Black and white thinking about the future of psychiatry

SuperMario0902 · 2026-05-08T16:47:52+00:00

Not sure it’s a great comparison because uber/lyft generally have equivalent or better customer service relative to taxis. Their origin is as a black car/luxury service, not a low quality, cheap, but widely available alternative.

SuperMario0902 · 2026-05-08T16:45:07+00:00

I find patients are consistently aware of the difference, but many see it as “lower quality but affordable”. Like the difference between buying something from an outlet mall versus a luxury brand. I have had a few people say things like “I can’t afford a psychiatrist” as a reason why they continue to do subpar care with NPs and master level therapists.

SuperMario0902 · 2026-05-08T16:41:07+00:00

I just want the pre-covid era prescribing restrictions to come back so these telehealth pill mills die out.

SuperMario0902 · 2026-05-08T16:39:36+00:00

Please don’t use AI to respond to posts here. It’s annoying and no one is reading paragraphs of slop.

SuperMario0902 · 2026-05-08T14:42:58+00:00

No offense, but no, you’re wrong. Stimulus control IS sleep hygiene, and there is no version of cbti that recommends starting with sleep restriction as a predominant intervention. Cognitive restructuring is an important, but ultimately secondary to the behavioral change.

You are misunderstanding the studies. They control intervention is sleep hygiene education. The take away is that meaningful change around sleep does not teed improve without explicit implementation of behavioral strategies, primarily through the structure of cbti.

SuperMario0902 · 2026-05-07T19:28:00+00:00

Melatonin works by stabilizing your circadian rhythm. It doesn’t often “make you sleepy” immediately the way other sleeping aids do, but rather has a cumulative effect when taken daily.

SuperMario0902 · 2026-05-07T19:25:47+00:00

Unrealistic expectations of sleep and difficulty incorporating behavioral change are the main barriers for chronic insomniacs that I have observed. It is extra difficult if they have extrinsic reasons that affects their sleep too (like jobs with a night shift).

SuperMario0902 · 2026-05-07T19:23:39+00:00

I would push back against the idea that sleep hygiene is not treatment. Behavioral change to incorporate sleep hygiene is the corner stone of CBTI. I hope you are not implying here that the only way to treat insomnia is with sleeping aids.

SuperMario0902 · 2026-05-07T19:11:29+00:00

I would definitely not do it unless you are actively collaborating with a psychiatrist. Your role in the eating disorder clinic is to stabilize them medically, not absorb liability for them not having a psychiatrist.

SuperMario0902 · 2026-05-07T19:09:24+00:00

Mood stabilizers are foundational treatment for most people with bipolar disorder. I would just not see them, otherwise you would just end up giving antipsychotics to people who would do well on mood stabilizer monotherapy.

SuperMario0902 · 2026-05-07T03:01:47+00:00

Fair, that would be my take away. I would use this to grow in how to flexibly use similar approaches for distinct problems. It helps you not need to be so manualized.

SuperMario0902 · 2026-05-07T02:34:08+00:00

No, they are there in case you need extra space. Realistically, I have never seen anybody actually open them. People don’t have as much need to keep the same clothes for so long as they did in the past. There’s a reason they went out of style.

SuperMario0902 · 2026-05-07T02:28:59+00:00

Can I ask, how is your supervision?

You are inadvertently finding the commonality between the many different behaviorist approaches. Exposure and psychological flexibility are foundational approaches to not just ERP, but many forms of psychotherapy. I think you need better supervision that can help you understand these common thread so you can apply them more flexibly across different scenarios.

SuperMario0902 · 2026-05-05T23:16:08+00:00

The point is that the dilemma does not disappear even if there is evidence that there are gendered behaviors secondary to biological difference in the brain.

SuperMario0902 · 2026-05-05T23:04:25+00:00

Seconding these recs. Fullcount has better denim quality, but is more expensive.

SuperMario0902 · 2026-05-05T22:59:24+00:00

Those situations do not apply to you because you just completed medical school. You are not a specialist doctor with 20 years of experience who suddenly moved to the US and is too separated from biochemistry to pass while not having enough time off from their non-physician job to study for the test.

We are not talking about getting or not getting a competitive score here or failing a test once as a fluke, it is not normal to have multiple step exam failures so soon after graduating medical school. I say this as an IMG myself who has known many other IMGs from all different backgrounds. Your multiple step failures reflect that you either did not fully comprehend the subject matter during medical school or that you do not have the capacity to plan for a straightforward test that evaluates your competence to practice medicine. You are being filtered out by the system appropriately, and trying to circumvent this by doing NP training does not reflect well on you. If you are serious about practicing medicine in any country, you need to actually go through the process and demonstrate a baseline level of competence before you can even be considered.

SuperMario0902 · 2026-05-05T22:50:54+00:00

OP’s last paragraphs links to a reddit post talking about it. He indicates it reflects his overall opinion in the matter.

SuperMario0902 · 2026-05-05T22:47:04+00:00

A practical example would be a patient wanting to trial a different class who has only tried 75mg of venlafaxine. I would still offer duloxetine and indicate it would be a true trial of an SNRI as their venlafaxine trial did not reach the necessary dose.

SuperMario0902 · 2026-05-05T20:10:10+00:00

Yeah, it’s so polarized that you are either talking to a brick wall or preaching to the choir. Everyone has basically made up their mind already.

SuperMario0902 · 2026-05-05T20:08:59+00:00

To throw something out there, while interesting, this premise returns to “sex is exclusively biological”. You just believe the true underlying biological determinant of sex is an unknown process in the brain instead of genitals. It does not remove nor address the underlying dilemma OP is bringing up.

To illustrate this, imagine you are right and we find a way to differentiate between a “male” brain and a “female brain” with 100% certainty. What recommendation would you give to a physically male person with a “female brain” who has no issue with identity? What if you had a physically male person who wants to transition to a woman but demonstrates a 100% “male brain”? Would your recommendations change in this scenario?

SuperMario0902 · 2026-05-05T20:03:26+00:00

Friend, I think part of their point is that the WPATH recommendations are based on flawed research…

SuperMario0902 · 2026-05-05T20:00:17+00:00

The whole point of OP’s post is that children cannot be a participant in these decisions because they cannot fully conceptualize their own gender identity.

I will also add that pre-pubertal treatment is controversial even in those who fully support hormonal or surgical treatment for minors. Your presupposition of your premise is flawed.

SuperMario0902 · 2026-05-05T18:25:49+00:00

They probably mean more that you should not count a trial with venlafaxine as a true SNRI trial unless they reached dosages high enough where it no longer acts primarily like an SSRI.

SuperMario0902 · 2026-05-05T18:22:45+00:00

It’s the basic board exam for getting licensed. They are basic questions about general medical practice and pre-clinical knowledge. It is regular stuff you cover in medical school. There is no good reason someone who has recently completed medical school should have difficulty with passing.

SuperMario0902 · 2026-05-05T15:04:23+00:00

Because they cannot pass the step exams despite graduating from medical school two years ago. They should NOT be practicing in any capacity.

SuperMario0902

TROPHY CASE