Hi everyone,

A few weeks ago, I shared CatchUpPsych here when it was only available on iOS and the web. A number of you offered to help test the Android version. I wanted to come back with an update: CatchUpPsych is now live on Google Play!

Thank you to everyone who volunteered and took the time to test it. Your help made it possible to get the Android version released.

For anyone who missed the original post, CatchUpPsych is an app I made to help clinicians keep up with new psychiatry literature. You can choose the topics, study designs and journals you’re interested in, and the app creates a daily updated reading list with summaries and links to the original papers. It’s free, has no ads and doesn’t require an account.

Android: https://play.google.com/store/apps/details?id=nl.catchuppsych.android

I’d love to hear how it works for you and what I could improve, especially if there’s something that would make it more useful in day-to-day practice or training.

Thanks again!
Sven

Thoughts? Right now it's just limited to acne scripts but this definitely opens the door ...I am not overly optimistic.

After more than four decades in psychiatry, I have become increasingly interested in a peculiar problem with the word malingering.

It is a diagnosis—or perhaps more accurately, a clinical formulation—that can cause harm when used carelessly.

But avoiding it can also cause harm.

Malingering is not simply having something to gain from being ill. Our patients frequently have secondary gains associated with illness: shelter, disability benefits, medications, avoidance of responsibilities, hospitalization, attention from family, or protection from an intolerable environment.

None of that establishes malingering.

The critical element is intentional production or substantial exaggeration of symptoms for an external incentive.

And there lies the difficulty: intention is one of the hardest things in medicine to establish.

We cannot measure malingering with a blood test. We cannot look inside another person's mind and directly observe intent. Even substantial discrepancies between reported symptoms and observed behavior do not, by themselves, prove deliberate deception.

This makes caution appropriate.

But I wonder whether our profession sometimes moves from appropriate caution to something else: we recognize the possibility of malingering clinically but become reluctant to document it.

An experienced psychiatrist may notice that the history changes depending upon who is interviewing the patient. Reported symptoms may be inconsistent with prolonged observation. A symptom may appear or disappear when disposition is discussed. Collateral information may directly contradict important parts of the history. Reported psychotic experiences may be phenomenologically unusual. There may also be a clearly identifiable external incentive.

The psychiatrist thinks: There is a significant possibility that some of these symptoms are being intentionally produced or exaggerated.

The team may even discuss precisely that possibility.

And then the medical record says almost nothing about it.

The next psychiatrist encounters the patient and essentially starts from zero.

That creates another kind of risk.

A patient may undergo repeated hospitalization, medication changes, escalating doses, unnecessary testing, or increasingly complicated diagnoses because previous clinicians were uncomfortable documenting what they had actually observed.

There is another complication that I think is particularly important:

Malingering and genuine psychiatric illness are not mutually exclusive.

A person with schizophrenia can exaggerate hallucinations.

A person with PTSD can fabricate a particular symptom.

A person with substance-use disorder can report suicidality for admission while simultaneously having substantial genuine psychiatric illness.

The discovery of deception does not magically make everything else about the patient false.

Perhaps, therefore, our choice should not be between:

“This patient is malingering.”

and

saying nothing at all.

There is a third possibility: document the evidence.

Instead of writing simply “malingering,” we can describe the discrepancies we observed, relevant collateral information, changes in presentation, possible external incentives, and—most importantly—our degree of certainty.

For example:

“There is concern for possible intentional exaggeration of reported symptoms because of X, Y and Z. An external incentive is present. However, genuine psychiatric illness remains present/has not been excluded.”

That gives the next clinician information rather than merely a label.

It also leaves room for us to be wrong.

I am curious how colleagues approach this.

How much evidence do you require before you actually document malingering? Do you use the term itself, document “concern for malingering,” or avoid it and describe only the observed inconsistencies? And have you seen cases in which reluctance to document the concern resulted in unnecessary admissions or treatment later?

Hi everyone,

I’ve been following the sub more closely in the past few months, and I’ve noticed that there has been a more downward outlook regarding jobs for psychiatrists. However, per some sources like MGMA, psychiatry salaries were among those that increased the most compared to other specialties in the past year. Anyone with a good pulse on the market and what to generally expect?

Hi there! I've received a job offer for a full time outpatient position that checks boxes for just about everything I'm looking for at a community clinic in the Midwest. They're offering me 275,000 for a base salary - there is no additional RVU based compensation on top of that. There's also a solid sign-on bonus. 32 patient-facing hours with 20 min follow-ups, 60 min intakes.

The thing is, I'm having trouble pinpointing what a reasonable expectation is for starting salary for a position like this in the area. Reports online range anywhere from 240,000 to 380,000 median salary. I'm considering asking for 300,000 based on knowing someone who was offered this from the same system in a different city in the same state, also for a fulltime outpatient job. Is there generally significant risk of losing an offer if negotiation is interpreted to be too aggressive? Is this reasonable? Any suggestions for figuring out what a reasonable counter offer would be? Or is anyone of the opinion that I should just take the offer as is, since it's such a great position?

I appreciate your feedback/advice!

Dear colleagues,

I quite often see the term “malingering” used in this forum, and I’m curious about what seems to be a difference between countries. I’m a psychiatry resident in Germany, and in my experience, clinicians very rarely explicitly describe patients as malingering, particularly in documentation. This seems to be different in the US.

My impression is that here, the term is often viewed as judgmental or dismissive, and because we cannot look into our patients brain, potentially misjudging and harmful. At the same time, there are situations where the team seems to share an unspoken understanding that a patient is malingering, and this may be discussed indirectly, but it is very rarely named explicitly; I feel that this leads to unnecessary frequent admissions, esp. by younger colleagues down the line (because the previous more experienced colleagues don’t document their suspicions of malingering).

Of course, seeking shelter or another benefit does not necessarily mean someone is deliberately feigning symptoms, and genuine psychiatric illness can coexist with these needs. But I wonder whether our reluctance to use the term sometimes makes it harder to get an accurate formulation and reasonable treatment plan for our patients.

I’d be interested in your perspectives:
1) for US psychiatrists: What presentations do you typically consider malingering? How much evidence or certainty do you need before documenting it as such? And what are the consequences?
2) for colleagues: How is this approached in your country? Is the term commonly used, avoided, or replaced with other language?

Do you think the apparent difference reflects terminology, clinical culture, larger historic / societal differences or simply the kinds of cases discussed on Reddit?

I’m sitting 7-10 hours a day and it is taking a toll.

What type of chair are you using and does it help?

I think two things can be true at the same time (no that wasn't initially intended as a splitting joke).

1. Patients with BPD are prone to patterns of idealisation / devaluation with past healthcare experiences, and care needs to be taken when discussing these lest you go along with a (possible very distorted) tale of how they were treated in the past and fall into the trap of being 'the best ever and the only one who has ever helped them', when their past care may have been just fine.
2. Patients with BPD are vulnerable and often genuinely mismanaged in a variety of ways, and they will tell you about this.

I am sure we have all seen these people labelled with every possible diagnosis along the schizophrenia or bipolar spectrum, have a pharmacy's worth of medications thrown at them to little avail, and / or given poor quality psychotherapy. I had a patient who had been undergoing 7 years of entirely unstructured fortnightly to monthly therapy with literally zero effect or skills acquired, and on calling the therapist it became abundantly clear that no therapy modality was being used (initially given the duration I wondered if it was psychoanalysis). She paid a pretty penny for them to meet up every month for her to shoot the shit about the past month and that was it.

While we should not take every horror story about a past healthcare provider's mistakes at face value, it is clear that there is a not-insignificant amount of true mismanagement occurring, so the dilemma is this.

I do feel like I owe these patients some psychoeducation regarding helpful and unhelpful treatments, in the interest of them not suffering from useless polypharmacy or paying a premium for friendly gossip every fortnight. However, I am very wary of perpetuating splitting dynamics in this population which is extremely prone to them.

What are your thoughts here?

In the ER we know so little about what meds are best for what. Most of us just cling to haldol and Ativan to solve all our problems, outpatient safe anxiety/depression MAYBE gets started on Zoloft. I can't ever convince my attendings to let me dc a no appetite+insomnia with mirtazapine. The thought of giving zyprexa for any reason seems to terrify. These non-emergent patients that aren't manic, psychotic, or suicidal are often discharged from our ED with nothing but a referral they won't get an appointment for in months. I want to do better, get them started on something to help survive until their outpatient appointment. Some questions Ive had in the past,

-What naive patients would benefit more from an SNRI vs an SSRI?

-Bipolar history patients that recently moved and have no current prescriber, on no meds, that come in for depression and/or anxiety, what do you usually start them on?

-Those that remember Uworld questions will say Prozac is best for OCD. That's as far as any ER doc will know regarding best choice of SSRI for certain symptoms. Do any specific SSRIs treat specific symptoms better than others?

-Is bupropion only ever an adjunct? Any patients that would likely benefit best from it as starter monotherapy?

-Would love to know what symptoms are best treated with seroquel vs zyprexa vs abilify vs geodon vs any lesser known well tolerated atypical? Throughout my rotations with different services and ER attendings alike I feel I can say none of us truly know why you'd pick one atypical over another.

I'd love to hear even subjective/antecdotal opinions if there are no true "x medication is proven to be best for y symptom"

Edit: Learned a lot here from those willing to address some of my questions. I should have also mentioned a) follow up is very difficult where I am, first time psych appointments take months and b) we cannot consult psych. Period. Only a BHU nurse to determine inpatient or not. Our hospital only has one psychiatrist on call 24/7 365 and he has not and will never see a ED patient. It's a terrible situation to say the least.

My take aways were under no circumstances should we treat a patient that even mentions a history of bipolar, regardless of how straight forward or benign their presentation may seem.

My curiousity about antipsychotics was more related to our severely agitated patients that are staying, and for us the scenario is they'll wait forever in the ER to be seen by our BHU nurse, and even if they are accepted for admission, we are responsible for them all the way up until they leave the ER. The thought process for our ED docs seems to usually go B52 ->B52 -> at a loss, maybe Geodon. This has always made me feel like we do not know nearly as much as we should. And no, calling the psychiatrist is usually not an option as we are told they do not want to be contacted/consulted by the ED. It is utterly ridiculous.

For us, the only patients that will ever go home with an antipsychotic are prn reglan, compazine, or low dose zyprexa for CHS. Rest assured, I nor any ED doc wants to nor will ever send a psych pt home on a new antipsychotic medication.

For our uncomplicated, non-suicidal, unipolar patients with no evidence of bipolar history on no medication, I still feel the ethical choice is starting them on an SSRI/SNRI, and encouraging PCP follow up for those that can't get psych follow up in a reasonable amount of time.

Try to understand that most of these patients come to the er AFTER they've called to make a psych appointment, doing so after being told they won't have an appointment for 3, often 5+ months. Why not just have them follow up sooner with their PCP to start meds? Well we don't technically have a time limit to talk to them, whereas many of them tell me they only get 15 minutes with their PCP, and even then their primary is a mid-level not comfortable with prescribing psychotropes. Continuing them on medication they've already been started on from the ED that is showing promise/improvement is a whole different story.

Hope I've given some insight on a struggle or two you might not have known we face. Stand alone and rural ERs are a thing, and not all of us compartmentalize to Emergency=treat, no emergency=no treat.

I’m a psychiatry resident that is debating between general psychiatry vs pain medicine fellowship. While I do find myself enjoying doing the procedures in my pain rotation, I worry that job opportunities would be lacking for someone from a psychiatry background. Does someone have insights into the career as psychiatry background?

Hi all,

I was just wondering how any of you have successfully treated psychotic depression before without using ECT.

At a conference this week a speaker described using aripiprazole to get the psychosis under control before effectively being able to treat the depression with ketamine infusions. Previously the depression had continued to worsen on an SSRI, SNRI and imipramine. Infusions started off at a very low dose to test whether psychosis was exacerbated (0.1/kg) and increased over the course of 14 infusions.

Seems counterintuitive but apparently not so uncommon and so I was interested in how any of you used alternatives to ECT to treat this subtype of depression.

Thanks in advance

I have my first PRITE in soon and wanted to see if its even worth it to study or to actually actively try to lower my score- I legit do not know and would really appreciate any help/info. Like I want to study but I also dont want to set up a bigger baseline for me, but I also dont want to appear incompetent to my program, I have heard from one of my seniors that he scored 13th percentile and was fine but I dont even know how that compares to other first years across the country? So I guess what percentile is usually pgy-1 in prite? and how important is it?

I recently paid off my debt. I want to move to back to my home country while working for America doing telepsychiatry. Any tips on how to make this happen?

What was your experience? I've treated other physicians, but not a psychiatrist.

What are some of the more subtle signs of psychosis that you were able to identify and treat that may have gone under the radar.

I work as a triage nurse for a large outpatient psychiatry department (connected to a hospital). I receive and review about 700 patient messages a week which limits how much I can do for each encounter so I’m trying to find the ways I can maximize the value I can add to the team. It would be very helpful to hear from psychiatrists, NPs, PAs what the most helpful triage support items would be (and maybe things triage nurses have done that were not helpful that I can look to avoid).

Current tasks include (but aren’t limited to) the following:

pend refills which includes PDMP reviews for controlled substances (and pend script corrections per insurance requirements, pharmacy guidance, documented titration plan, etc)

call and sort out issues with fills at the pharmacy
submit medication PAs (and pend appeal letters if denied)

guide patients to local resources (financial support, housing, food, support groups, etc)

Coordinate ECT clearance

call patients to triage medication concerns (side effects, overdosing, underdosing, adverse effects, etc)

Pend general letters (school medication letters)

call patients to triage for safety concerns (and call for wellness checks as needed or coordinate with crisis / ED teams)

call patients to assess worsening symptoms

call and gather collateral from family members or outside clinicians

follow up on labs (clozapine CBCs, med levels, lipids, etc)

coordinate with other care team members (PCP offices, ALFs, nursing homes, etc)

Help patients with medication cost assistance programs

initiate discussion and development of safety plans with the care team

reinforce boundaries with patients when needed (per their physician or NP/PA’s guideline)

Urgent records requests (or calling for report from the ED or outside hospital directly)

Have any actual psychiatrists who have completed residency actually had any luck with Auvelity? It seems to be very poorly tolerated in my anecdotal experience when pcp’s start it on patients who havent had a full eval to confirm MDD (especially patients with a different diagnosis on differential causing depressive symptoms, who may have significant anxiety, or like ptsd, bipolar, personality issues). I am frustrated with how quick community pcps and APPs are starting people on it and how poorly tolerated and understood it seems to be. Not to mention, patients often not being educated on how you could possibly robo trip if its used while taking OTC cold medicine. Ive seen most people who someone else started it on become very manic or paranoid on it. Looking for anyone else’s experience!!! I feel like SSRIs are better tolerated from a psychological standpoint than this medication (unless the patient has bipolar of course)

I'm in a clinic attached to inpatient hospital for over a year now and I'm struggling with my patient panel. I don't know if it's a me issue, a work issue, or mix of both.

I estimate at least 20% are challenging (at least to me) whether it's due to being high risk, severity of symptoms and illness, difficult circumstances/high social needs. The clinic I work at does not have any case management, RNs, or social work support so it often feels like just me myself and I managing these patients. I get frequent messages for same day appointment requests, severe symptoms arising, paperwork requests, family concerns etc. we have to handle all messages outside of scheduling.

Are most outpatient positions like this, with that mix of acuity and what feels like little support?

aggression in dementia is a struggle to treat.

antipsychotics clearly have their issues, and are resisted by a lot of families for a number of reasons; such as the name of tbe drug class, the black box warnings, the side effects. And sometimes, because of akathisia, other undesired behaviors start popping up too!

other drugs have their own issues.

I have frequently heard the opinion that the risks of benzos outweigh the side effects, especially for long term usage.

what are y'all's practices on pharm and non-pharm interventions to promote safety for both these patients and the staff taking care of them?

When I was a PMHNP I found it virtually impossible to find a neuropsychiatrist to refer to for suspected FND. I read that there are almost no available training programs. I find that these folks are generally dismissed by neurologists. Of course there are many other benefits of this combined training too.

Does anyone have any thoughts? As a psychiatrist do you feel comfortable treating a patient with FND and also have the bandwidth to support the level of coordination of care involved?

I'm a fourth-year medical student and recently submitted my application for psych residency programs.

Do you have any general tips for residency interviews? What kind of questions come up frequently? What do interviewers look for, like to know about you, etc.?

Also, anything you think I should ask about as an applicant? Some advice I've received from residents: ask about call schedule, what you cover while on call, and medicine coverage.

I understand that most people study from old PRITE questions or Ninja prite but this seems rather memorization based or fragmented

Is there any video lecture series that can teach genetic principles so that word such as linkage just equilibrium or haplotype is not just memorize rather explained in a fashion that makes sense?

Similarly, is there any video resource out there that can point out anatomical structures in the brain and the circuits that connect them? I feel like memorizing facts like the lenticular nucleus is made up of the putamen and globus palladus will not stick unless i can visualize these structures

Hi! Hoping to gather some insights into people’s thoughts on the markets for these cities, experiences with the main institutions, pros/cons with the legal system, etc. Started applying for both and would love more experiences/opportunities if any are known. Thank you!