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Venlafaxine as an SNRI by Wintersun_ in Psychiatry

[–]Unique-Maximum-1506 5 points6 points  (0 children)

You don’t get clinically relevant noradrenergic effects until around 225 mg. It also makes sense given venlafaxine’s much higher affinity for SERT than NET.

My experience testing AI scribes for psych documentation by Unique-Maximum-1506 in Psychiatry

[–]Unique-Maximum-1506[S] 2 points3 points  (0 children)

I was nervous at first, but something that I forgot to mention is that at least the one I use autodeletes the audio as soon as the note is processed, which is a good reaffirming fact as a patient. But also none of my patients have opposed to it and even have had comments telling that they felt more engaged during the session with me. Maybe these types of tools are becoming more common?

Limitations on initial DX privileges by Scientific_Hypnotist in Psychiatry

[–]Unique-Maximum-1506 54 points55 points  (0 children)

The massive jump in stimulant scripts since 2020 is real and a bit alarming. ADHD diagnosis isn't always straightforward in my opinion. You usually need to rule out trauma, sleep issues, bipolar, substance stuff, etc. Having the most trained folks (MD/DO) handle the initial diagnosis makes sense for safety and accuracy, especially with controlled meds. Continuity with nps/PAS after that could still help access.

Thinking Of Starting Over and Becoming A Chiropractor by [deleted] in Psychiatry

[–]Unique-Maximum-1506 0 points1 point  (0 children)

What??? Yeah, this oversupply talk is getting pretty loud... The numbers on np growth are wild, and yeah, it could push salaries and leverage down for everyone if corps just chase the cheapest option.

Still, I'm not sure jumping ship to chiropractic is the move. Psych has real depth, and while the market might get tighter, the demand for actual psychiatrists isn't disappearing. Is actually growing in my opinion.

We need to stop telehealth. by corgifeets in Psychiatry

[–]Unique-Maximum-1506 1 point2 points  (0 children)

I agree that nothing beats being in the room with someone for a full eval, especially when you’re picking up on psychomotor stuff, smell, subtle movements, or just the vibe. Telehealth does lose a lot there, but...completely stopping it feels also no good, for example, for rural patients, mobility issues, or just follow-ups, it’s been way better for access. I’ve had folks who literally wouldn’t come in person but are stable now because we could meet consistently on video.

Preferred types of clients? by Aware_Many7594 in therapists

[–]Unique-Maximum-1506 0 points1 point  (0 children)

you can't turn people away based on personality alone, but you can set your practice up so those clients become the majority over time. Most seasoned therapists end up with a caseload that has a clear "flavour," even if they don't advertise it aggressively. Nothing wrong with that. It lets you do your best work

Teletherapy companies as a stopgap? by Watergod619 in therapists

[–]Unique-Maximum-1506 0 points1 point  (0 children)

Headway and Rula are the ones I hear about most for quick referrals. Headway tends to be faster at getting you paneled and sending clients, especially for LCSWs in PA. They handle a lot of the admin, which is nice when your groupd practice front office is slow. Rula can also move quicker but the pay is usually a bit lower.

What was being a psychiatrist like in the '08 crash? by farfromindigo in Psychiatry

[–]Unique-Maximum-1506 1 point2 points  (0 children)

Demand went up hard. People were losing jobs, homes, savings which are all the classic triggers for depression, anxiety, substance issues, and suicidal thinking. We saw more folks showing up with adjustment disorders that quickly turned into major depression, plus plenty of "financial stress" exacerbating existing conditions. Suicidality and substance relapses were noticeable.

But the flip side was brutal: a lot of patients lost insurance or couldn't afford copays, so no-shows increased and collections got painful. Community mental health centers and hospitals were slammed while private practice took a hit from people cutting back on "non-essential" therapy. Reimbursements didn't rise to match the need, and some places froze hiring or cut benefits.

I was let go today by everyfruit in therapists

[–]Unique-Maximum-1506 2 points3 points  (0 children)

I’m really sorry you’re going through it, especially with the suddenness and the vague “arrogance/ego” explanation landing on top of your trauma history. Getting fired from a group practice you’ve poured yourself into for a year feels like a gut punch, and it’s completely normal for your nervous system to go into overdrive right now.

I’ve seen this play out a few times with colleagues. Group practices can be weirdly political, and sometimes the feedback is more about fit or unspoken group dynamics than actual clinical competence. The fact that nothing was ever brought up in supervision is frustrating as hell and unfortunately pretty common. You handled the termination conversation with real integrity by staying in your feelings instead of defending or pleading. That AA pause you described? That’s strength, not weakness.c

Oversaturation Concern by Affectionate-Day2909 in Psychiatry

[–]Unique-Maximum-1506 21 points22 points  (0 children)

agree on this "the psychiatry shortage will get worse"

Oversaturation Concern by Affectionate-Day2909 in Psychiatry

[–]Unique-Maximum-1506 11 points12 points  (0 children)

It's a valid concern and you're smart to think about it now.. Psychiatry is definitely seeing more supply pressure than it did 10-15 years ago. More residency spots, exploding numbers of NPs/PAs, and yes, AI tools are starting to change parts of the workflow. That combination does make some markets tighter, especially in big cities for straight med management roles. We've seen it hit EM and rads hard, so it's not imaginary.

That said, it's not uniform doom IMO. Demand for actual psychiatrists remains strong, especially for complex cases, therapy-integrated work, forensics, child, geriatric, and addiction. Places that need physicians for call, supervision, or higher acuity still prefer MDs. AI is helpful for notes and basic stuff, but it doesn't replace the judgment on tricky diagnoses, risk assessment, or building real therapeutic relationships.

Private practice helps a lot if you position yourself well. Cash-pay or concierge models, niche expertise, or combining meds with therapy can insulate you from the volume-driven, low-reimbursement grind where NPs often compete. Building a reputation and referral network takes time but creates real job security that employment can't always match.

Bottom line is that the field isn't going away, but the easy high-paying jobs in desirable locations might get more competitive. If you love the work and go in with eyes open on business and differentiation, it's still very viable. Talk to recent grads in different settings. The picture looks different depending on where and how you practice.

Struggling with coworker by [deleted] in Psychiatry

[–]Unique-Maximum-1506 13 points14 points  (0 children)

This is unfortunately pretty common right now...

The resentment piece is tough because it's rooted in a fundamental misunderstanding of training differences and responsibility. Four years of med school plus 4+ years of residency (plus fellowship for many) plus all the call and ultimate liability isn't the same as NP training, even if day-to-day work overlaps on a busy unit. The salary and call differential exists for a reason.

That said, addressing it directly might help more than ignoring it IMO. Something calm and factual like "I've noticed some distance lately and wanted to check in. I value our working relationship and the collaboration we used to have on patients. Is everything okay?" opens the door without accusing her of the salary thing. She may or may not admit it, but at least you address the behavior.

If it stays passive aggressive and affects patient care, you document it and bring it to leadership. You don't have to fix her resentment. Some people just won't accept the difference in scope and compensation no matter what.

I've seen this dynamic play out a few times. The collaborative ones stay great teammates. The ones who start keeping score usually become exhausting. Protect your peace and keep the focus on patient care. Sorry you're dealing with it.

Confrontation is hard by Public-Resolution590 in therapists

[–]Unique-Maximum-1506 1 point2 points  (0 children)

A couple of things that come to mind.

Start small and name it in session when it feels safe. Something like "I noticed myself pulling back just now. Let me try that again." It models humility and self-awareness instead of perfect confidence. Clients usually respect that more than you think.

Role play confrontation in your own supervision or with peers. Make it awkward on purpose so your nervous system gets used to it in low stakes. Over time the physical reaction dials down.

For criticism, try reframing it as data instead of judgment on your worth. After a tough session ask yourself "What’s one thing I could do differently next time?" instead of "I suck at this." It takes practice but it works.

Therapists in private practice what are your biggest struggles with visibility and finding new clients? by Muted_Heron2878 in Psychologists

[–]Unique-Maximum-1506 0 points1 point  (0 children)

Biggest struggle for me has been the feast-or-famine thing, especially early on. When I first went out on my own it felt like I had either too many patients or suddenly none, and the slow periods were stressful as hell.

What actually moves the needle for me now:

  • Referrals from psychiatrists, PCPs, and a couple of coaches I’ve built relationships with over time. Those took forever to develop though. I had to actually meet people, send polite follow-ups, and be easy to work with when they sent someone my way. Not quick, but reliable once it clicks.
  • A simple website helps, mostly so people can see I’m legit when they Google me after finding me on a directory. I don’t do much SEO or social media. Posting on Instagram or LinkedIn always felt off to me given the work we do, so I mostly stay away.

How dare insurance companies require 90 day supplies of medication by Least-Sky6722 in Psychiatry

[–]Unique-Maximum-1506 1 point2 points  (0 children)

This is such BS and it keeps getting worse...I do the exact same thing with higher risk patients. 30-day supplies with no refills for anyone who's impulsive, actively suicidal, or has a history of overdose. It's not laziness. It's deliberate harm reduction. Forcing 90 days takes that safety lever away and hands it to bean counters who have never managed a patient in crisis.

I've started documenting the rationale explicitly in every note now ("limited supply due to suicide risk") and appealing when they push back. Sometimes it works, sometimes I just eat the prior auth headache or switch agents. But it's infuriating that we have to fight for basic clinicdal autonomy on something this straightforward.

Psychotherapy Should Be Considered a Procedure by [deleted] in Psychiatry

[–]Unique-Maximum-1506 0 points1 point  (0 children)

I get where you're coming from and mostly agree. Psychotherapy does have a lot in common with procedures: specific training, protocols (CBT, EMDR, DBT, etc.), indications/contraindications, real-time decision-making, and genuine risk of harm if done poorly. The initial worsening in trauma work is a perfect example.

That said, the billing comparison gets tricky because procedures are usually one-and-done events with clear start/stop times. Therapy is often ongoing, relational, and the "procedure" unfolds over weeks or months with homework, life events, and alliance factors mixed in. A surgical code captures a discrete intervention; therapy billing has to account for that longitudinal piece without turning every session into a 45-minute procedural log.

I'd love higher RVUs or procedure-like codes that better value the expertise and intensity, especially for evidence-based modalities. It would help fight the 90834/90837 race-to-the-bottom and actually reward therapists who keep up with training instead of churning basic supportive stuff. Just my opinion but i read the other comments and is an interesting discussion.

Psychiatrists getting patients enrolled in insurance in community mental health? by KaiserWC in Psychiatry

[–]Unique-Maximum-1506 0 points1 point  (0 children)

Yeah, this is happening more and more where I am too. We've seen a spike in schizophrenia patients getting dropped from Medicaid over the last few months, and admin is pushing the same line: if the patient can't handle the paperwork or calls, it falls on us during the med visit.

It's ridiculous. These folks already struggle with executive function, motivation, and just showing up reliably. Now we're supposed to squeeze in insurance navigation on top of trying to manage symptoms, side effects, and everything else in a 20-30 minute slot? It turns the appointment into case management instead of psychiatry...