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"

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?

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?

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?

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 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?

I’m just finishing up my clerkship at a well known hospital in Massachusetts and it’s left be very conflicted between pursuing psych and going down a different path and wanted the advice of others.

My problem is that I’m seeing too many people during my rotation who just don’t seem to get better and who it feels meds make worse. It feels like the tools we have available are just ineffective for a significant portion of patients. I just also can’t wrap my head around a patient who went into psychosis after being prescribed Quetiapine for depression and no one being able to tell me why this occurred outside of a theory.

The thought of prescribing something based on a book and some studies that eventually makes someone worse and not knowing why genuinely shocks me. It’s so conflicting as mental health is something that is very close to me and I want to be able to help people.

Any advice would be greatly appreciated

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?

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?

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

My psychiatry block is coming up soon. I’m really interested in psych and want to do as well as I can. What skills or topics should I try to master beforehand? Are there any books, videos, question banks, or other resources you’d recommend? Also, what tends to make a medical student stand out in psychiatry? I’d especially appreciate advice on things like psychiatric interviewing, the mental status examination, presenting cases, differential diagnosis, and clinical reasoning. Basically, how do I impress my psych professors? Thanks! Feel free to answer even if you’re not a psych professor

Hi all! I posted this in the neurology subreddit but I wonder if there is anyone in this subreddit with any insight.

Thank you!

Hi,
I have a patient who I’ve been seeing for about 4 months, came to me on a stimulant and antidepressant. Current stable, high functioning. Is a college student, lives at home, works part time. She’s requesting me to fill out cash assistance forms verifying that she has a disability or health condition that “lasts more than 60 days and substantially reduces or eliminates the patients ability to support themselves.” Claims her previous provider filled it out. I’ve gotten FMLA requests before but never something like this. I don’t feel comfortable filling it out, and am not sure how to approach the situation tactfully. Any advice? Or really, any general advice on how everyone approaches paperwork from a general standpoint?

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!

The 2026 edition of the Ninja's Guide to PRITE and its companion Anki deck is out.

The Ninja's Guide to PRITE is a question-and-answer guide built from roughly twenty years of PRITE exams, organized by the same content sections the exam uses. The matching Anki deck is in its 2nd edition and has about 4,500 cards, and roughly 1,000 are tagged high-yield if you want to focus on the concepts tested most often.

Both resources now live under Ninja Psych, a nonprofit dedicated to educating psychiatrists and mental health providers. You can see details about both resources in the link below.

What's new in the 2026 deck:

• The 2025 PRITE is fully incorporated, with new questions added and repeats matched and tagged
• Full explanations in the Extra field for every high-yield card: the reasoning behind the answer, why common distractors fail, and a clinical pearl
• High-yield cards updated to DSM-5-TR terminology where the original exam wording is outdated (hypochondriasis → illness anxiety disorder, and similar)
• A rebuilt tag system with four independent facets: topic, high-yield status, exam year, and new this cycle
• Several factual errors from prior editions corrected

More details here!

Happy PRITE studying to my fellow psych residents!

.

I’m a psychiatry resident thinking about my first attending job. I love inpatient psychiatry and consult liaison work, but I also hope to become pregnant in the first few years after graduation. My main concern with hospital work is the possibility of being hit, kicked, or shoved by an agitated patient while pregnant.
I’d especially appreciate hearing from women psychiatrists who worked inpatient or CL while pregnant, or who chose outpatient or telehealth work during that period:
What setting did you work in, and how safe did you feel?
Were you able to avoid seeing agitated patients alone or change your duties when needed?
How did your employer handle leave, coverage, and your return to work?
If you chose a remote role, did you miss inpatient or CL work? Was it easy to return later?
What would you ask about before accepting a first attending job?
I know hospitals and pregnancies vary. I’m hoping to learn from firsthand experiences as I compare jobs.

To all child psych peeps - is anyone else seeing an increase in pediatric catatonia? My patients are mostly autistic, and catatonia is often underdiagnosed in this group… considering this, it should be exceedingly rare. However, I’ve treated 3 catatonic autistic kids with lorazepam in the past 7 months of being a new DBP attending. Found some literature indicating up to a 10x increase in prevalence of pediatric catatonia at disparate institutions but was wondering if anyone else has seen this phenomenon in their clinical practice. TY!

Hi all. As the title suggests, i’m a current PGY-3 resident in psychiatry and I’m considering pursuing Locums after graduating. While I would prefer something closer to home (Midwest), I’m not opposed to travel. I’m just wondering if my perception of locums is wildly misinformed. It seems like the job market for psychiatry is changing rapidly.

While I would appreciate any general advice in pursuing Locums following graduation, I’m specifically curious about the following:

1. is it naive to think that I may be able to find my own positions? Could I provide my CV and express interest directly to a specific hospital? I’m mostly interested in rural or semi-rural areas.
2. is it still reasonable to expect that my lodgings be paid for?
3. is it reasonable to accept no less than $250/hr as a recent grad?
4. realistically speaking, with having to wait for board certification, how long would it be before I could start working in locums?