How long does it take (typically) to ween comfortably off 225mg of Effexor taken daily over several years.
Does the protocol (if there is one) call for drug replacement at any time?
Is there a difference between Psychology and Pop psychology? It seems to me as totally uninformed layman that there is an unfortunate trend to blame disturbed behavior on outside influences such as video games and movies. Is this view held by real Psychologists?
BTW: Am I crazy?
Purple Scottie,
Do you have any interest in working in private or group practice? Just curious about what career paths people choose 
Also, do you have any thoughts on the rather high number of days to first available new patient appointement in many clinical settings? I’ve always thought it was kind of criminal to make depressed/ill people wait a month for an appointment.
Thank you for opening this thread. I think we’ll all be learning a lot. I do have a few questions for you.
What are your thoughts on treatment-resistant depression? Have you seen any evidence for or against vagal nerve stimulators and transcranial magnetic stimulation in these patients? Do you see any new treatment options around the corner for TRD?
Finally, in your opinion, why is there such a shortage of physicians choosing to specialize in psychiatry? What do you think could or should be done to change that?
Do you mean that you are seeing patients whose primary reason for being in the hospital is not psychiatric? If so, to what extent are patients cross-examined by a psychiatrist? E.g. if I end up at your hospital due to a herniated colon or pneumonia, to what extent would I be expected to see a psychiatrist as part of my stay?
What are the most common traits in people with anti-social personality disorder?
How do you get them to change? I presume there’s a fair amount of CBT. How does that CBT differ with them? What else can be used?
What’s the best way to deal with people with ASPD in everyday life, that is, when you interact with them in business or social settings?
Lastly, has been thetan been audited lately?
How do you spot a psychopath? Is it possible for a clinician to work with one for years and never realize it?
What do you think of the survivors/consumers/ex-patients movement? Would you support an initiative to end forced psychiatric treatment?
Does your practice involve talk therapies (yes broad umbrella term there), or do you prescribe meds the majority of the time? Do you often do both at once with the same patient?
How have you helped depressed people, exactly? I ask because I found a cure for mine (we can compare notes in PM’s if you wish).
On a related, note, how often do you fail to make any progress with someone?
How do you determine if someone needs to be on medication? Is it something you can tell in one meeting, or do you have to see them multiple times?
What happens to a therapist - psychiatrist or psychologist, because I’d assume they would be treated the same way - who discloses something about a patient that they’re not supposed to?
Can dyslexia be mistaken ADHD? My husband was dxed with dyslexia as a child, but as an adult with ADHD. Could he have both, or was is misdiagnosed as a child?
He’s on Adderal now with stunning results.
Thanks for making this statement. My mother suffers from borderline personality disorder and in my experience, even clinicians can be strongly biased against people with this diagnosis. The world needs more people willing to extend compassion toward those with even the most troubling behavior.
I suffer from severe chronic depression and over the last several years I have tried somewhere between 12-15 different medications (in addition to evidence-based therapies) to try to alleviate it. While I’ve made some progress with behavioral therapies, no medication seems to work. Not even regular exercise seems to work. I wonder, what is the current prevailing theory (from a neuropsychological perspective) on why certain depressed brains are so resistant to medication? What do you do when the meds just don’t work?
In your opinion, how much of psychiatrity is bullshit? I mean that in a pretty broad sense.
Also, how intellectually curious do you feel most of your contemporaries are? Are they willing to experiment - do they really understand - or do they do everything by the book.
What do you think about women taking SSRIs during pregnancy and breast feeding? Are there other antidepressants, or specific drugs in the SSRI class, that are better or worse?
This is gonna be a long thread. Thanks for indulging our curiosity.
Why is it spelled with a ‘P’?
What is the difference between having a personality disorder and simply being an asshole?
So many questions…
I’ve seen a lot of stories lately about the recently discovered use of low-dose ketamine to treat refractory depression. What are your thoughts on that?
What do you think about the off-label use of Adderall to treat depression?
When you’re deciding on a drug for a patient, how do you choose which one? Is it just based on side effects (e.g. if the patient is low energy, give them something activating) or is there more “targeting” to it?
Are suicidal thoughts always dangerous? Or is it possible that they could serve as a sort of stress relieving plan B that makes it easier to get through the day?
I hope I’m catching all the questions here; I apologize if I missed any. It may help for me to be a bit more specific about my particular practice environment and training (I’m still keeping it a bit obscure – I don’t want to identify the specific training programs or my current hospital).
To start with the basics, all psychiatrists must first complete medical school and have a MD (or DO or equivalent degree from non-US program, frequently MBBS). Psychiatry residencies are four years in length. There are several fellowship options that residents may later complete. Child and adolescent psychiatry fellowship is two years and probably the most popular; residents who know early on they want to do child psychiatry can structure their residency so that they finish both residency/fellowship in five rather than six years.
The remaining fellowships require completion of the full four years before entry. There are various research fellowships but the accredited subspecialty fellowships include geriatric psychiatry, addiction psychiatry, sleep medicine (which actually is open to residents from psychiatry, neurology, or internal medicine), forensic psychiatry, and psychosomatic medicine.
Residency programs vary in their strengths and focus. Some programs place significantly more emphasis on psychotherapy while others are considered more “biological”. I interviewed at some at both extremes but found one more in the middle and very strong in addressing psychiatric issues that may be the result of medical issues. I have basic training in therapy, more so in cognitive behavioral therapy, and also took a couple of psychoanalytic seminars through a local psychoanalytic institute to supplement the education from my program. I admit though I’m not as strong in psychodynamics or psychoanalytical theory; eventually I would like to study further at a psychoanalytical institute but for various reasons it is not an option currently.
Anyway, after fellowship, I accepted a staff psychiatrist position with at a VA hospital; this VA provides both inpatient (for psychiatric and non-psychiatric conditions) and outpatient care as well as having a nursing home on premises where I see patients. I have a few scheduled patients but really I’m on call for emergent cases most of the time; one day this week, I ran around seeing five new patients on the medical service, one stat consult on a patient in holding area for the surgical suite, three patients in the emergency room, and one patient who resides in the nursing home.
To start with, I try to look at what a patient is saying verbally and nonverbally. A patient who states that they are very happy while sobbing uncontrollably may be an extreme example of a mismatch between what a patient is telling me in words and telling me in body language. If patients give me (or other individuals on the treatment team) to speak with the family to get collateral this is invaluable.
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There are no specific protocols. Effexor (generic venlafaxine) and Paxil (paroxetine) both have relatively short half lives and for an unknown reason there is a percentage of patients who when stopping the medication may get a discontinuation syndrome. I’ll explain to patients that this is different from alcohol withdrawal (or other withdrawal that can be life threatening) but for those affected can be anything from mild symptoms to feeling like a bad case of flu.
(Disclaimer: I am NOT giving medical advice here. Discuss with your physician before stopping any medications).
There is no one set strategy if a patient has discontinuation symptoms. Many patients do well with a slow taper. I may advise a patient that we’ll reduce dose by small increments every few days but with the stipulation they are to call me if they feel worse – I also usually will call them a day or so after the first dose reduction just to touch base and to remind them to call me if they have problems. With paroxetine, sometimes a switch to another medication in the same class (i.e., Prozac or fluoxetine) which has a long half life and effectively self-tapers itself can be tried.
Not a psychologist but I tend to stay away from most pop psych just because I don’t feel qualified to speculate on the motivations or inner workings of people who I have not personally examined. That being said, there are some “pop” psych books that are quite good and that I will recommend as educational resources for some patients.
In fellowship, I was mostly interested in an academic position but more on a clinician/educator track than on research/administrative track. These positions are less common, generally aren’t tenure track, and with the economy being down, fewer than they were a few years ago. I decided to add to my interviews then the one with the VA that I ended up accepting and a couple of private practice groups. I ended up really loving the VA – more financially secure than the other ones, I still am involved in teaching, and I really like the patient population.
Regarding wait times, the VA goal is for all requests for first time mental health evaluations to occur no later than 14 days after they are requested. Unfortunately, there are usually delays in the private sector just because there usually aren’t enough psychiatrists unless one lives in a relatively saturated market like NYC or Boston.
I promise I’m not running around the hospital, jumping out behind the curtains in the patient’s rooms saying “surprise! Just soon as they finish the rectal exam, you get to see the shrink!” My evaluations are part of a consult service; just as all individuals in the hospital do not get a cardiology consult not all get a psychiatric consult. When I am asked to see a patient, the referring provider has to have a clinical question and I always confirm with them that they have discussed with the patient and have the patient’s consent for the evaluation to occur. Only in rare cases will I see a patient who may be refusing a psychiatric consult and these usually are emergency situations where there is evidence of imminent harm (or risk therefore) to the patient or others (acute suicidality, status post suicide attempt, paranoid and aggressive behaviors such as attacking medical staff.
A large portion of the consults are actually requested by the patient – the primary team may pick up on that they seem unusually anxious or sad and ask if they would like to talk to psychiatry. We also see a large number of patients for delirium (acute alterations in mental status) on the medical/surgical units.
This could be a separate topic but to answer briefly, I take very seriously the privilege and responsibility granted to me to in limited situations be able to enact initial paperwork (which then triggers legal processes) for involuntary hospitalization. I need to have clear evidence of high imminent risk of harm to self or others or grave impairment due to a primary psychiatric illness before considering depriving some one of their civil liberties. Specific statues and cases vary from state to state; rarely forced administration of medication may be necessary but really it is more optimal that if medications are needed that it be a joint decision between the patient and physician.
I promise to return to answer the rest and I apologize for any typos I have missed. One of the furry dictators has decided that my laptop is his rightful throne and the other one is doing his best to distract me from typing by making cute kitten faces.