POSTING RULES:

Is anyone getting any odd accommodation requests? One of the people I see is asking for accommodations for an ergonomic desk arrangement at work for mental health reasons.

Not that I really care as it is minor to me. But it seems weird to ask a psychiatrist and not a PCP as it seems more a physical issue.

Hello, everyone. To the forensic psychiatrists: is the conclusion of a fitness for duty evaluation: the evaluee is fit for duty or the evaluee is not fit for duty? Is it an either or kind of thing? Thank you.

I'm curious what those of us in private practice who are opted out of Medicare do if the need arises for supplemental income while growing a practice or in the event of unexpected family/life circumstances, relocation to a new region, or a financial downturn reducing demand for high-end cash pay psychiatry. I imagine being opted out would narrow the options and preclude some of the old standbys like picking up ED shifts or doing inpatient consults a few hours per week.

edit — not looking for advice on whether to opt out…that ship has sailed.

🙏🙏

What type of phone service company is best if I already have a doximity fax number? Something that is hipaa compliant and low cost.

I have a few patients who see psychiatrists on 5-6 drugs each. What reasoning guides this?

Example: lithium qd, risperdal qd, xanax prn, atarax qhs, Zoloft qd

I’m about 4-5 years out from psychiatry residency and didn’t get much child training in residency - just did 2 months of inpatient work, which I can’t really remember too well anymore.

I’ve been considering a psych ER job where I’d have to see 25% child/adolescent cases. I did moonlight in psych ER before and have done shifts in psych ER intermittently but in general I assess the child patients pretty similarly to adult when making decision to admit/not admit.

The main difference is sometimes there are cases where the parent/guardian desires admission for NSSI or aggression at home, but there is either a) no inpatient bed, or b) the behaviors are chronic with little chance of altering the behavior with inpatient admission.

I have seen child psychiatry trained docs discharge such pts with safety planning and close coordination with outpatient but can be difficult to make a middle of the night decision on this. Usually I get pressure to discharge the pt with a small psych ER if we don’t have inpatient beds.

Previously when I worked psych ER, I got the advice to just go with the parent/guardian wishes on admit vs not admit unless I was actually child psych trained. I also got advice to avoid starting new meds in child psychiatry ER as I am not child trained.

I don’t have a good grasp of what level of NSSI or aggression can be managed outpatient nor good knowledge of what outpatient resources are like.

Curious if there is any reading to get more comfortable with these decisions about admission for child/adolescent patients?

I also have minimal knowledge about what residential treatment centers are and when these are better options to manage chronic behaviors. My understanding is that RTCs can take a very long time to get in so sometimes child/adolescent patients are admitted if unsafe or discharged home with safety planning with longer term plan to go to an RTC, not sure when that would be the more appropriate option.

Finally, curious if you all think such jobs (with 25% child/adolescent caseload) are appropriate for psychiatrists with only adult training or maybe I should just look for a different job?

I am generally pretty comfortable with adult psych ER patients, provided I have good backup from social workers that know the area/resources.

Hey everyone,

I was wondering what kind of rates you all are being pitched for mainly inpatient locums in states like Tennessee or Arizona? Any info on other settings would be appreciated!

I’m a PGY-4 looking to start up once I finish up with my residency program.

Hello, 4th year med student here in the process of ranking residency programs-

I have been rotating at various psychiatry programs over the past 8 months as a subI and have learned that no training program is perfect (nor a psychiatrist).

That said, do you think there is any value in trying to discern which residency program provides good training vs not, and ranking according to 'quality of training'?

Or should I truly prioritize location, weather, and vicinity to good things?

My priority is to stay sane during my training (fwiw no family ties to any region, life happened to be that way for me), but also come out a great (or at least a good) psychiatrist who knows how to interview well, diagnose accurately and be competent. How much does residency training come into play in terms of future practice?

Also would love to have a life outside of work but it seems that all residencies are brutal when it comes to calls/work-life balance...

So

1. How much did your residency training affect your practice quality in hindsight?
2. Do you ever see fellow psychiatrist who are competent/incompetent, and is there a correlation b/w their residency training (as they describe it) and level of care/competency?

Thanks

I'm curious to hear psychiatrists' experiences preparing for paternity or maternity leave, especially those of you in solo private practice. Most importantly, how do you handle scheduling uncertainty, particularly if baby arrives early or late? If baby arrives a week early but you have patients scheduled that week, how do you find time to cancel/reschedule things once baby is already on the way? When do you start telling patients you'll be taking off for an extended period of time? How do you handle coverage? How much time do you take off? How far in advance of expected delivery do you stop accepting new patients? For men, do you tell patients you're taking off for paternity leave, or are there patients to whom you don't disclose?

Resident here, having a particularly challenging week of feeling underappreciated. I know it's part of the job and certainly not specific to psychiatry. Just curious to know how you all cope, especially who have been out in practice for awhile.

Hello everyone. I’m a pediatrician who works with a lot of patients with ASD. I was wondering if anyone had any thoughts on the following

1. I will see a lot of patients who have been put pretty chronically on hydroxyzine for sleep maintenance. Do psychiatrists worry about potential cognitive effects from long term use of first generation antihistamines and anticholinergics in pediatric patients? Some parents do worry given the effects on older adults. Some of the literature I could find seemed reassuring [1]

2. I will run into kiddos who have had their sleep hygiene optimized by highly motivated parents, they have no OSA per sleep study. Communication issues might mean CBT—I is not an option

There will be trials of melatonin, clonidine, and hydroxyzine leading to failure. What medications are your favorite go-tos in none of the above don’t work in children? Are there medicines we should be less afraid of?

Trazadone and Mirtazapine seem to be used by specialists. Uptodate actually pointed me to this small study on Doxepine, which I’ve never seen or worked with in children [2]. The idea of a tricyclic sounds terrifying with the interactions and toxicities.

1. Ghezzi E, Chan M, Kalisch Ellett LM, Ross TJ, Richardson K, Ho JN, Copley D, Steele C, Keage HAD. The effects of anticholinergic medications on cognition in children: a systematic review and meta-analysis. Sci Rep. 2021 Jan 8;11(1):219. doi: 10.1038/s41598-020-80211-6. PMID: 33420226; PMCID: PMC7794471

2. Shah YD, Stringel V, Pavkovic I, Kothare SV. Doxepin in children and adolescents with symptoms of insomnia: a single-center experience. J Clin Sleep Med. 2020 May 15;16(5):743-747. doi: 10.5664/jcsm.8338. Epub 2020 Feb 7. PMID: 32029069; PMCID: PMC7849801.

Media does not appear to have picked up on RFK Jr's incorrect assertion in the Wed 1/29 confirmation hearing that SSRIs have a black box warning for homicidal ideation.

6:30 in the video, at the tail of the exchange with Sen. Smith:

PBS Newshour

SSRIs have a black box warning for data showing potential for increased risk of suicidal thoughts and behavior in adolescents and young adults, based on short-term studies. There is no black box warning for homicide ideation – currently.

It was an interesting error by an individual who has spoken extensively on the topic, and who would presumably have familiarity with the text of the warning. As HHS secretary, Mr Kennedy will oversee the FDA and could potentially advocate for expansion of the current black box warning. There may be implications in his testimony for increased liability risk for prescribers - not to mention, of course, increased stigma for patients and fear surrounding antidepressant treatment.

Planning for residency applications in the Fall, didn’t realize we needed a non-psych LOR, preferably from IM (according to advisors). Problem is, I did my IM rotation in August, was with two preceptors, two weeks each. I strongly doubt they remember enough about me to write a solid letter.

However, I do have the opportunity for a 4 week Neuro elective in a few months. In your opinions during the application cycle, is it best to ask for the IM or Neuro letter?

I am strongly dedicated to psych, and it’s the only field I want to apply to. Just want to make sure the application is as good as possible

Thanks!!

It appears Psychiatry is getting a lot of newer medications with unique pharmacodynamic direction for MDD and Schizophrenia. With MDD, there’s been an interest in glutamatergics (such as Srpavato and Auvelity), and with schizophrenia the possibly game changing M1/M4 agonists (Cobenfy and others to come…).

I was wondering if anyone had any comments on why Bipolar Disorder hasn’t seen anything very interesting in the pipeline? The past 5 FDA approvals for bipolar depression have been for antipsychotics, as have been the maintenance approvals, and mania treatments. We haven’t had a new anticonvulsant or mood stabilization medication since Valproate (1995), lamotrigine (2003), and carbamazepine (2004).

Does anybody have any experience with global health? I am a current M3, and part of my dream as a physician has always been to do something like Doctors Without Borders or a similar medical mission. I’ve heard someone say that depression and schizophrenia are the only cross-cultural mental illnesses. I imagine global health in psychiatry would look really different than traditional medical missions. Medical students and resident trainees go to resource poor areas around the globe. Could a psychiatrist be part of the traditional medical team? I don’t plan on forgetting medicine in whatever practice model I engage in. What are your thoughts?

Hi all, somewhat early career attending here. Recently got put in a position with a lot more PCP-like responsibilities.

Anyone know of any good resources for urgent care/FM type stuff? Besides UpToDate. Would like to actually learn this stuff and check rather than search for it after I see someone.

Hi everyone!

Working on my residency rank list right now and was curious if there are any opinions on comparing different facets of call schedules. For example, programs that have you take psychiatry call while on off service rotations (but no off service call), or comparing night float to 24 hour call.

If there any other thoughts or recommendations on what to look for or avoid that would be very helpful!

Hello all,

I truly appreciated responses to my questions on part 1. I genuinely learned so much from the answers - I have read them multiple times while taking notes - and hopefully others have also benefitted from the detailed insights that were posted.

I have a few more lingering questions that I would like some input on. Admittedly, I feel that these are less "hard-hitting" and less imperative when compared to those posted few days before, but still would very much appreciate some feedback on them. As advised, I will certainly pose a lot of these questions to my attendings also, but it's always good to get different perspectives.

Once again, I am grateful for your help!

1. On criterion B for diagnosis of PTSD, it describes flashbacks as "dissociative reactions." Is this referring to a phenomenon that is separate and distinct from the dissociative subtype of PTSD which refers to depersonalization/derealization?
2. In the inpatient/CL/psych ER setting, when might you consider ordering B12, Vitamin D, HIV, Syphilis labs? When the patient has a mental status change and/or encephalopathic presentation?
3. In a patient on medications like Sinemet with Parkinson's, who presents with hallucinations, how do you ddx between diagnosis of psychotic disorder due to another medical condition (ie. Parkinson's) vs medication-induced psychosis? I suppose we can look at things like onset of hallucinations, and how symptoms respond to tapering of dopaminergic agents. Anything else? If symptoms still persist after taper, do we start considering things like pimavanserin, quetiapine, clozapine?
4. For the thought process section of MSE, I have conceptualized that "tangential" is more loose/disorganized than "circumstantial", and that "loosening of associations" is even more loose/disorganized than "tangential". Within this framework, where do the terms "illogical" and "disorganized" fit in?

5a) I remain somewhat puzzled by criterion C of schizoaffective disorder ("symptoms that meet criteria for mood episode must be present for majority of total duration of active/residual portions of the illness"). Say, for example, the patient has a stretch of time in that fulfills criterion A of schizoaffective. But, also proceeds to have multiple episodes of psychosis in the future which is NOT accompanied by mood symptoms. Would this patient, then, not meet criterion C for schizoaffective because the mood episode does not constitute "majority of total duration" of the illness? Would the diagnosis be MDD + Schizophrenia rather than Schizoaffective?

5b) Another scenario that I am wondering about (things are becoming far-fetched, admittedly) is when the patient has an episode that meet criteria for schizophrenia and, during that time (either during active or residual portion), he has an episode that meets criteria for MDD which does NOT last long enough to meet criterion C for schizoaffective. This patient otherwise never meets criteria for MDD before or after this time. In that case, would you still give diagnosis of schizophrenia + MDD or just schizophrenia?

5c) Finally, let's say there is a patient who met criteria for schizoaffective disorder in the past. But since then, he has not had residual symptoms of schizophrenia (unlikely as it may be) but has had multiple episodes which meet criteria for MDD. Would we, then, give separate diagnosis of MDD and Schizoaffective? Once again, another unrealistic and contrived scenario, and I realize that I may be going too "OCD" and nitty-gritty here.

This is originally a comment I made in a different post but I'd love to discuss this in its own post. I mostly mean to discuss restrainting a patient that is attacking another patient or a staff member. Obviously patients engaging in self harm sometimes require restraints and that can be discussed too.

From a nursing perspective, it seems negligent to wait until harm occurs to employ restraints if all signs/symptoms indicate harmful behavior is imminent. I imagine being in front of a civil court due to waiting until a patient harmed another patient before I utilized restraints and being ask: "You're trained to recognize situations when harm is imminent and how to safely intervene using de-escalation or restraints if needed. Why then did you wait until this patient harmed another patient to intervene and restrain the aggressive patient?" I feel like waving around the idea that I should wait until harm occurs before I restrain would hold no ground even if this was presented in a "patient rights" angle. Indeed, if I was a patient and another patient attacked me after saying/indicating/gesturing that they were going to do so then I would feel the care provided to me was negligent. Similarly, if I was feeling suicidal, verbalizing intent to imminently harm myself, becoming agitated, and staff waiting until I harmed myself before restraining me then I would feel that was negligent as well.

Leadership at my hospital, however, actively prevents nurses from restraining until harm has occured. Indeed, leadership at my facility seems to think that restraints should not be used unless a patient is actively pummeling another patient with punches and that if the patient stops for one moment then restraints should not be used even if the aggressive patient remains agitated/unreceptive to de-escalation. I chalk this up to the fact that they would not be the ones facing accusations of negligence if harm occurs. This is despite: (1) My states voluntary hold form requires patients to agree to be restrained if harm is imminent and (2) involuntary patients have their right to refuse restraints taken away.

Obviously restraints can be misused and I have witnessed this myself, but I can't seem to square this idea that restraints should only be used after harm has occured.

Tldr: Restrainting a patient before harm occurs seems appropriate and waiting for harm to occur seems to fit the definition of negligence. Thoughts?

Edit: I should have specified a few things.

(1) Restraint is a terminal intervention so verbal redirection, problem solving, exploration of other options, encouraging use of coping skills, voluntary use of PRN medications, removal of stimulus, ect. are always offered first before restraint occurs. I assumed this was understood and went without saying in my OP.

(2) At my facility we only have psychiatrists on site to evaluate the need for restraint in person during regular business hours. Even then, RNs are permitted to initiate restraint as long as a provider order is obtained within 30 minutes.

(3) My facility does not allow the use of chemical restraints despite the term being nebulous. PRN IM medication for agitation does not count as a chemical restraint.

Edit #2: More specifics for those who want to know.

(1) I work on a 20 bed adult acute psychiatric unit. Medical diagnoses are stable and easy to manage things like diabetes, non-complex wounds, HTN, ect. It is a stand-alone facilitity so we have no in-house services like radiology. Acute medical concerns out of bounds cause the patient to be sent to the local ED.

(2) Leadership (specifically our nursing supervisor and/or Director of Nursing) will tell nursing to not use restraints even when Psychiatry is there in-person giving the order. We have even had leadership tell nursing to not restrain when it was a Psychiatrist that was attacked by a patient throwing things.

Edit 3: My question presupposes that every non-restraint intervention has been attempted and failed while the patient remains agitated/physically threatening/verbally threatening. Please don't bring up alternatives as that is not the point of this post.

I’m an RN who has previously worked in med surg and HDU but now work in adolescent inpatient psych (which I’m really enjoying) on a voluntary unit, mostly depression/anxiety/BPD/BPAD/OCD. I have noticed that a large proportion of the patients report frequent nausea without vomiting and often request antiemetics (to a greater degree than medical patients) and I’m not 100% sure why. These are some possibilities I have thought of but I’m not sure if I’m missing any.

• withdrawal symptoms
• medication side effects, particularly from new meds added during the admission
• discontinuation symptoms
• lifestyle factors like not eating breakfast/lunch then binging at night
• other??

Why is this population so prone to nausea? Does anyone have insights or is this not a thing.

Thank you in advance!

Hello - I apologize in advance if this is the wrong subreddit to ask this. Please let me know if it's more appropriate for a different community, but I wanted to get the insight of predominantly psychiatry residents/attendings.

I'm a 3rd year in a US medical school planning for application season and 4th year scheduling and am stuck between 2 specialties. I became interested in a very competitive surgical specialty during MS1 and was encouraged by faculty and peers to explore it early on. As a result, my CV does reflect a lot of specialized involvement with this field. I've invested an immense amount of myself into it.

Come clinical rotations, however, I really fell in love with psychiatry. I realized just how much of my life already held a history in the intellectual, personal, and artistic pursuit/exploration of the human psyche. I realized how much I cherished just the conversation of a psychiatric visit. To be honest, maybe I was denying myself this possible connection because growing up I had limited access to healthcare and additionally, mental healthcare was really stigmatized in my culture.

The thing is, I really love working with my hands or at least, doing procedural work. I know that if I do psychiatry, my chance of this would be limited unless I incorporate more interventional psychiatry (which I'd love to do if I go into psych). The surgical specialty I devoted a lot to makes huge impact to quality of life with direct handiwork and that capacity really appeals to me.

Without rambling further, my biggest question is what do I do moving forward and how should I do it?

I've been considering doing a psych acting internship early in my 4th year to help me decide if I should abandon the surgical specialty completely. Deep down I want to dual apply but because of how competitive the surgical specialty is, I know I'd have to do an away and I believe that it would show up on my transcript. The away would also help me see how the surgical specialty is practiced at another institution, and I feel like that could further help in my decision whether to commit or abandon.

The downside of a dual application with a surgical specialty away is the possibility that psychiatry programs may interpret this as reason to suspect psych a back-up and not a commitment... which saddens me because it genuinely is not... I fear I am just someone who earnestly doesn't know where I would be happiest quite yet and only recently decided psychiatry could be for me within the past month...

Any thoughts or advice is extremely appreciated. I did not specify the surgical specialty as I am a prospective applicant.

Hi all, I'm looking for some direction in finding outpatient psychiatric groups in a city my family and I will be moving to. Any suggestions on the most efficient way to find a list of such groups? I've tried googling clinics, but I imagine that this wouldn't be a comprehensive list of all available practices in the area. Thanks!

Placebo? Initial elevation of DN that levels?

I inherited a 53 y/o M who has quetiapine 25 that he uses once a month second-line PRN for insomnia. Not great, we've talked about it, he's quite attached to the med. Also, he lives far away and we overwhelmingly do telehealth (though I can insist he come into the office).

My understanding is, any SGA means the full monitoring gamut. So I'm trying to be scrupulous about it, but I have the following questions.

1. Patient gets weight, BP, A1c, and lipids checked by PCP. Do I need to check these on my own, too?

2. PCP doesn't check waist circumference. The patient already has metabolic syndrome. Does my checking WC add any value?

3. If you find one of these parameters has worsened, but the patient is followed by PCP for it, how do you handle it? Do you just call the PCP and let them know?

4. Finally—how reasonable a substitute is virtual AIMS for in-person?

Thanks for reading. He's going to be annoyed by any request for any extra monitoring, so I want to get my own ducks in a row—to make sure I'm being neither overzealous or colluding in avoidance.

Hi all, any recommendations on an AI scribe that:

1. transcribes zoom, teams and any telehealth interactions well
2. is able to do so when the psychiatrist uses a headset with mic rather than the computer's speakers and mic
3. is able to so with phone consults using bluetooth headsets

Also, are there any scribes that can review a psychiatrist's pre-written letter (in prose), learn from this and produce future transcriptions based on this?

Many thanks for your suggestions

Hey everyone, just wanted to share an Anki deck I just finished making, which covers the 6th edition of Carlat's "Medication Fact Book for Psychiatric Practice." Would love any feedback on it (don't have the energy/time to update for the 7th edition lol). But hopefully it's helpful

https://ankiweb.net/shared/info/374240323?cb=1737949706920

Hi all!

Another M4 here looking for some rank list advice! I'm trying to figure out how much program ranking matters when:
a) Deciding between top-tier NYC psychiatry programs (like Columbia, NYU, Cornell, etc), and
b) Comparing those to Chicago programs (e.g., UChicago, NW etc).

I'm open to the different locations, though psychotherapy training is a big priority for me. Many of these programs offer great fellowship opportunities, but I’m curious if prestige significantly affects job placement or long-term career goals (academic vs. private practice, etc.)

For context, from what I've gathered, I could be happy at various places so it feels hard to narrow down.

Thank you in advance for any insights or advice you can share!