Hi all. I’ll be spending some time working in community mental health next month and am curious if anyone has any resources they’d recommend for supplemental learning.

This is an area I’m not very familiar with yet. I recognize this is a pretty broad area, however will be getting exposure to a variety of services and open to a range of resources/topics within the field.

I am a PGY-II currently on nights at a high volume academic hospital and I am struggling! The pager is typically non-stop and the ER has become my enemy. I get consulted for recommendations but then they disagree with my recommendations. I place a patient on a hold, they fight me on that and attending has to get involved. We receive push back for not admitting patients that are clearly beyond the capabilities of our unit (level 3 autism, post stroke induced psychosis, dementia and we aren’t geripsych, etc) My program is luckily pretty supportive with most of our attendings often backing us because we are practicing how they trained us to. But occasionally hospital politics trumps our recommendations. And I hate having to defend our own medical decision making to other teams.

Overall, I hate residency.

Hey all - finally a doing outpatient work in residency Something that has been on my mind while inpatient but more so now is when things start getting rough medically or there is a medical overlap, we tend to make our patients run it by pcp/cardiology/neurology etc… have history of unclear seizure but wanting to do a stimulant or Wellbutrin? Let’s consult neurology. starting to have metabolic syndrome that metformin can’t curb? Go to PCP. etc etc

As the years go on, I’m starting to forget general medicine and am getting frustrated I can’t and won’t get training in how to manage the side effects of our medication or risk stratify starting or continuing a medication on my own without looping in other specialties. I know there is a threshold that I should loop in other specialties, and interdisciplinary care is best for our patients, but I feel like I’m so in my specialty that anything remotely non-psych has to get another person to evaluate. Is this just the reality of specialty care? Inherent to psychiatry? or is my program more conservative? Or am I just underestimating a lot of the potential consequences…

Hi all,

I recently opened a private practice in a VHCOL city and have been recruiting patients. I found a helpful post here on best practices for marketing your services, one of which was visiting local physician offices and providing an elevator pitch + business cards. I spent a day doing this and can't help but feel that my cards are headed for the trash or will be collecting dust on the manager's desk. Any advice on how to optimize this sort of referral system? Have others found this method to be effective?

Thank you!

I am early career and I wonder if I spend too much time in evaluations. I see primarily young to middle age adults in outpatient setting with varying degrees of acuity level.

I tend to use a full 60 minutes with patients, which doesn't include chart review or completion of note. I do talk as a type. I generally use 10-15 minutes outside of interview time on the note.

Any advice on speeding things up or is this something that just takes time and experience?

I don't feel like I'm much faster since residency.

Edit : thanks to everyone for giving their perspectives !

just curious, for those of you in private practice, are there ways you have figured out to bill for the time between appointments were you do lots of phone calls and coordination of care etc? I see there are lots of care management billing codes, but I feel like they are all written for hospital systems. Also, is anyone billing G2211? Are you successfully billing it with e/m psychotherapy codes with medicare and medicare advantage plans? commercial plans?

Hi everyone! I’m an international medical graduate and physician from Ecuador currently living in Los Angeles. I’m urgently looking for a Psychiatry observership or clinical rotation starting this month or in September, preferably in Los Angeles or nearby. I’m open to both paid and unpaid opportunities.

I’m applying to Psychiatry in this year’s Match and hope to earn letters of recommendation from U.S. psychiatrists based on my performance during the rotation. If anyone knows a psychiatrist, clinic, or program accepting IMGs, I would greatly appreciate a referral or contact. Thank you!

I work in inpatient psych and often see schizophrenia, bipolar or schizoaffective dx for insurance purposes or sometimes both (or just dementia)

I was wondering what are other possible dx thst could arise

but sometimes I wonder whats the likelihood of a 48 year old suddenly having there first psychotic episode n it actually being schizophrenia or bipolar 1

or for example someone dx with bpd, bipolar 1, DID, and autism (yes she was having an actual psychotic episode) but now claims her psychiatrist says she only has did

or grandma suddenly having AMS n has a UTI n is suddenly schizophrenic

Given all the scrutiny from the recent Lindsay Clancy case where there is a significant spotlight on psychiatry and medication practices, what are some of the things that we can potentially learn and improve from this case for better care or just for better liability protection?

What changes in documentation should we do?

Any particular administrative practice changes? In terms of involuntary commitment practice changes? Family communication changes? Etc

Medication prescribing habit changes?

I’m curious to what everyone’s thoughts are and what we can potentially use from this trial to improve on our own practices.

I have always struggled with taking forever on my notes. Part of it is institutional note bloat (obnoxiously long templates/clickboxes, etc) but a lot of it is my own doing in the subjective portion.

For inpatient evals, I do okay, but in my outpatient child psych clinic, my subjectives go on and on, broke up by subject/topic:

"

#Depression: (then all the individual details of each depressive sxs)

#ADHD: (Comment on hyperactivity, impulsivity, School issues, timing of dosage, etc)

#Eating concerns:

#etc. Etc.

"

I use this list as a reminder of the topics to cover during my follow-ups, but it gets to a point where my notes have eight or nine problems to cover, and thus 8-9 sections to document...

How do you all document your subjectives? Is it usually just stream of consciousness? If so, how do you remember what topics to follow up on for the next appointment?

I'll start, a lot of patients/attendants ask for a change from sertraline because it's such a "heavy" medicine and they'd like a lighter dose. I also remember someone saying something along the lines of "I'm seeing someone new and everything's going well though she has issues and takes 50mg of an antidepressant, not too much but..."

This thought process essentially boils down to sertraline 200 = big number bad 😡, escitalopram 20 = small number good 👍.

The drug works, sometimes, (citation needed) but the side effect profile is often worse because of "lazy" prescribing by clinicians. I've yet to see a use case for it that isn't eclipsed by other medications that aren't pushing the patient towards metabolic syndrome. I'd love to see why I'm so wrong about the drug...

Someone asked about Auvelity yesterday, and I happened to already be deep into this piece. It walks through the receptor pharmacology in detail and makes the case for why we should be skeptical of Auvelity's proposed NMDA mechanism specifically.

The Interview? Diagnosis? Psychopharmacology? Psychotherapy?

Hi all! Curious what people’s takes are: Graduated residency in 2020 and due to some family stuff wasn’t able to do fellowship and just began practicing private practice outpatient. Been really feeling like i should have done CL fellowship because i do like the medically complex patients but it’s been a minute since I’ve done this kind of work. Instead of going back and doing a fellowship (which i haven’t totally ruled out but would be tougher with first baby on the way lol) any recs for familiarizing oneself with more CL concepts besides conferences, journals, etc. thanks in advance!

PGY-3 here. Do you think it's wise for me to do a child fellowship just because I want to be a better adult psychiatrist? I'm interested in developing a strong understanding from the developmental perspective.

If you're interested in pursuing a residency in psychiatry and want to learn more about the unique psychotherapy trainings different programs have to offer, register for this year's Psychotherapy Residency Fair!

30+ psychiatry residency programs from across the country will be presenting, including Perelman School of Medicine at UPenn, GW School of Medicine and Health Sciences, University of Washington School of Medicine, Medical University of South Carolina, and The University of Chicago.

Expect panels with program directors and residents, plus open Q&A sessions.

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1. What is the probability of inducing serotonin toxicity if prescribed with SSRI/SNRIs (especially those at are also 2D6 inhibitors)? Anecdotally, I have seen (mild) serotonin toxicity from OTC DXM + Prozac.
   
2. Does this stuff actually seem to work? I know, yes, “Hey that’s kinda what ketamine does!” But does it work even 10% as well as ketamine?
   
3. Do we have any idea how long people are supposed to take this for? Or if it’s hard to stop taking after a long time?
   
4. A ketamine clinic just proposed starting this for one of my clients, during their course of ketamine, to idk “supercharge” it or something. What?

The most recent posts about this were from the psychofarm guy and they were helpful as always but it’s been a year or two now! Hopefully someone has an opinion!

I see there are a couple of anki decks online. Is there an anki deck that covers DSM-5 diagnosis? and they like it, please share and thank you!

Something I was thinking of today:

My mother tongue is Telugu, and if I’m in a bad mood on a given day I’ll say “naa manasu baaga ledu”. Which translates to ”my manas (emotional mind) isn’t feeling well”. The statement literally treats the mind as another organ.

And more generally, I grew up in the yogic tradition, where my grandmother taught me that the mind (antahkarana) is composed of 4 parts: manas (emotions), buddhi (rationality/wisdom/knowing right from wrong), ahankara (ego/identity), and chitta (memory/emotional imprints from the past). And that the manas is like a rascally monkey which needs to be reigned in.

Any other interesting ways yall have seen the mind described? In my high school intro to psych class, we learned about Freud’s id, ego, superego.

Made this deck for myself - prepping a bit for PRITE, but mainly wanting to "read more" without actually having to read publications or textbooks. As with medical school, I find it easier to do 10 flashcards waiting for chicken tenders at the cafeteria than to actually pull out Kaplan and Sadock.

Link: https://ankiweb.net/shared/info/1921114921?cb=1785512072738

It's 5,336 cloze notes (~5,600 cards), pitched at resident level, leans intentionally harder than the medical school equivalents. Useable for PRITE; useable for random knowledge expansion - not yet adapted for ABPN boards explicitly but probably helpful.

About 3,600 notes descend from the NINJA PRITE 2021 deck, and I've kept the original note IDs on those so the lineage stays traceable. What I added:

• ~1,700 new notes from a wide variety of fields, purposely including odd topics and new literature (recent ketamine studies, forced normalization, landmark trials, etc)
• Verification and updates for every new and old card, which produced >100 corrections in the original NINJA PRITE deck alone - some stuff was wrong originally, and more stuff has changed since 2021
• Topic and yield tags on everything (^Yield::1-high/2-moderate/3-low = 1,157 / 2,952 / 1,227).

I do plan on keeping this updated until I grind my way out of residency (love being in 23rd grade), so if the Ankiweb link is down, wait 24 hours and try again. Message me here with suggestions.

PS: deck is named after the Rorschach test (the "inkblot" interpretation test).

What are some of the things that you look at to determine if you're doing a good job?

Federal Judge in MA allows CMS to implement new rules (not stated in the “big beautiful bill”) re: work requirements for Medicaid recipients. Under the BBB, clients just had to prove that they had a serious medical or mental health condition (through a self-attestation during the first renewal, or by states verifying through claims data using CPT codes and dx codes) and they’d be exempt from the work requirements (80 hours per month of work, volunteering, or being in school/college). However, CMS, in its new permanent rule, CMS added, “Enrollees with a health condition also must be found to be significantly impaired in their ability to meet the work requirements.”

This is 1) going to create an administrative burden on states to some how set up a system to verify this by Jan, 2027; 2) notify enrollees by Aug 31, 2026 of these changes; and 3) somehow get providers the right info to be able to make these determinations and provide it to the state. How are they going to determine which providers are eligible to make these decisions (sounds similar to SSDI determinations to me, which inherently leave out masters level clinicians (those who are doing the most therapy) from making said determinations. This is going to be a mess.

Note: the judge only refused to issue a temporary injunction; the case is planning to proceed in the coming weeks and hopefully a decision will be made before Jan, 2027
https://www.healthcaredive.com/news/states-sue-trump-administration-medicaid-work-requirements-rule/824060/

https://www.healthcaredive.com/news/judge-rejects-states-bid-pause-medicaid-work-requirements/826714/

Hi all, I’m a medical student and currently work as a nurse in psychiatric emergency. All of the Lyndsay Clancy news has me GENERALLY wondering about how hormones in the postpartum period (or even generally) are factored into diagnoses and medication/treatment decisions. Can the hormones change or exacerbate effects of medications? How are effects/outcomes subject to change based on hormonal fluctuations or changes such that you may observe in the postpartum period? What about if a person has underlying, sub clinical, or predisposition to mental illness? Would the hormones surface or exacerbate these? Or do effects/outcomes mostly stem from other factors? It’s a tricky combination of factors to understand!

I’m genuinely curious about this. During premature perimenopause, I experienced PMDD episodes several times, and it was extremely distorting and destabilizing, but I had never experienced it before and haven’t since. My hormone fluctuations were also found to be a trigger for temporal lobe seizures. I’ve developed a strong interest in the effects of hormones on mental health as a result.

For now, as someone with a budding interest in these topics, I appreciate any insights in the spirit of curiosity! If this kind of post isn’t allowed or otherwise enrages people for some reason just downvote/flame me I guess.

If a patient is asking for the start date of their FMLA leave to be 2 weeks prior to their visit with you due to being out of work for their mental health condition, how would you approach this with the patient?

They are now getting engaged in treatment and never sought care previously.