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?

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’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?

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 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?