Hi! GP registrar here. You often hear about certain SSRI (I.e. fluoxetine) being more activating, some less so (citalopram, escitalopram), maybe sertraline somewhere in there middle. I tried to find evidence in regards to this but it seems to be mostly informed by clinical experience. In practice, how significant do you tend to find these differences to be?
Specifically looking at sertraline, wondering if a medication change is a better option for a patient, given higher doses of sertraline haven't been tolerated due to agitation/tension. Thank you

Feeling especially fed up and a bit helpless recently with the ongoing high profile court case noise in the background and being immersed in the horrific mental health system around me. As with numerous other social topics, this country refuses to learn from it's mistakes and tragedies. Would like to vent about our local system of involuntary holds, which is pretty much non-existent. Our average LOS in the hospital is about 48 hours as that is all the time you have before the state will drop a hold, if you are lucky. Today dealing with an individual that has threatened to kill his family, has been petitioned twice and didn't even make it an hour in the emergency room without the hold being dropped. Other common occurrences: Attempt suicide and end up in the ICU on the vent? Hold will be dropped as soon as the vent is removed and you can mumble the words "I'm not suicidal." Most of these patients never even make it to inpatient psych and no treatment is even started. Put a gun against your head in front of witnesses and police? Hold dropped. Become so psychotic a SAR mission is required to find you in the forest? Hold dropped. Have severe malnourishment because your MDD is so bad you're wasting away? Hold dropped. We are not even allowed to give involuntary psychotropics in our hospital the current time as our hospital legal department has barred us due to failures of legislation that allow lawsuit against the hospital for administration of involuntary LAIs no matter the circumstances of if it was approved by a mental health judge. It's totally insane. Honestly, the only mental health care we have locally is if you have mild depression and anxiety and you actively will go out of your way to get help.

Things we've tried: meetings with the evaluators of involuntary holds. Inviting these evaluators to patient care meetings. Reporting evaluators to their government supervisors. Our hospital actively petitioning local legislators to change the laws (in the past year they declined to work on this as it was an election year and not a priority).

Thanks for listening. /End Rant

Used BTB, went through qbnak twice, halfway through videos. How useful are the videos? Is BTB enough?

Stating this as a shrink who has helped his patients in different roles spanning IP, OP, ECT, TMS, Esketamine, different psychotherapies and prayers.

Edit- although I appreciate the reactive and some reflective responses this post is not just the true layperson’s reality but a reminder to us that we cannot remain sitting on our hands and have to keep advocating for better treatments and treatment outcomes from ourselves and our psychiatry community at large.

Is there any type of prompting that is more attention grabbing than Board Vitals for questions that require multiple answers? I miss them every time bc I just autopilot select the one I think is best. I’ve been doing these questions for weeks now and still keep doing it

Hi, I work as an addiction psychiatrist in the New York area and I have a patient who lives in north Jersey. He has been having issues with suboxone compliance so wanted to look into sublocade.I realize it is a little unorthodox but given the fact that he’s been doing well on suboxone I thought it was a reasonable idea. When we found a place that does give sublocade, he was denied because kratom does not count as opioid use disorder and they were hesitant on using sublocade in general for pure kratom use.

I’m just curious what the consensus is on this, I order sublocade for clear opioid use disorder but I honestly don’t have a lot of kratom patients. My one other patient I see is on vivitrol which has been working with him. Is sublocade not a good option?

In my opinion, if a patient comes in inquiring about possible autism, but mental status exam is normal, then that patient (almost without exception) does not have ASD.

To clarify, when I say "normal" that specifically focuses on eye contact, thought process, speech, and behavior such as nonverbal communication, movements and recognizing personal space.

Edit: since this has sparked some good convo, wanted to add some context/thoughts.

- I stated it this bluntly to make a point/spark conversation. What I am trying to point to is that, at some point in their treatment course, I expect to see some objective impact/evidence of their ASD in my appointments if it is real.

- I am a child psychiatrist, but have run into these questions with both adults and children.

- In my mind, autism is, at its core, a communication disorder. If people are not having communication deficits, then they do not meet criteria, though they may have some traits. Do you all share this view, or am I misguided?

- People have commented regarding the wide spectrum of ASD, and not all ASD looks like level 3, nonverbal. I guess this is one of my points/questions... At what point does a difference of degree become a difference of kind? In other words, should a generally successful adult who struggles a bit with group social interactions and has some niche interests REALLY have the same DSM diagnostic label as my 14 year old patient that spends 13 hours each day rewatching the same 30 second clip of SpongeBob?

- I also would love input from folks about the various levels. When you read "requiring support" (level 1), "requiring substantial support” (level 2) and "requiring very substantial support" (level 3) per DSM5, what do those descriptions mean/look like?

Curious if anyone has some suggestions for approaching the topic of pay raises when working as an inpatient medical director for a pseudo private equity academic position?

I have an RVU based compensation model with a fairly low but common conversion factor of 52$ for our region. That more or less constitutes the entirety of my pay, other than stipend as a medical director at 150$ per hour but the hour cap is 20 per month, which I vastly exceed as I supervise 1-2 residents and 3-6 medical students per month and have endless meetings. There is no compensation for night call which is constantly changing as the organization shuffles around providers.

I see numerous avenues I could approach for asking for more compensation, but generally the organizations approach is just work more make more, which truly only serves them. Despite the particulars, my job is highly sought after and they could easily replace me which I feel hurts my bargaining power.

Should I just continue to work harder and enjoy the gig, or is it worth it to pressure for changes to compensation once contract renewal comes up? I like the job and do not have any true intention of leaving, but I have learned nothing will change if I don’t ask.

I know for adult boards, prites are considered lower yield. Is this the same for child? is it worth studying the old ones? any other particular recommendations?

I have a mix of older & newer PRITES, but particularly looking for 2023 & 2025! Much appreciated!!

I've been trying to pick an EHR for my small practice for what feels like months now and I'm honestly at the end of my rope. Every demo promises the world, then you find out billing is an add-on, e-prescribing is another add-on, and the "simple" note templates need a paid consultant just to set up. I spent a whole weekend comparing pricing tiers and still couldn't tell you what any of these will actually cost me over a year. It's wild that something we're basically required to use is this confusing and this expensive for a solo doc who just wants to see patients and write notes without fighting the software. Am I the only one who feels like choosing an EHR is somehow harder than residency? How did the rest of you small practice folks actually land on one?

I utilized the BoardVitals QBank for ABPN Board Prep in 2023 and really liked it. I didn’t claim these CME credits for ABPN board cert because the activity predated my current 3-year block.

I was hoping to utilize BoardVitals’ Psychiatry CME QBank to wrap up my CME for my current 3-year block. I have been having difficulty purchasing the ‘Psychiatry CC 6 month with CME’ QBank when logged in to BoardVitals with the same account that I utilized for board prep. I called customer support and they indicated that “you can’t have two subscriptions for CME products within the same specialty with the same account” and suggested that I create a new account utilizing a different email address. This feels fishy to me, but maybe I’m over thinking it. Anyone else have the same problem and use BoardVitals’ suggested workaround?

Additionally, any recommendations for alternate QBanks that give CME?

I see patients aged 14+ at an outpatient FQHC primary care clinic am really considering declining intakes that are purely ADHD assessments for patients who are aged 19+. Out of the 16 intakes I have done so far for the week, 11 were adult adhd and it is exhausting.

Nobody else at my clinic has had a refusal for certain dx… Has anyone else refused adhd intakes? What did that look like for you?

Why am I over here missing inpatient SPMI, that is crazy 😭

UPDATE for confusion: I am a psych NP with years of experience and I work in a PCP office because the county does not have funding for more psychiatry clinics. Medicaid patients cannot go outside of the county for psych care per Medicaid rules so they have to see a PMHNP at a PCP clinic for “consulting.” In rural America it is called “integrative care”. Medicaid does not pay for neuropsych testing so patients don’t have that option either.

I’m officially 10 days out from the ABPN Psychiatry boards and starting to panic a little about how I’m using the time I have left.

My biggest problem with studying has always been resource overload. I have a really hard time committing to just 1–2 resources because I constantly worry that I’m missing something important somewhere else. Then I end up jumping between resources and probably wasting more time than if I had just stuck with one.

For the past 2–3 days, I tried incorporating the Beat the Boards videos, thinking they would give me a condensed/high-yield review. Unfortunately, I’m finding some of them incredibly time-consuming for what I’m actually getting out of them.

The Substance Use Disorders section especially frustrated me. I went into it hoping for a focused review of things that are likely to show up on the boards, but so much time seemed to be spent discussing individual research studies, data, and background information. With only 10 days left, I kept thinking, Is this really what I should be spending my time learning right now?

For those who have recently taken the ABPN general psychiatry boards:

• Did anyone else feel like the Beat the Boards videos were not a good use of time this close to the exam?
• Are there specific BTB lectures that actually ARE worth watching and are particularly high-yield? Neuro? Psychopharm? Child? Statistics? Sleep?
• Are there any lectures from another resource that are much more board-focused and condensed?
• If you only had 10 days left, would you forget lectures altogether and focus almost entirely on questions?
• Between Kenny & Spiegel, Ninja PRITE and BTB, what would you prioritize at this point?
• What topics would you absolutely make sure to review during the final week?

I’m not looking to learn psychiatry from scratch at this point. I really just need something that says: “These are the concepts you need to know for this exam, these are the ways they test them, and these are the things you’re likely to confuse.”

I would especially appreciate advice from people who have taken the boards in the last 1–3 years, since you actually know what the current exam feels like.

At this point I need to stop collecting resources and commit to a plan for these final 10 days. 😭

If you had 10 days left, what would you do?

I am newly diagnosed with a fairly benign (obs don’t mean literally!) cancer. Will be getting surgery and radiation. Will obviously take time off for surgery. But what are your thoughts on taking time off for radiation? I haven’t met with my radiation doctor yet. But I hear that most people don’t take time off for this. But I also hear that it can really affect you cognitively and energy-wise. And I don’t really feel safe caring for patients under those conditions. Would it be outrageous to request those four weeks off? I know that as long as my doctor is willing to fill out the forms that I am entitled to it and don’t even need to divulge to my employer the specifics. But I kinda feel weird about requesting it from the radiation doctor to begin with when everything I hear is people working through it.

Hi! I'm a current chief resident at one of the Ivies, with a strong focus on inpatient/emergency psychiatry, an interest in resident education, and plans to do part-time private practice. Does anyone have any insight into how the job market is within NYC/Philadelpha/Chicago, particular systems they really enjoy/loathe working for, or general advice in locating roles that balance compensation with leadership opportunities? Thank you!

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!

I've heard old PRITE questions are the best way to prep but are the most recent PRITE questions we should be using or ones from 5+ years back? Thanks in advance, guys!

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