk of suicide and not sharing that. It seems like a safety issue and a real big clinical problem.

I'm not sure what my question is but I wondered whether there is anything un-kosher about my refusal to treat at the outset if a patient is not comfortable with exchange of information between all members of the treatment team? Is there some reason why I have to take all comers even if they refuse to authorize such exchange of information?

I realize HIPAA provides for such exchange of information. I've never been clear on whether ethical principles for psychologists are more restrictive than HIPAA in this regard.

Thanks for any thoughts!

I'm a psychiatry resident (almost finished, 30 years old) in the Netherlands.

From April 30th - May 3th I will be in Ho Chi Minh city (Vietnam) with my wife.

I know this is kind of a long shot, but is there someone working in psychiatry who would like to meet up for a coffee/drink?

Would be interesting maybe to share some stories.

One, it raised the cost of the drug (a life saving drug, buprenorphine) and put treatment out of reach from many if not most.

Two, the addition of naloxone made the combo intolerable for so many. I meet so many people with opiate dependence who don't think buprenorphine (subutex) can help them because they had a bad experience with Suboxone. That leaves them with the only choice of going to the methadone clinic and so many people will not do that.

The addition of naloxone has killed and injured far more people than were ever helped by the putative deturance to IV use. IMO

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.

Hey all,

I’ve run into several sources on the internet that suggest (or flat out claim) that psychiatrists can go into clinical neurophysiology. Anyone out there with any further knowledge/exposure regarding this?

Thanks in advance!

PGY-3 in the USA going into 4 soon.

I’m nervous about the idea that in a year I’m going to be looking for my first “adult” job, practicing independently. I’m doing well in residency, and all the feedback I’ve gotten suggests I’m exactly where I’m supposed to be. Yet, I still feel that there’s so much to learn and so many complex situations I have yet to face. Plus, I plan on eventually returning to the region where I’m from, which is rural and has very few psychiatrists.

Did anyone else feel this way coming out of residency? Are there jobs aimed at early career psychiatrists where there’s still a built-in mentorship situation? Can I pay for a supervisor to discuss complex cases with if I can’t find such a job?

My ideal job would be outpatient with a mix of therapy and medication management. Open to tristate area / NYC for my first job but would want go back to my home state which is rural at some point soon-ish

Despite over 60 years of clinical use and a large body of evidence, a committee from the World Health Organisation (WHO) has repeatedly excluded methylphenidate for ADHD from the WHO’s list of essential medicines for children. That committee’s decision has dire implications for millions of individuals with ADHD worldwide, especially those living in low and middle income countries where governmental decisions to make medicines available are contingent on EML listing.^(1) ^(2) ^(3)

The committee responsible for this decision rejected an application for inclusion in 2019, and a second application backed by 51 professional groups in 2021; with further discourse occurring in 2024. Their decisions and claims are not consistent with the evidence and global scientific consensus, diverges from WHO’s own established recommendations and stands in stark contrast to the decisions of many regulatory agencies and professional groups around the world.

Below I derive highlights from the literature exposing the flaws in their rationale. Thus refer instead to the consensus statement, current reviews and existing guidelines, which include methylphenidate as a safe and efficacious first-line treatment for ADHD.

(Involved are the Expert Committee, Ponnou, Storebo and colleagues, whom expressed concerns around the pleas of scientists and professional groups for methylphenidate to be included as an essential medication for ADHD).

The committee, Ponnou, Storebo and colleagues claim there is very low level of certainty that methylphenidate is more efficacious than placebo for reducing symptoms of ADHD

Their claim was based on the citation of a well-refuted 2015 Cochrane meta-analysis concluding there is very low certainty about evidence that methylphenidate reduces symptoms of ADHD. Relying on Storebo’s et al., 2015 evaluation of research and clinical relevance is dubious and must be rejected for several reasons. This meta-analysis is flawed because it used a controversial idiosyncratic application for assessing evidence quality, and made numerous gross errors and misinterpretations, which led to false results; for details please see: ^(4) ^(5) ^(6). It thus contradicts all 15 previous reviews and meta-analyses. The International Consensus Statement on ADHD shows that the results from randomised controlled clinical trials are resoundingly clear: methylphenidate is not only more efficacious than placebo, it is among the most efficacious drugs in all of medicine.^(7)

The available evidence on this is extensive: Between 1962 and 1993 alone, more than 250 reviews and 3000 further single works on the effect of psychostimulants were published. Between 1975 and 2007, the efficacy of these substances for the therapy of children and adolescents with ADHD was examined in over 180 randomised, double-blind, placebo-controlled studies, comprising over 12,000 children and adolescents, the results of which were published in peer-reviewed journals. Additionally, the prior 15 systematic meta-analyses and reviews, including the meta-analyses conducted by the National Institute of Clinical Excellence (NICE), unanimously report effect sizes between 0.8–1 for the efficacy of methylphenidate in terms of reducing the core symptoms of ADHD in children and adolescents of moderate to high quality, compared to the "very low quality" in Storebo and colleagues controversial analysis.^(8)

Treatment guidelines internationally, including those of the National Institute for Health and Care Excellence (NICE)^(1) identify methylphenidate as a first-line treatment for ADHD.

Although WHO has not yet agreed to include methylphenidate on the EML, they do paradoxically to this committee's claims support the use of methylphenidate as an effective treatment for ADHD, including in non-specialist settings within low-income and middle-income countries. The 2023 WHO Mental Health Gap Action Programme guidelines for mental, neurological, and substance use disorders makes a clear recommendation that methylphenidate should be considered for children aged 6 years and older who have ADHD, noting specifically that, “methylphenidate treatment shows substantial effects on symptom reduction”^(9) - showing that this committee's claims are in spark contrast to WHO's own guidelines and recommendations.

Ponnou and colleagues claim that methylphenidate is an amphetamine analogue with addictive potential

Methylphenidate has - as does dexamfetamine - a very different pharmacology to stimulant drugs that are misused, such as methamphetamine and cocaine. These differences, primarily pharmacokinetic in nature (like absorption), reduce drug-liking effects, misuse potential, and the development of addiction.^(10) Substantial evidence shows that when used therapeutically, stimulant treatments for ADHD do not increase, and may even protect against, the likelihood of later substance use problems.^(7)

The committee, Ponnou, Storebo and colleagues concluded that prescribing methylphenidate is problematic because tolerance may develop

Tolerance has not been well-documented for ADHD medications as the research on this topic is very limited. The most comprehensive review of the topic (2022) found tolerance rate of 24.7% in a clinical study of days-weeks, and 2.7% over the course of 10 years in another. Although it concludes that tolerance exists, it is typically manageable, the rate is small and the data regarding actual physiologic tolerance is weak at best.^(11)

Ponnou, Storebo and colleagues express concerns about the tolerability of methylphenidate

The adverse effects of methylphenidate, if they occur, are typically mild and can be addressed by changing the dose, formulation or the medication.^(7)

The committee, Ponnou, Storebo and colleagues claim that there is a low level of certainty on the safety and long-term effectiveness of methylphenidate

They cited the short duration of most supporting randomised controlled trials (RCTs) to support this claim and indicated that an RCT of 52 weeks would be needed to support methylphenidate's inclusion. This requirement is perplexing, given the fact that WHO does not require long-term efficacy and safety data from RCTs for other medications in the EML. Because long term RCTs are not ethical, scientists rely on large, naturalistic population registry studies to assess longer term functional outcomes. These show that methylphenidate treatment for ADHD significantly reduces or even eliminates the elevated risks for obesity, accidental injuries, traumatic brain injury, substance abuse, cigarette smoking, educational underachievement, bone fractures, sexually transmitted infections, depression, suicide, criminal activity and teenage pregnancy, among others.^(7) Their claim that there is no strong evidence for the long-term effectiveness of methylphenidate also ignores data from relapse prevention studies, which demonstrate the persistence of clinically meaningful benefits for people with ADHD with continued long-term methylphenidate treatment.^(12)

Long-term meta-analyses and systematic reviews, as summarised in the International Consensus Statement on ADHD^(7), show that the medications used to treat ADHD are not associated with observed deficits in brain structure,^(13) ^(14) ^(15) ^(16) ^(17) but with improved brain development and functioning, most prominently in inferior frontal and striatal regions.^(18) ^(19) ^(20) ^(21) ^(22)

It also identifies that systematic reviews, meta-analyses and large-scale studies show, except for the rare event of hypertension in one large-scale study, long-term methylphenidate use is not associated with statistically significant increased cardiac risks or events or all-cause death compared with placebo or controls.^(23) ^(24) ^(25) ^(26) Subsequently, the most comprehensive meta-analysis available (19 studies with over 3.9 million participants) found "no statistically significant association between ADHD medications and the risk of cardiovascular events [and CVD] among children and adolescents, young and middle-aged adults, or older adults".^(27)

A recent observational study found that long-term cumulative treatment of methylphenidate, for up to 14 years, was correlated with a very small but statistically significant increased risk of hypertension and arterial disease for a couple years before terminating, but no increased risk for other serious cardiovascular conditions (including heart failure).^(28) This study's results contradict previous research and does not show a causative effect, as it did not control for significant confounders, such as severity of ADHD. Although these findings reinforce the recommendations found in all evidence-based guidelines to monitor cardiovascular parameters when prescribing methylphenidate, they are not an argument to withhold such an effective treatment from those who would benefit.^(29) ^(30)

Safety and efficacy data have been reviewed in great depth by regulators (e.g., the US Food and Drug Administration and the European Medicines Agency), the developers of evidence-based national guidelines (e.g., the UK National Institute for Health and Care Excellence and the American Academy of Pediatrics), and government agencies who have endorsed these guidelines (e.g., the Australian National Health and Medical Research Council). These professional groups all conclude, based on the scientific evidence, that methylphenidate is safe and effective and should be considered as a first-line pharmacological treatment for ADHD.

EDIT: If you have any objections, they should be rooted in scientific fact - provide references to relevant literature, just as I have done. It is a bit disheartening to see the upvoting of baseless rejections of established medical guidelines, scientific consensus and a massive evidence-base, and ad hominem attacks to flippantly dismiss decades of research.

I am 1st year psychiatry resident. I have one week each year to attend conferences. I don’t know where to go since I never tried it before. In addition, anyone of you have received invitations for a conference including all travel tickets and accommodations, could you share your experience and process of application please 🙏🏻

I was just listening to the Psychiatry & Psychotherapy Podcast Q&A with Dr. Michael Cummings and he mentioned that if a patient is on haldoperidol dec and it was augmented with something like aripiprazole, this may exacerbate positive symptoms due to the stronger binding affinity of aripiprazole at D2 receptor sites - essentially displacing haloperidol at those receptor sites. I was just reading an article Combining Aripiprazole and Haloperidol: Focus on D2 Receptor in the Journal of Clinical Pharmacology and it mentions "Conversely, the addition of haloperidol to aripiprazole may yield a stronger D2 blockade and subsequently an improvement of positive symptoms, while at same time potentially reduce some of the benefits of aripiprazole's atypicality, namely, its activity on serotoninergic and dopaminergic transmission (dopamine D2/D3 partial agonism, serotonin 5-HT1A agonism, 5-HT2A antagonism)." Can someone explain why the addition of haloperidol to patient on aripiprazole would have different effects than the addition of aripiprazole to a pt on a stable haloperidol regimen? Thank you.

Has anyone ever gone this route? PGY-3 and already super burned out of psychiatry, trying to see what career options are available after grad. Does anyone know of someone who successfully transitioned from psychiatry to aesthetics (filler,botox,lasers,etc)?

Hello. I am a current PGY3 and have been searching for psychiatry programs with PGY4 vacancies for the next academic year (2024-2025). I have been checking the APA Clearinghouse website (now Job Central), but I haven’t had much luck. If anyone knows any programs with vacancies they’re looking to fill, or programs that have accepted PGY4 transfers before, can you please let me know via private message? I can also provide more details via private message. Thank you.