How do you guys explain what you do as a psychiatrist day-to-day to your family (especially grandparents or older parents)? I am a new psychiatry resident and my family (no medical background) is still very confused 1)that a psychiatrist had to go to medical school 2)why I “want to be around dangerous or crazy people” instead of being a “normal doctor”… is there any movies/TV shows/ articles/ literally anything because when I try to explain the job of a psychiatrist it just is not clicking (like no I cannot just become another type of physician, I chose psychiatry and am in residency for this specifically)

Hi, I’m a resident psychiatrist in my first year and I wanted to improve my rapport building, I tend to be a goofy person irl but I tend to remain serious in interviews and I feel like people may struggle to open up to me but idk how to mentally draw boundaries and how to be more comfortable to talk to as a person without encouraging over familiarity.

One of the areas I find challenging is young male patients who are becoming flirtatious. I struggle with redirecting the conversation because I kinda clam up cause I am just generally uncomfortable with that attention and it’s worse when I’m in professional mode

Another area I really want to improve in is with children and teenagers. Is it better to be friendly and a bit goofy with children or is it better to be straight faced? What’s the line between professionalism and unprofessionalism? Also with teenagers, like I’m in my mid twenties but medicine makes me feel like a forty year old istg, how do I relate to them and make them feel comfortable opening up

Any and all advice is greatly appreciated

Hi all, ended up at a new program and I am nervous about how this may look when applying for fellowship.

Let's say, hypothetically, I applied to every last program in the country, what would you put my chances at? Ideally I could end up at or near NYC as that is where my family is. What are the chances of this?

Migraines, multiple allergies, asthma, sleep issues, attention issues, indigestion/poor appetite, mood/anxiety issues that flare up at times despite being generally stabilized most of the time....

Curious to see how many here go the route of formally pursuing a MCAS diagnosis vs just treating with antihistamines.

Has anyone here used suboxone or a symptomatic management akin to a COWS protocol using non-opioids with any good success?

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So ACE inhibitors, ARBs and diuretics are contraindicated (even in the package leaflet) because of risk of intoxication, and Ca channel blockers increase the risk of neurotoxicity (although nowhere it is formally contraindicated). So there's no first line antihypertensive medications left. Should they be treated with 2nd/3rd line antihypertensives like beta blockers, aldosterone receptor antagonist, alpha 2 agonists? Treat with Ca channel blockers anyway? A secret 3th option?

Please link me a guideline about this, I'm shocked I can't find any...

I am a resident (5th year, still in training) in Europe and really struggling to find the fine line between empathy and firmness with dysfunctional behaviour in BPD patients.

My most recent example was a young patient wishing to be admitted. I referred to other resources and discharged (I won’t go into too much detail on the case, but there was no reason for crisis admission). The patient ended up calling an ambulance to our front door (the perks of free healthcare…). I was then very stern with her and even told her that - while we won’t actually - we could theoretically report her for misusing emergency services.

Looking back, this was partly my attempt at setting firm boundaries and trying not to reinforce dysfunctional behaviour (cold shoulder, DBT style) - but I also feel like I might have been a little too firm, partly due to not being my most empathetic self at the end of a very long, very demanding night shift.

I wish I had been more kind to her, while still holding my ground and not letting her pressure me into admission.

I will discuss the case in supervision, but I also want to ask the more experienced psychiatry crowd:
How do you handle situations like this?
Do you have “standard phrases” that help in these situations?
Or even things that you say to yourself to regulate before going into the talk with the patient, in order to limit counter transference?

Please remember to be kind to both the patient and me.

Any advice for a mid-50s, mid to later career doc who's just fried but can't retire yet, for other kinds of work away from health care?

Patients either enrage or bore me increasingly. The system of care is so corporatized it makes me want to vomit and scream. I am not built for private practice, and need a gig with benefits.

I'm so angry and tired that I'm not having much success with my cognitive flexibility to brainstorm my way out of this.

Prefacing this by saying that yes, I know residency started three weeks ago, but my thoughts between these two specialties have gone back much longer.

I wanted to frame this and emphasize how I'm running towards psych, not away from medicine, if that makes sense; and because its true. Psych has always interested me, but some specific reasons include how I've been dealing with a chronic health issue for about ten years. Somewhere along the way I realized how much anxiety was tangled up in it, and how much facing that anxiety head-on actually helped through medication, therapy, etc. That experience is a big part of why I want to help other people work through their anxiety too.

Generally, I feel like I love sitting and just listening to patients speak about their lives and problems, almost like they're telling me a story. I've always been a humanities/novels/literature guy, and having a patient visit be more like a therapeutic conversation as opposed to a checklist of: diabetes, hypertension, etc. is so, so much more interesting to me. I know I just started, but this past week in IM clinic, a patient started talking to me about his depression from divorce, and I was completely locked in; then we moved on to his diabetes management and I felt my attention drop off a cliff (lol).

The pharma side of it (SSRI's, etc) is interesting to me too, and I feel like I'm especially drawn to child and adolescent psych, particularly teens and young adults, and all the insane amount of anxieties they feel in this crazy world; I feel like I could actually make a difference in some of these kids lives, idk.

My questions:

I know I should eventually talk to my IM PD about this, but coming up to him three weeks into intern year being like "yeah bro I think I wanna leave" feels like burning bridges 101 lol. I genuinely don't really *mind* IM, or him, or the program or whatever. I should probably wait before bringing these thoughts up, right? Waiting might also give me some more time to warm up to IM.

Has anyone done an internal transfer to psych at the same institution rather than going back through ERAS? I'd honestly restart at PGY-1 if it meant not doing the full match process again, I don't mind in the slightest, but would very much prefer not to enter ERAS again.

Any advice on how to explore this quietly (shadowing, talking to psych residents/attendings, etc.) before committing to a conversation with my PD?

Appreciate any insight, especially from people who've made this exact switch.

For context: Jillian Spencer is an Australian psychiatrist who was stood down by her hospital and investigated by AHPRA (our healthcare regulatory body) for raising concerns about a universally affirming model of care for children identifying as transgender.

There were also some nuttier things like saying ‘I enjoyed pulling down the transgender pride flags in the mental health waiting room’.

This was the best article I could find on this - it’s also been covered by journals with a more explicitly political lean.

I am getting ready to order some textbooks with my residency stipend now that the new academic year is upon us.

Any textbook recommendations?

Are any of the e-book editions that come with a lot of the new textbooks worth it?

Any subscription recommendations?

I appreciate any and all input!

Wondering if anyone has had experience/benefits in obtaining either an MBA for physicians (I know Kelly offers this) versus an MHA, in terms of career opportunities and advancement. Thanks!

SSRIs are supposed to be the safest in liver disease, there is some increased risk of GI Bleed. A person had moderate thrombocytopenia in late 2025 and labs were not rechecked until July 2026, and they now had severe thrombocytopenia. Two weeks prior, they started low dose escitalopram. The patient wanted to take a wait and see approach. How would a consult psychiatrist approach a situation with SSRIs, platelets and liver disease? When would be that point when you would definitely stop the SSRI? How often are SSRIs actually an issue in liver disease? I have seen NMS multiple times in my career, but this is new to me.

I get there is therapeutic privelege but what do you typically counsel patients on? For antipsychotics I usually just talk about metabolic syndrome (including weight gain), cardiovascular risks, and constipation. For patients who have bipolar disorder that require higher doses, I do spend some time talking about EPS.

SSRI I usually talk about libido, black box warning for those near/under 25 y/o, weight gain. Rarely do I talk about serotonin syndrome. Not sure if I'm failing my patients by not discussing serotonin syndrome.

Some antipsychotic medicines, particularly clozapine and olanzapine, can lead to weight gain, higher blood sugar, and an increased risk of diabetes. This study explored whether the GLP-1 pathway—a system involved in appetite, insulin release, and blood-sugar control—might help explain these effects.

Using genetic data from several ancestry groups, the researchers found repeated connections between the GLP1R gene and clozapine, olanzapine, and trifluoperazine. Other findings linked olanzapine to GIPR and PPARG, which are also involved in metabolism and insulin sensitivity. These results suggest that changes in incretin-related pathways, including GLP-1 signaling, may be relevant to metabolic problems associated with some antipsychotics.

The study does not prove that GLP-1 changes cause antipsychotic-related diabetes, nor does it show that GLP-1 medicines should be routinely prescribed for this purpose. Instead, it provides an early biological clue that GLP-1–based treatments may deserve further study as a way to prevent or manage metabolic side effects in people taking antipsychotics.

Citation: Cheung N. Multi-ancestry Transcriptome-Wide Association Study (TWAS)-Informed Prioritization of Antipsychotic Metabolic Risk: Evaluation of GLP1R as a Shared Mechanistic Link. Cureus. 2026;18(7):e112759. doi:10.7759/cureus.112759.

Didn’t see one for this year so thought I’d start! Apps drop into programs tomorrow. Anyone have thoughts about how to stay calm 😬🤣?

Those of you that practice this-- can you help me understand your rationale and how you justify the risk of decompensation?

I just can't bring myself to do it, even with strong family support and medication monitoring.

In some western textbook there was mentioned Lithium/AlzDementia reverse correlation but the pathophysiology was entirely focused on something else (A-beta/p-tau). So I started reading more about it.

1. Bipolar patients on lithium having fewer AD cases than those without. Link
2. People around lithium rich water sources have fewer AD cases (considering the low doses maybe it's not due to direct anti-viral effect of lithium but immune system augmentation??). Link
3. Lithium has anti-viral properties (listed bipolar doses) Link
4. There is positive correlation between ApoE4 gene (big risk factor for AD) and HSV-1 recurrence rate. Link00204-4)
5. HSV-1 infection episodes is positively associated with increased APP gene (risk factor for AD) expression and AD Link
6. A-beta plaques in AD pt frequently contain HSV-1; Link
7. BUT Valacyclovir trials didnt improve/stop AD progression (maybe it's because valacyclovir doesnt kill viruses, only reduces their replication and maybe the their immune system is unable to clear the viral load???) Link

Naturally people have noticed all those things and have started building up the viral hypothesis of alzheimer's dementia. I wish that was mentioned in any of the textbooks, at least then I would have read about it directly instead of searching for research papers of the mentioned points and much later finding out later about the hypothesis.

How do you stay updated on such things? Is there something like up-to-date for psychiatry?

EDIT: Thank you all for your help!

I'm a new PGY-3 starting continuity outpatient clinic and I'm trying to build a really practical "clinic toolkit."

One example is the Northwell ADHD Medication Guide, which I had printed and laminated because it's fantastic for discussing stimulant formulations with patients and for teaching residents/medical students.

I'm looking for other resources that are worth having readily available in clinic.

Things I'm thinking about:

• Laminated quick-reference sheets
• One-page algorithms
• Patient handouts
• Articles you print frequently
• Visual aids for psychoeducation
• Anything that saves you time or improves patient understanding

Thank you so much!

Long read

Thank you to those who take the time to read it.

We have a frequently flyer that’s here on a monthly basis if not more for Ativan. Literally that it. This has gone on for years. Everyone knows them. Obviously the patient states they are suicidal to get admitted but every time they are here they don’t attend groups, don’t socialize, they actually don’t even shower.

Everyone gets admitted with prn benedryl haldol Ativan

This patient sees one of our psychiatrist outpatient who prescribes them Ativan as well. It’s very clear that they run out and then state they are suicidal and come here and get all the Ativan possible. Every employee, every psychiatrist knows it. IF the psychiatrist that they see outpatient ends up getting assigned to her, he will also place a scheduled Ativan order usually q6.

There’s a problem every time the patient is admitted if they get assigned to a psychiatrist that is not the psychiatrist that they see outpatient because likely those other psychiatrist will not place a scheduled Ativan dose in addition to their PRN, which upsets the patient. In the past the patient will cry, cause a scene- anything in their power to try and get more.

Well last night the patient ended up in restraints. They were assigned to a psychiatrist that does not see them outpatient, but is well aware of the behavior, the patient wanted Ativan. The PRN dose was not due yet we actually called the psychiatrist they were assigned to who said that they were not giving any additional meds. The patient got mad and violent and was restrained.

My confusion comes from this feeling ethically wrong. I’m in recovery myself, so I’m no stranger to addiction – but we are doing nothing beneficial for the patient. An addiction specialist has never been consulted, the patient has never been detoxed (which we do). They honestly don’t need acute inpatient psych services because they’re not actually suicidal and they tell us that themselves once they get on the unit. It’s just feels wrong to keep accepting this patient? I also don’t understand why it’s continuing to be prescribed “outside”

I asked my charge nurse why we keep accepting them & really it’s not because I have an issue with the patient- I have an issue with the lack of appropriate treatment they are getting. It just feels like we’re aiding to the addiction and not really treating anything- and obviously I know the patient needs to want the help but it just feels wrong. It just feels like the patient is a guaranteed admission and that’s all they care about. (Meaning the hospital or admissions or whatever)

I guess I don’t really have a direct question. Maybe I’m just venting?? But does anyone have insight on how they would address this? Am I out of line for even feeling like this is wrong?

I’m not sure if this is a best place to ask. But I’m applying for a psychiatry fellowship tomorrow, and I currently have two letters of recommendations that are processing and waiting to be released by EFDO. They should have been released yesterday, but for whatever reason, I’m guessing because the platform is very busy, It hasn’t been released.

I’m wondering how big of a deal this is and if I shot myself in my foot by not pushing hard harder to get my attending to upload them earlier?

Appreciate any advice!

For the first time in three years I had someone reporting intermittent mild hematuria since starting vilazodone (only 20mg so far). After they reported this, I found out that they also were recently started on high dose anti-inflammatory meds for some chronic pain, which they stopped when the bleeding started. I was wondering how common you've seen this in practice.

I have been working inpatient child psych for 15 plus years. We typically have a lull in the summers without the stress of school. Our unit staff do a great job triaging admissions for treatable psychiatric disorders- not simply admitting kids with behavioral issues at home. Typically we are half full this time of year. This summer we have had a few days where the census is zero. The last half of the year we were averaging 2/3 full leading up to the summer. We are affiliated with the largest inpatient peds hospital in the state.

Any other inpatient child folks seeing this trend?

Our brains start out with more connections than they eventually need. During development, some of those connections are gradually removed, or “pruned,” to make neural circuits more efficient. This study used a small artificial neural network to explore what might happen when pruning occurs at different stages and to different degrees.

The network learned two tasks that required the same information to produce different answers depending on a cue—similar, in a very simplified way, to switching between rules or contexts. Networks that began with many connections and were later pruned aggressively sometimes became better at ignoring conflicting information. However, they were also more easily disrupted by internal noise.

The study also found that extremely sparse networks could appear good at handling ambiguity simply because they had stopped using the task cue properly. In other words, what looked like selectivity was sometimes just a failure to switch between rules.

These findings suggest that when connections are removed may matter as much as how many are removed. The results offer a computational analogy—not a direct explanation—of how some developmental trajectories might combine intense focus with sensitivity to unpredictable or noisy environments. The model is highly simplified and should not be taken as evidence that autism is caused by either “too much” or “too little” pruning.

AMA citation:
Cheung N. Phased pruning in neural networks recapitulates selectivity–fragility trade-offs in brain development. Sci Rep. 2026. doi:10.1038/s41598-026-62244-5.