r/Psychiatry

Hi all,

I’ll be scheduling for my ABPN exam on July 8. After completing applications for the exam, participants received a lengthy email a few days ago that said that test-takers can schedule their exams on July 8 but did not mention at what time (whether this means midnight, 7am, etc) and did not mention which time zone. I’m concerned because there are only two testing dates at Pearson locations (September 8 and 9) and I absolutely need to take it on the 8th. Additionally, I will be out of the country on July 8 for the actual scheduling so it would be good to know when exactly the exam openings are released.

I’ve emailed their ABPN contact service multiple times over the past week but to no avail. No one picks up on their scheduling questions phone service. Google gives mixed answers (from previous years).

Anyone have any insight or info on this? Thanks in advance!

I've recently passed a few of these patients off to my attending for full reformulation.

It seems that they got a schizophrenia diagnosis while under the influence of drugs or a cognitive impairment, and antipsychotics thrown at them. The antipsychotics didn't work (or worse, work 'a little bit' because their behaviours 'improve' from being sedated all the time), so they got more antipsychotics thrown at them, and some of them go on clozapine.

These people end up on bizarre combinations of 3+ oral + depot antipsychotics +/- clozapine, 'residual psychotic symptoms' and a high burden of side effects which inevitably get more medications thrown at them.

Of the patients I've had reformulated so far, one was pseudopsychotic secondary to severe BPD with erratic behaviour and impulsivity labelled as 'disorganisation', one had previous episodes of drug-induced psychosis (but no primary psychotic illness) + aripiprazole-induced impulsivity + had ongoing perceptual disturbances from HPPD, and one had ASD + a cognitive impairment + a prolonged grief reaction which could not be distinguished from actually perceiving dead loved ones due to the impairment.

All improved markedly once delabelled, deprescribed, and put through intensive psychotherapy (though behaviours initially worsened as sedating medications were removed).

How frequently do you see this kind of presentation in your practice and what are your thoughts? Leaving this question quite vague as I'm keen to hear an open discussion with whatever clinical gems people feel inclined to drop.

Hi everyone! I'm a fourth-year medical student starting a psychiatry Sub-I about 11 days after foot surgery for a non-healing sesamoid fracture. My surgeon expects I'll be able to participate, though I will still be in a walking boot or using a knee scooter initially.

I'm not worried about being able to do the work, I'm much more worried about how this would be perceived by the program. If you were a resident or attending working with a visiting student in this situation, would this raise concerns, or would you just appreciate a heads-up ahead of time?

I'd especially appreciate perspectives from people involved in medical student education.

I just got a call this morning from a patient stating that her insurance requires Amazon Online Pharmacy for her lithium. Patient has two prior suicide attempts via overdose, most recent in 2024. I have literally been on the phone for over an hour with BCBS and can't even get to the right department- every single redirect is a five or six minutes of listening to options and verifying the patients, identity, and insurance. I literally want to call the patient back and just tell her "your insurance sucks, go buy lithium out of pocket." but she's already financially stressed. Anybody else have success with overriding 90-day refills? This BS is practicing medicine I dont care what the lawyers say. Something's definition is its function, not what we call it; substance-over-form doctrine, straight out of Black's Law Dictionary.

A) Drug testing, must be negative unless there is a medical card.

B) As long as not reaching cannabis use disorder criteria, and is social/not heavy.

C) No issues.

I honestly want to lean toward B but the hospital/ clinic and my boss I work for presses for A. Thoughts? I don’t actually think there is a law, just different opinions (correct me if wrong).

If the general psych residency requirements can be condensed into three years with the first year of CAP fellowship covering the final year, why can’t fellowships like Addiction and CL do the same, allowing for a general and fellowship certification in the same four years?

It doesn’t really seem to make sense from a training standpoint.

Is it a fair to assume that population level help seeking behavior correlates strongly with self-diagnosis?

As a field we promote help seeking behavior through mental health literacy, stigma reduction and more. Despite it being an unintended consequence, is it a fair to assume that both the absolute number and rate of self-diagnosed help seekers would go up in response?

God knows I understand venting, but if it's never linked with action, positive change isn't likely. Considering through this mechanism alone this is likely to get worse rather than better, would discussing patient management techniques for this increasing population warranted?

For example, when you start your first in-person interaction, asking them why they're there and following-up with a question(s) when you smell this possibility. "What are your expectations? Are you open to my advice if I arrive at a different conclusion than the one you expect? etc."

If other specialties cope with health illness anxiety, we can manage this without blaming the patients that *are* ultimately seeking help.

Edit:
This is a response to posts on the subreddit complaining about ADHD and autism diagnosis seekers. These posts often give an air of annoyance, dismissal, and lack of compassion that I think is counterproductive to our fields. Especially considering it's a natural consequence of positive goals, like reducing stigma etc. I think managing them as part of our jobs as experts. Yet, while I see plenty of post critical of these patients, we don't have many constructive discussions about how to work with them.

Watching this freaky promotion triggers feelings of dread at the next wave of people who cry out, "All of my life I felt distracted and isolated by all of the endless isolating distractions in my life and now I realize I am not alone...THIS IS ME!"

The MGMA compensation report dropped recently where apparently psychiatry salaries saw the greatest gain at 8.7%. This contrasts with the Medscape survey earlier this year that reported a 3% decrease in psychiatry salaries. Image below is from Marit, where I'm told you can access the MGMA data if you share your salary.

https://preview.redd.it/pzi5ngr0frah1.png?width=1064&format=png&auto=webp&s=5225ae8ef8273df9cadef476e142a1ac973e0e76

IFEDD Action Item: Requesting your help putting public pressure on Highmark Blue Cross Blue Shield.

The company has a new rule that limits nutrition counseling to 5 visits per year regardless of diagnosis, starting August, 24 2026. They say they are doing this because they don’t have evidence that nutrition counseling beyond 5 visits is helpful. They are wrong. This policy for people with eating disorders is dangerous and deadly. You can help.

Please email the email address in the link above - Reddit keeps removing my post when I include the email address.

Don’t overthink it – this doesn’t have to be a formal letter of any kind. The goal is mass public outrage. Share with family, friends, colleagues, everyone. We need emails from every discipline of healthcare providers, as well as clients. Send from all the email addresses you have. I will post an example email in the comments below.

Recently, I've noticed a strong uptick in antipsychotic prior authorizations for Medicaid plans with a lot of my adult bipolar patients. I feel insulted somewhat, of having to write clinical rationale as to why 10mg of aripiprazole is medically necessary to prevent a manic episode, and having to write out all previous failed medication trials to justify use. I almost feel like writing "Patient at risk of slapping the shit out of gas station clerk and becoming hospitalized, in which you will foot the bill.'

Whew, I feel a bit better now. At least it's Wednesday.

What ways of asking questions have you found most effective for different conditions? As you have grown in your practice, what phrasing have you found most useful? For example, I’ve found that when asking about self injury, I get better information and catch more cases when I add “like burning, cutting, or hitting yourself.” “Are there things happening around you that feel suspicious?” is obviously better than “do you feel paranoid?” I still haven’t found my favorite way of asking about history of mania. I recognize every patient is unique and there is no one-size-fits all, but I’m asking for some “tricks-of-the-trade” input. Thanks!

Still credentialing/working on contract negotiations, but I may potentially have another offer from a county system, and I'm having doubts. Assuming my contact from the for profit hospital isn't going to be a problem, is it hard to make that transition? Would working for a for profit system lock me out of working in a nonprofit system in the future? Thanks yall!

ETA: also wondering if folks ever switch from a pure inpatient to an outpatient setting? How difficult is that transition?

Wondering if anyone has any thoughts on how feasible it would be to switch from a largely outpatient/community health career of over 20 years to locums inpatient next year. Considering locums because I want more flexibility. There seem to many more inpatient locums opportunities.

Hey, friendly neighborhood ER doctor here.

I feel like in the ER we regularly see the lower end of the psychiatric spectrum. Patient's with recurrent psychotic breaks, substance abuse, food and housing insecurity, and all manner of other circumstances that keep them sick. Many of these patients are unable to have normal conversations, let alone a highly complex thoughts... honestly you can get a bit jaded about it all

But I had a patient the other day... and I must say this makes me so fascinated in what you all may experience on a regular basis...

45-ish yo M with a history of well-controlled bipolar (off meds, currently) comes in.

From the get go he's wide-eyed and speaking fast, it appears like possible mania, but different than I usually see. He's well-groomed, well-dressed, well-spoken... So I ask him what brought him in and he just unloads.

Him: "I'm going to be honest with you. I've been up for several days. I'm having some really complex thoughts and I need to get evaluated"

Me: "What are these thoughts?"

Him(speaking rapidly): "You know. It's just human nature. Our original sin. We fear 'other'. From tribes to expanding empires, nation-states and politics, down to different fucking football teams. We want to define people as and hate them for being the 'others'. It prevents us from being a truly functioning society. We've got a lot of complex problems we're not ready to solve man. AI, population inversion, wealth inequality, diminishing resources... no one is ready for these things man"

(my internal monologue...like yeah dude, 10/10, no notes, I kinda agree).

Him(continuing): "So i've just been worrying about and thinking about it non-stop. I think we need solutions and I have some but I'm worried about it. I think I might need thorough psychiatric evaluation to evaluate the veracity of my thoughts"

Me: "okay... What are your thoughts that make you feel you need evaluation"

Him(excitedly): "I think that I may have insight... I believe God has chosen me to guide us through this. He's talking to me and I can unite us. I know it sounds crazy but I think I'm here for this reason..."

From here on he digressed a bit and it fell apart the more he talked but I was like "Damn, he was so close!"

It was truly fascinating. I once heard a med-school professor say that if all the professions were sat a dinner table together that psych, EM, and trauma would have the "best stories." And for the first time in awhile, I saw how fascinating and unique some of the psychiatric conditions can be. It's still sad, but it's uniquely astonishing at the same time.

It shines light on how people can become cult leaders or how Kanye (etc) can gather such a following. They are powerful before the fall in some ways. He was wide-eyed, spoke with conviction, he had big thoughts and it really is magnetic. There's a real gravity to people when they are high-functioning like that.

Just thought I would share.

Edit:
To address some accusations of me violating privacy

1. I misrepresented the timing of this
2. That is not their real age
3. That is not their real gender, or is it? Who knows
4. There are no details about where this occurred
5. I paraphrased and edited what transpired. There’s some artistic license here in order to tell a story. Some things are added, some left out, some entirely false.
6. Maybe this never happened at all and I just wanted to have a discussion

If this is real, the person who had this interaction could read it and not know it was them. This was just supposed to be a conversation about the intensity of mania for those who don’t see this side of it often

Did you know that they send 3 texts, 2 emails, and a phone call about a different doctor than a patient sends a correspondence about because that doctor has sooner availability? All within 10 minutes. Why pay for a service that may orient to a different psychiatrist? I do not believe it’s a good facilitator for either the psychiatrist or patient, especially in the beginning. Has anyone else gotten complaints from patients about this entity?

I would like to start a discussion with you all to see how many of you are concerned about the current circumstances of how Healthcare is going in the United States especially in the psychiatric realm. It appears that reimbursement rates are going down according to the government and also certain insurance carriers despite rapid increases in costs. Personally I've seen no alternative route other than removing myself from the circumstance of starting my own clinic in effort to start cutting out the administrative burdens and administrative cost. 

I have additional concerns about the consolidation of various Healthcare entities being purchased by insurance. Optum Health is a good example of that. I suspect that they will lower reimbursement for their physicians in order to have profit for the administrators and for anyone invested in the company.

 The American Medical Association and the Psychiatric Associations have all been fairly ineffective in their advocacy.

It appears that everything has started to unravel after everyone started going W-2 employee. I'm wondering if you all are seeing what I am seeing and are also having similar concerns. I do not see any effective way for any physician pushback other than becoming individual companies ourselves.

Hi All,

I'm entering into my 3rd year of psych residency, so I'm starting to think about fellowship and career pathways. Since I'm at an academic center, of course most of what I've seen is that but I know that the scope of possibilities is large.

I know conceptually that psychiatry is vast and that people have a lot of flexibility building their careers based on what they want/find priority in and that can change in different facets of life. I guess where I'm curious is how does that look like in the real world? For example, I'm considering doing a C-L fellowship, but I also can't imagine that all C-L trained people are working full time C-L at some hospital and they do that for the rest of their lives. Same thing with outpatient -- it feels a bit like a black box. I know some people jump right into full time outpt private practice, but I conceptualize that most people have some combination or transition of some sort.

I apologize if it sounds like I'm rambling (I kind of am), but I hope my question makes sense!

I'm a neurologist who sees many patients who also need (usually geriatric) psychiatric care. It is nearly impossible to get them to a local, in-person psychiatrist in less than 3 months, sometimes closer to 6. Meanwhile, there are numerous telehealth companies (e.g. Mindpath, Headway, Talkiatry) that seem to have no trouble hiring psychiatrists to work for them, and patients can get seen in a matter of days to a few weeks tops.

My questions: why is this such a popular model for you all; that is, why is it better than working for a brick-and-mortar clinic/hospital/health system? How am I supposed to make a referral? Do I just trust that my 75 year old with a h/o bipolar disorder who now also has mild dementia is going to be seen by someone with the appropriate training and expertise (that is, is someone doing triage on the company side, or do they simply assign the patient to the doc who's next up on the list?) What happens if someone needs to be hospitalized; do any of these companies have a relationship with a specific hospital, or do they just say "go to your local emergency room?"

Anyway, you get the idea. I don't want my patients to wait 3-6 months when they're in extremis, but I am very hesitant to refer them to one of these companies. Should I be wary, or are they better than they seem?

Hi all,

I am starting a private practice and am in the market for an EMR. I have heard a few recommendations but was wondering what others in a similar situation have used. I will be out-of-network and offer hourly dynamic treatment. I will also provide medication management, but will not be offering medication-only visits.

I have heard from colleagues providing similar services that they use Google or Microsoft templates and save their notes, but I was hoping for something slightly more robust. Any recommendations are appreciated!