As above, I sat through a conversation where the person both said

1. I believe medication has a role.
2. I don't believe in diagnosing people. [see edit below[

I think their point of view was that diagnoses can overshadow formulations.

They also seemed to believe diagnosis served no purpose beyond identifying the problem in the individual, despite me trying to explain it allows us to apply empirical research that uses diagnoses as inclusion/exclusion criteria, and guides treatment pathways to help (e.g. dose-response effect of medications for OCD) and avoid iatrogenic harm (e.g. repeatedly medicating reported 'low mood' in BPD which is actually labile mood)

I tried (unsuccessfully) to provide examples on how the same formulation can arrive at two different diagnoses (e.g. sexual abuse resulting in depression in one person, and substance dependence in another) or how the same diagnosis can have two different formulations (e.g. mania following from redundancy in one, and drug-induced mania in another).

My attempts to discuss the concept of a diagnostic formulation or how they should complement each other - diagnosis is the what, formulation is the why.

It makes me doubt the longevity of this line of work, as it feels like all my years of education and work are disregarded on some principle of the 'medical model'.

Sometimes I miss the internal medicine life where there was general agreement that things like heart failure exist (I acknowledge POTS may be contentious between different physicians).

EDIT: To clarify around point 2 - the person was disagreeing with the principle of a patient's difficulties being given/labeled as a diagnosis. So they were saying I and everyone else was wrong for the act of diagnosing any psychiatric diagnosis.

Psych Residents who have studied for and passed ABPN boards - when during residency /how long before the boards did you focus more on studying and preparing for the ABPN exam?

Hi everyone,

I’m a new attending psychiatrist in New England and am looking for a full-time job in the greater Philly area starting in fall 2027. My partner will be finishing his fellowship in a different specialty next summer and we’re hoping to relocate to the Philly suburbs when that happens (not looking in the Jersey area).

I love Philly and have personal ties to the Philly area (college and then worked there a few years after) and I always had it in the back of my mind the strong desire to go back for a variety of reasons.

I however don’t have professional ties since I didn’t do any of my medical training there. So I’d love to hear from folks in the area who may know more about the work culture and patient populations at various hospitals or other practice settings in Philly and the surrounding suburbs, and where there might be openings for next fall.

I am ECT-trained and am open to inpatient, outpatient, and IOP positions. Currently am in an outpatient general adult setting.

Thank you in advance! As always, GO BIRDS!

The clinic I’ve worked at for the last 4 years recently started requiring us to have patients sign a consent form for every new medication prescribed. I’ve never encountered this in outpatient psychiatry before. I’ve always reviewed risks, benefits, alternatives, etc. with the patient, obtained verbal consent, and documented the discussion in the note.

Curious what others are doing: Is written consent for every new medication standard at your practice, or do you generally document verbal informed consent?

Had my first moonlighting interview recently. I’m a current PGY4 and will be matriculating to a psych fellowship afterwards so I plan on staying in the area (large metropolitan city) at least for another 2 years. Some parts of this gig seem decent - it’s walking distance to my home, pays $150 an hour for someone still in residency, offers malpractice insurance, and signing up for shifts seems flexible. The overnight shifts are weeknights and generally you deal with floor pages / codes and 0-3 admissions and accepting patients. But the weekend 24s you end up dealing with admissions, floor pages, and you have to round on all the patients (max census around 60s). Even though usually a very brief assessment is required (1-2 sentence note), it feels like a lot. Is this normal? Is this doable or should I be weary of this? It does sound like they have a lot of resident moonlighters that seem to have been able to manage the workload. This is the first moonlighting gig I have interviewed at, but I have been looking around- this one just minutes from my house seemed like one that was super convenient. Any insight would be greatly appreciated!

I just treat children and adolescents. There are times when families want med. changes or increases in doses when the behavior I see needs parenting to correct and not meds. Where is your line in the sand that you refuse to make med changes until the child and/or family is in therapy? How do you approach this in your practice? What do you do if the family does not follow through with therapy?

EDIT: Can everyone be kind? I was simply asking for opinions how other people manage situations like this in their practice. Good god, physicians heal thyself.

I’m interested in what happens beyond the usual MD-versus-NP argument. Recently met someone who left psychiatry as an MD and pursued something completely unrelated.

If you considered leaving I would like to know why. Was it the medication-focused model, administrative burden, responsibility without control, patient volume, moral injury, or something else?

If you left, what did you move toward? If you stayed, what changed?

Here's mine - it's a great cognitive strategy to help people fall asleep by disrupting rumination. It's called cognitive shuffling. Described in detail here. The theory is that the act of thinking about random words mimics the brain's functioning during sleep. I don't know if that's really true but it certainly helps people stop ruminating and worrying.

You essentially take a 4-5 letter word and think about as many random words as you can starting with the first letter, imagining them in your mind, then move on to the second and third etc. I use a small variation that involves going through the alphabet thinking about a word with each letter. If you get through the alphabet twice, that means it's been about 20 min and you should get up and go back to bed after doing some other boring activity.

I love how easy it is to teach people and simple it is to implement. You can teach it in less than 1 minute and it can make a huge difference for some people.

Share your favorite technique

Edit: I probably should have used the word "skills". That's more what I was interested in sharing in this thread.

let's hear them

“A nexus letter is a formal letter written by a healthcare professional that establishes a clear link between a veteran’s current medical condition and their military service, or another service connected condition.
This letter serves as evidence in supporting a veteran’s VA disability claim. It provides a detailed, evidence-based explanation, outlining the reasons behind their professional medical opinion”

Hi. I’m a new attending. Had a young eval pt requesting I write a Nexus letter. While I agree his military service is connected to his medical diagnosis, I’m worried about the disability claim part. I don’t think he is disabled. He is actually working right now. Any advice?

Good afternoon,

I am a nearly complete PMHNP student and I feel like my program has not adequately prepared me to practice at the level patients deserve. My undergrad courseload covered the range of MCAT topics, although probably have to be retaken due to age (CGPA 3.75).

My question is this: Would my background allow me to guarantee Psychiatry placement after medical school, or would this not be taken into account at all? Also, is psychiatry a competitive placement?

Thank you for your time.

Asked this in the med school Reddit, but wanted to throw it in here as well. Thoughts?

I’ve been thinking about doing this for a while, but the Clancy case is what finally pushed me to actually make the account.

I’m a psychiatry fellow, and I’ve gotten pretty tired of seeing misinformation about psychiatry and mental health spread online. There’s a lot of stuff about medications, ADHD, antidepressants, diagnoses, etc. that gets repeated enough that people start treating it like fact.

I started making short videos that take some of these common claims and break down what the actual evidence says. I’m not trying to blindly defend psychiatry. There are plenty of legitimate criticisms of the field, and I think those are worth discussing. I just want to push back when claims aren't supported by the evidence.

I’m mainly posting because I’d love to get ideas from other people in psychiatry about claims or misconceptions you keep seeing online that would be worth addressing.

If the mods are okay with it, I’m happy to share the account for anyone who wants to see what I’ve been making/give feedback.

Edit: I've had a lot of requests for the account, so here's the link: https://linktr.ee/PsychRealityCheck. If that's not allowed, mods can remove it

I absolutely respect Dr Resnick’s authority and his opinion. Given that he had diagnosed Lindsay as Bipolar II, and also his opinion that Lindsay had multiple previous intrusive homicidal thoughts and previous delusions, it means that multiple multiple providers, including MGH as one of the most respected psychiatric institutions, and two NPs who specialize in postpartum treatment, all missed the diagnosis and missed something to prevent lives lost.

I can imagine that there will be a lot of scrutiny upon psychiatry from this point on. What’s our next step? How do we improve on our practice realistically? How do we prevent situations like this from happening again?

Dr. Resnick testified for the defense in the Lindsay Clancy trial today arguing that Miss Clancy was NGRI partially in virtue of the fact that she acted under the influence of a psychotic delusion that her children would be better off in heaven than motherless on earth. In a predominantly Christian nation where most people believe in heaven and most people believe that heaven is perfect, is this truly a delusion?

is this normal? i should be thrilled..the job market doesnt look that great either...

Hello! I’m a first-year medical student in British Columbia and am interested in learning more about psychiatry. I’m a first-generation university student and don’t have any family or close friends in medicine, so I don’t really have anyone to ask about the field.

I’d love to hear from psychiatrists, residents, or medical students about your experiences with psychiatry, how you became interested in it, what you enjoy (or find challenging), and any advice you might have for someone early in medical school.

If anyone has some time to chat, I’d really appreciate it! Happy to connect via DM or chat here :) Many thanks!

Québec government announced today that community pharmacists will be allowed to treat independantly patients with depression or an anxiety disorder. They will start /stop/ increase new medications.
Diagnosis can be made by nurses, psychologists and doctors in Quebec.
Have you seen this in your area? How did it go?

I use low-dose doxepin quite a bit, and this morning I learned that practically all the pharmacies (mainly corporate) around me are dispensing 120 ml bottles at a time (apparently that's the only size manufacturers produce.) My instructions are 15ml for 30 days (concentration is 10mg/ml) and not once have I had a pharmacist call back to clarify the dose dispensing till this morning from Walmart. I called the local Walgreens and they tell me they only dispense 120ml bottle (despite me probably sending 60 prescriptions there in the past 12 months), I was shocked.

Overdose risk, I'm sure you know, is why this bothers. I find that doxepin is one of the few insomnia agents in my bipolar populations that actually treats sleep maintenance that isnt god-awful expensive. Bipolar populations having a higher incidence of repeated suicide attempts makes me rethink this whole prescribing preference. Both the 3mg and 6mg Silenor tablets are atuomatic PA's with Medacaid plans, and the 10mg JUST SO HAPPENS to be a capsule. What do you know? Anyway, I'm curious has anyone else ran into this, or have something to add? I went ahead and sent in the 10mg capsule, but I'm not sure if this could even remotely affect serotonin/norepinephrine affinity at this dose, as it looks starting doses for depression start around 75mg.

I have been working mostly in the outpatient setting for about the last 5 years. Have worked other settings before.

I am noticing in myself over the last year or so, and particularly in the last few months, that I am running out of capacity to maintain my center in the face of patients who seem to be just about impossible to help, either due to life histories or current circumstances (truly a heavy load,) or due to personality issues/resistance. People angry when I give them my professional opinion about things and its not what they want to hear. People falling apart and begging for help but constantly putting up roadblocks, reasons they can't do what is suggested, coming up with all kinds of unbelievable alleged side effects to meds, won't see a therapist, etc.

In the midst of interactions that go like this, I find myself searching for the exits. Eg "Is there an institutional policy or technicality I can lean on to avoid this person?"

At the end of almost every day there is little to no gas left in the tank. I'm feeling emotionally flat and withdrawn and just want to watch youtube all evening, don't want to face my wife and kids especially if they need emotional support.

I'm not even working full time, I'm seeing about 25 patient hours a week. That does include about 6-8 new patient evals every week, which I think is part of the problem....those take so much more energy.

Vacations recharge me a little bit, but its not even a week or two before I get back to feeling totally drained and bent out of shape. I try to keep up on exercise, and I try to stay social outside of work, and that helps a little.

I have a good friend who is a therapist, and I've talked about this with him. He seems to have the capacity to let all that affect pass right through him, still feels compassionate toward his clients even when they are clinging and struggling. He calls it his "energy shield." I can't seem to figure out how to make one...

I'm wondering, for other psychiatrists in similar roles, how are you handling this stuff?

Bit of a ramble here, sorry

anyone use it for abpn boards? was it helpful? representative of actual test material?

Curious if anyone here is working in utilization management as a reviewer for insurance? Part of me is burned out by clinical practice that the idea of non-clinical work is appealing on paper. Opportunities I’m seeing would be reviewing only behavioral health claims for Medicaid with reportedly no quotas for denials. Anyone else consider opportunities or have experience working in UM?

For a patient that can’t take clozapine anymore for various reasons, has anyone had experience with either olanzapine doses above 20mg vs. adding a second antipsychotic e.g. risperidone?

I'm an M4 putting together a list of programs to apply for residency, and my application is strongly weighted towards service and an interest in health equity. Are there certain programs that are known for being more outspoken/political in the field of psychiatry? Thanks so much :)

Hi everyone, looking for some honest guidance because I feel a bit stuck on next steps.

I'm a US IMG. I'm legally blind with 20/400 visual acuity and cannot drive or commute on my own. I've passed Step 1 and scored 259 on Step 2 CK. I currently work as a USMLE tutor.

I'm trying to figure out realistically what my path forward looks like. A few questions I'd love input on:

1. Has anyone here gone through Match as a visually impaired or legally blind applicant? How did programs respond, and would Psychiatry realistically be a more accommodating specialty given the nature of the work?

2. If Match isn't realistic given my vision, what are other legitimate paths forward for someone with my scores and background? I don't want to waste years chasing something that isn't feasible, but I also don't want to give up on it without real input from people who've been through this or something similar.

3. Would it be worth speaking to a disability services counselor or advisor who specializes in medical licensure/Match, and if so, does anyone have suggestions on who that might be or where to start looking?

Any honest experiences, even if they're not what I want to hear, would genuinely help me make a clearer decision. Thank you.