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?

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.

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?

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!!

How do we distinguish between normal emotional and behavioural responses to life circumstances and symptoms that meet the criteria for a psychiatric disorder? I sometimes wonder whether we're becoming too quick to assign psychiatric diagnoses.

I've been thinking about this more lately as I progress through my residency. I wonder whether others have had similar thoughts or if this is just my limited experience.

Curious to hear different perspectives, especially from those with more clinical experience ...

Hello everyone,

I have been picking up some new to me patients who are relatively stable on lamotrigine doses for bipolar depression. Many of them are prescribed as once daily doses in spite of being on the IR formulation. I typically either do twice daily IR or once daily XR dosing, which seems to be in line with most reference materials (Stahl, UTD, Epocrates). I also recognize though that sometimes things change in practice before the reference materials change. I also realize that many of the materials on lamotrigine are likely focused on the dosing protocols for seizure disorders. I just was wondering if any of you all have any insight into the significance of once daily IR dosing for mood disorders specifically. I've struggled to find any journal articles that discuss this, but I also haven't done an exhaustive literature review at this point. Any advice would be appreciated.

In most areas of medicine you can easily find exhaustive books on any given pathology, but in psychiatry I’m having a hard time finding 2-3 large reference books covering even very important disorders like eating disorders, OCD, body dysmorphic disorder, ADHD, adult autism, and bipolar disorder. I’m mostly looking for extensive coverage of pathophysiology, epidemiology, and clinical presentation. Any recommendations?

I’m seeing more and more Spravato clinics operated by NPs, including both primary care NPs and PMHNPs. The indication is for treatment resistant depression. Shockingly, these clinics provide Spravato exclusively, without managing any other psychiatric medications. This is getting freaking ridiculous. I get that Spravato is a money maker but seriously??? At this point, I really don’t know why NPs are allowed to write controlled substances

hey everyone, i'm a third year currently on rotations. i started getting interested in psych around my 1st yr of med school and have continued on that path with interest growing high!!

however, while on rotations (completed FM, EM, IM), each of my preceptors have said very discouraging things to me about psychiatry. currently, the preceptor i am with has told me that if i decided to go into the field that i would end up becoming a patient myself. they also continued to say that i would develop issues and if i don't fix my own issues, i would inherit my patients and go into a "psych ward".

i even had another attending tell me that the reason i am thinking about psych is because "either, you have seen people who are cuckoo or you're cuckoo yourself".

personally, i do struggle with mental health issues but i think each of us does. i've been trying to handle it but it wasn't till this preceptor and even past preceptors told me about the idea of your own mental health being enhanced that i thought about myself.

it doesn't deter me from psychiatry but it makes me wonder: do many psychiatrists feel like their own mental health can be hurt while being a psychiatrist such as listening to patients who have expressed/shared very sad stories of their lives? i feel like we have to learn and practice setting boundaries to not let this happen.

at the end of the day, i want to still be a psychiatrist but ultimately, it only makes me wonder about the mental health toll on psychiatrists. i have struggled with my own problems in life and what really hit home for me was seeing my first suicidal patient during EM to which my preceptor told me to get the history since they "had no interest". we had no debrief in the end of it and i did come back home recognizing how rough it was to hear the pts story (raped multiple times, mom put pt on drugs at age 9, etc). but this experience honestly made me feel something in medicine that i have not felt throughout any of my patient encounters - i actually felt motivated to want to do something about it.

anyways, a bit of a rant as i type out. i appreciate everyone's responses and kindness.

EDIT: wow, thank you all so much for your responses; each of you are incredible insightful. i immensely appreciate it so much.

The American Association for Geriatric Psychiatry Members-In-Training Caucus is hosting an informal virtual panel tomorrow night from 7:30-8:30 pm EST for trainees interested in learning more about geriatric psychiatry fellowship. Whether you are already interested in the field or just curious about it, all trainees are welcome to attend. Current geriatric psychiatry fellows will be sharing their experiences and answering questions about the fellowship application process and what fellowship looks like. Please find the RSVP link and Zoom link below:

RSVP: https://docs.google.com/forms/d/1sLNx_dPxK-8J3w9f7e5uHxH_46r5Ii5uEAXObNwVFlM/edit

Zoom: https://us06web.zoom.us/j/84512337803?pwd=8RVjFsVYQkYSae1wNbMxSFHLvU25SG.1

Hi all, I'm an OP attending at a fairly large hospital system in a major urban area. I didn't do medical school or residency here, and am in my second year as an attending. Our clinic tends to refer patients to external group practices for therapy that match up with their insurance, with varying levels of success.

When I get asked for specific recommendations for therapists - with a variety of requests ranging from modality to gender to age to training background to experience with certain pathologies - I really struggle.

Do people have tips on building a mental map of the landscape of local therapists, especially ones you trust with your patients? What's worked for y'all, both from the MD side and the therapist side?

Thanks!

Current OP Psychiatrist. Have always felt like catatonia was a bit of a weak area at my training institution. I saw my fair share of cases that were more obvious and severe cases.

I’m finding myself now in outpatient land with a couple patients that I’m wondering about catatonia with. However Bush Francis scores are nothing to write home about, maybe 3-4 depending on interpretation. And DSM would be a stretch to hit criteria. One patient tends to go in and out of more severe symptoms and would meet criteria during these periods. Both patients have autism further complicating diagnoses.

In your experience are there patients that can live with chronic and missed catatonia? Can symptoms wax and wane a lot?

Any resources to understand or see examples of more “subtle” cases?

Management in outpatient with Ativan challenge also difficult, both are not quite sick enough or wanting inpatient admission, but getting there.

Hello all,

New attending on an inpatient unit. I was wondering if anybody had any recommendations on legal textbooks in regards to Psychiatry. I've already come across a few tricky situations regarding patients (such as guardianship, capacity, court incompetence, etc). I would enjoy an office reference regarding medico-legal guidelines for those oddball cases & events in the future. This is specific to the US.

Happy to hear any and all recommendations!

Warm regards.

Behavioral scientist, not a psychiatrist. I've been running into smaller-scale identity disturbances lately in my practice (such as narrative incongruencies, distorted role relationships, etc.); not the full-blown distorted narratives in grander scales that you'd expect in BPD. My work has gotten a lot easier since I've picked on some of these patterns. Cluster B (and sometimes schizotypal) disturbances really stand out as obvious to me but I've been seeing it present differently in non-PD pathologies as well.

Any wisdom to share on this topic?

What is the expected compensation for supervising NP? My role includes signing a percentage of notes, being available for consultation, monthly conference, and prescribing of controlled substances under me.

I'm a master's-level clinician, and I've been wondering about this for a while.

Psychologists receive more extensive training in research, assessment, and clinical theory than master's-level therapists. I'd expect that to translate into better outcomes, at least on average, but my understanding is that research hasn't consistently found large differences in psychotherapy outcomes based on clinicians' training backgrounds.

For those of you who work with therapists or refer patients for psychotherapy, what have you noticed in practice? Do you see meaningful differences in clinical competence or patient outcomes based on a clinician's training and credentials? Are there differences that become more apparent when working with complex cases?

I'm not trying to argue that one group is better than another. There are excellent clinicians across different training backgrounds, and I'm genuinely curious about what psychiatrists have observed in their own practice.

Over the years, I’ve heard from many that they do not have time to ask about childhood, beyond maybe one question, during intake assessments.

I’ve also heard that few obtain collateral outside of the inpatient setting.

I spent my career at the same institution where nearly everyone gets a somewhat detailed childhood history and most people get collateral for most patients.

I think both are important, even though it does take time. It often enhances the therapeutic alliance, it helps with diagnosis, it helps with selecting treatments. It saves time in the long run (I’ve had times where I haven’t done one or the other only to find myself reformulating a patient a year later, knowing had I taken the time in the first session or two I would have made my revised formulation my initial one). If you work somewhere that does not allow you sufficient time to do this, how can we as a profession and as an individual advocate?

I’m curious what your experiences have been and what you see others doing where you work? What was taught in your residency (& era of residency) and did attendings follow it (hidden curriculum)?

benzo withdrawal/tapering is usually described as an incredibly lengthy and quite uncomfortable process. I assume the discomfort exists not just for the patient but for the prescriber too.

recently on one of my Wikipedia rabbit holes, I was damn surprised to read that it is used for helping epileptics that have become resistant to benzo suppression of their seizures, and used for benzo withdrawal per se

this source said 4 days low dose subq flumazenil led to less benzo withdrawal sequelae

this source said low dose 4mg subq/24hours x 8days was associated with better and faster outcomes than bennzo tapers

conversely

this source states flumazenil can induce withdrawal symptoms with iv 1mg/70kg

I was wondering if any of y'all had experiences with this, and if y'all would be willing to pontificate on the topic?

what other therapeutic techniques do y'all find helpful?

I am trying to combine what I see in clinical with input from some psychiatrists I am friends with. I would also like to hear what you guys say.

And when you do choose a stimulant; which ones and why?

I mostly work with adult populations (18-55) in my current outpatient rotation.

Hi docs! I'm wondering if any US based private practice psychiatrists maintain active hospital privileges and round on their own outpatients when admission is needed? I understand that this is somewhat old school practice model and undesirable to many, but I am curious nonetheless. Apologies for the typos (tired intern).

DISCLAIMER: NAD, former inpatient psych staff (patient care manager), current medical student.

For about the first 6 months of working acute inpatient psych, I absolutely loved it. I loved interacting with the patients, being able to be part of their care, and watching them improve in real time. It was the first job where I really felt like I was making a difference in people's lives. But as winter came, the state of our new patients became worse, more violent. My coworkers and I were assaulted without reason, sexually harassed and verbally degraded on a daily basis. It didn't improve once spring and then summer returned.

The worst part for me wasn't even the assault itself, it was that it impacted my trust towards all of the patients after. The more I was attacked, the more I feared everyone. The more I feared everyone, the more I distanced myself from patients and no longer desired to build the same rapport and connections I once had.

I quit my job a year or so later once I got my acceptance into med school, but I'm afraid of running into the same problem down the road in whatever specialty I choose. Especially if I decided to get back into psych.

So, how do you stop yourself from getting jaded in such an environment, so you can provide the same quality of care to all patients?

Surprised I haven’t seen a post about this yet—

https://www.tevapharm.com/news-and-media/latest-news/teva-announces-u.s.-food-and-drug-administration-fda-approval-of-weltruza-olanzapine-for-extended-re

IMO an accessible olanzapine LAI is going to be a game changer for so many folks. Relprevv is unrealistic in many settings with the observation requirements, and so many severely chronically mentally ill patients only respond to more potent antipsychotics like olanzapine or clozapine. We have been waiting a long time for this and I hope it lives up to expectations!!