r/Psychiatry

What do you say to patients who try to insist on specific appointment times that don’t affect their work schedule? Eg after 5pm or 12:30pm.

Context: med management with brief psychotherapy sprinkled in, all adult patients.

I’m changing my clinic schedule and do not have many afternoon appointments anymore. I sometimes want to tell patients “you need to just take time off if this is important”

I get frustrated because I have to take time out of my work day to attend appointments.

Advice?

I

A 48yo client with a history of ADHD and GAD transferred to our clinic. I have been seeing her for about six months. Her Concerta was discontinued and she was then switched to atomoxetine 80mg daily. She states the atomoxetine has been much more helpful for her ADHD.

Over the six months, she has reported her atomoxetine lost about four times (only once an early refill was provided). She has also three times tried to adjust her dose before her monthly refill. She makes an appointment about every two weeks either because of loss medication or to discuss changing her medication dose. I believe she is doing this so she can try to get more atomoxetine before her monthly refill is due .

I can’t find any research to support any abuse or an addiction potential of atomoxetine. However, there is clearly something going on. The last appointment when I told her I will not be prescribing any more atomoxetine until her monthly refills are up and she began crying saying that no one will help her.

Has anyone else experience this type of behavior regarding atomoxetine?

Hello all,

I am a German medical student and work part time in a homeless shelter for active drug users. It's located right next to a massive gathering "hotspot" for homeless people.

The city has recently invested in expanding psychiatric care for this group, including (1) a new psychiatric outpatient clinic right next to my shelter, and (2) an outreach psychiatry program run by the university hospital, still in the planning phase.

Overall, the psychiatric department in my city's university is weak on research, and particularly in this niche there has been almost no research in my city in the past decade.

However, since I've been working in this environment with these patients for a while now I'd love to do research on these new care programs and psychiatric care of this patient collective in general. I am currently trying to find someone to mentor me, but it would be easier if I already had a specific direction or research question in mind.

I am not particularly excited about just doing a meta analysis on studies related to this topic. Ideally, I'd like to collect my own data, for example doing questionnaires on homeless people (who I already work and interact with regularly at my side job) or my social worker colleagues. I feel like I am in a uniquely suiting position to collect data from this population.

I could simply do a questionnaire to investigate the homeless people's attitudes towards the new outpatient clinic, for example. But I feel like this might be kind of... useless, and wouldn't help in improving psychiatric care for this population.

What could be interesting and worthwhile questions or aspects to investigate here?

Appears to be growing resistance against SSRIs in the public sphere lately related to long-term use and side-effects (e.g. bad "withdrawals" after years of SSRI use, PSSD). Thoughts? What were your discussions related to this? How did you approached these discussions?

Edit: It's an uncomfortable conversation, but ignoring this conversation, avoiding people who disagree with our practices, or labeling them as the problem will not help us know how to have constructive, amicable conversations with them to expand our mutual understanding and improve our practices. We learn the most by engaging with our "enemies."

^

Curious about the following items this cycle
from those who matched:

1. Applicant type: MD/DO/USIMG/NONUSIMG
2. Step 2 score
3. Number of psych away/subi rotations
4. Backup specialties applied to

Do you feel at all hesitant about stimulants as an option for this crowd? What is your experience trying to get Qelbree covered by insurance as first line for someone with those risk factors?

I am a new graduate and will be doing 5 hours per week of private practice. What is the cheapest malpractice insurance option?

Abstract >To assess the extent and types of financial ties to industry of panel and task force members of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR), published in 2022.

...

The DSM was written with the involvement of $14.2 million in undisclosed industry compensation. The full extent of this is outlined in this article.

The author outlined their report here.

>What should readers take away from your report?

>The DSM has been referred to as the "bible" of psychiatry and industry influence over the development of this diagnostic guideline can have a profound effect on public health (e.g., by broadening diagnostic categories and influencing what medications will be prescribed and covered by insurance). Thus, it is critical that this psychiatric taxonomy is free of industry influence, or even the appearance of such influence. There is an abundance of research documenting the impact of financial conflicts of interest on medical literature, including randomized clinical trials, meta-analyses, and clinical diagnostic and practice guidelines. Such research has consistently shown that conflicts of interest lead to subtle but impactful pro-industry thinking and conclusions.

This is more of an ethical issue, I suppose.

Severely overweight patient, lives alone, diabetes, GERD, you name it. Says Trazodone & melatonin don't help, and the only thing that helped them "once" was Ambien (nothing recent in CRISPR). Refuses a sleep study and strongly rejects the possibility of OSA.

Would you even go the DORA route or just refer to a sleep specialist?

As someone working in addiction psychiatry, I increasingly feel that undiagnosed or untreated ADHD is one of the most under-recognized drivers behind many substance use presentations.

Not in every patient, obviously — but often enough that missing it changes the entire trajectory of treatment.

Some recurring patterns I’ve noticed:

Early nicotine/cannabis use as “self-medication”

Severe impulsivity mistaken purely for “poor motivation”

Repeated relapse despite genuine intent to quit

Chronic functional impairment predating substance use

Patients describing “mental quiet” for the first time with substances

In busy clinical settings, once the addiction becomes the focus, developmental history and executive dysfunction can get overlooked.

At the same time, there’s also the opposite risk:

overdiagnosing ADHD,

confirmation bias,

and stimulant hesitancy in SUD populations.

Curious how others approach this clinically:

Do you routinely screen for ADHD in addiction settings?

Which tools/interview style do you find most useful?

Have you seen treatment outcomes improve after identifying ADHD?

How do you navigate stimulant vs non-stimulant treatment decisions in high-risk patients?

Would genuinely like to hear perspectives from both psychiatry trainees and consultants across different systems.

Pretty much the title.

This doesn't happen too often in my case. Out of curiosity, how do you deal with situations where your medical decisions affect other professionals' work or where your non-physician/psychiatrist colleagues fundamentally disagree?

No matter how medically sound your decision is or how liable you are, in case that wasn't clear.

Personally I try to listen to their point of view but I occasionally struggle with the feeling of being "bullied" into doing things that are clearly off to me. Thorough explanations tend to be futile.

If you have any examples where this happened to you, I'd love for you to share!

Early career outpatient psychiatrist here, looking for advice managing anorexia in this setting. I recently saw a patient with clear comorbid BPD and anxiety, who IMO needs a higher level of care as weight has continued to drop recently (BMI <15).

She also reports severe ADHD diagnosed in childhood, and was most recently seeing a psych NP who prescribed 60-80mg of Vyvanse and 10-20mg of Adderall daily.

The patient has no primary care doctor or cardiologist, dropped out of several residential programs in the past year, and was discharged from an outpatient program recently due to hypokalemia / not being medically stable (she did get K repleted in the ED after that).

I'm frankly not comfortable refilling any stimulants in this kind of case due to both appetite suppression and increased risk of cardiovascular side effects, especially without close medical monitoring. While I realize that untreated ADHD can be debilitating, that is not likely to kill her like anorexia might. However, all other options are unacceptable to her - I recommended a higher level of care (patient adamantly refused) and trialing non-stimulants (also refused). My attempts to build trust seem to be failing, and I imagine that she will simply fire me and find another, less scrupulous provider to prescribe her stimulants (and whatever else she demands). Is that simply the way it goes with these cases? CAN anorexic, highly anxious patients be safely prescribed high dose stimulants when weight restoration is the immediate priority?

AI psychosis is very uncommon and very new here , however they are so hard to treat. Anti-psychotics are not working (patient is compliant on medication) his thoughts tho did not change. Its hard to challenge those thoughts too when the AI is enabling him into thinking he’s a superhero and working with intelligence agents. He’s of no harm to himself or others. But we have been discussing admitting him and take away his phone.

One of my M3 psych clerkship attendings was saying that of all the pathologies he treats, eating disorders (especially restrictive ones) are some of the most difficult. What makes them so uniquely challenging?

A bit of an atypical situation, would love people's candid advice

USMD U.S citizen, graduated from a top 20 med school 3 years back. Previously aimed for a competitive specialty (e.g, ortho, derm, etc) but decided to pursue non-clinical healthcare business work past few years. However, now wanting to return to clinical medicine (long story, parental illness etc.).

Going to spent next two years finishing up my current work, take step 3 (had high step 1 and 2 scores 260+ and 270+, so good test taker previously. Half Honors half high pass for core clerkships with HP in psych for more info), do observerships then apply next year 2027. Currently planning on applying family medicine for sure given it's most receptive to people with gaps, but also considering whether I should consider doing an observership in psych then dual applying as it was one of the specialties I heavily considered but ultimate did not pursue while in med school. Or should I not even bother since it's unrealistic and just focus my efforts on FM instead?

Thanks for your help!

USIMG from Caribbean. Graduated last month. No failures or remediations. Have a few gaps (1.5 year gap between preclinicals and clinicals and a few months gap during fourth year between rotations mostly due to scheduling). 1.5 year gap was explained in PS. Great fourth year MSPE comments esp from 3 psych sub-Is. Good/great psych letters.

Step 2-237. Step 1-pass. Preparing for step 3. Will be working with an Addiction specialist (medicine trained) for the next year to stay clinically relevant. Any way to really improve my application?

Okay, this seems like it should be a straight forward thing that any psychiatrist, resident, or even med student can do.

Make a medication recommendation. Check. Discuss most likely potential side effects. Check.

Provide education about treatment of depression and goals of hospitalization (it takes weeks to months for full benefit, it may not be the right med and she may need to switch, it may be only partially effective and she may need to augment, she should increase frequency of therapy, she is not going to be perfect when she discharges, goals for discharge is tolerating the med, being safe, and having appropriate post hospital support in place, etc) in setting of first antidepressant trial and patient views it as “a last hail mary” and I don’t want her to be become discouraged and not take it long enough or not do other med trials if it is ineffective. But, ultimately, she wound up in tears and I feel like I really messed this up.

Tbf, I work inpt on a unit primarily with mania and psychosis. If I get a depressed patient it is usually someone on track for ECT. But the unit that this pt would ordinarily have gone to was completely full. So she wound up with me.

How should I have handled this?

ETA: At this point I am now 100% sure that I messed something up with her because I seemingly can’t even convey here, amongst peers, what the issue was. At this point I am just typing the same thing over and over in response. And I would love to know how I could have communicated the issue here, in this post, better. But I will try to rephrase to make it more clear.

It was about the fact that it will take weeks to months to see full benefit. And that it might require more than one med trial. It might require augmentation. And that she will likely still feel like crap when she leaves the hospital. And that it is not as simple as okay, let’s start this and you will feel better in a week.

So it was definitely a conversation that needed to happen. Because otherwise, when she didn’t see the results that she was expecting, she was likely to just stop the med. And unlikely to try again.

But I feel like the way I went about it wasn’t great. But I don’t know how I could have done it any better

We’ve all been there. A patient wants a medication that, while it might help them, has a side-effect burden that keeps you up at night. The patient has capacity to make the decision. Maybe a patient who’s failed everything for crippling anxiety doesn’t want to stop benzos after a fall where she broke her hip. A metabolic pt with schizophrenia and a BMI of 70 will only take olanzapine. A patient with severe TD refusing VMATIs refuses to reduce their haldol dose. These are just some examples.

where do you draw the line between “the patient can make this decision,” vs. “this is straight up malpractice?”

Please note: I am asking about the risky intervention specifically. When answering, please do not recommend continuing to talk the patient into a less risky alternative. Assume this has been tried and failed.