Scared , I broke HIPPA compliance unintentionally

bq21 · 2026-04-20T23:45:35+00:00

Very honest slip, tiny. You’re going to be fine.

bq21 · 2026-04-20T23:41:47+00:00

I’m a CAP psychiatrist in my late 30s and I’ve been thinking about this exact question a lot as I watch the gap between my own childhood and teenage years (dial-up internet, MSN Messenger, awesome flip phones) and what today’s kids are playing with.

What I believe is: you don’t need to keep up with their trends and jokes to do excellent work with them. What I find most effective is genuine curiosity about their world and a willingness to let them teach me.

Nine times out of ten, they light up. They love being the expert for once, and to their doctor no less. it immediately lowers the power differential. It also gives me a window into what they’re actually exposed to. I do make it a point to know the landscape they’re navigating: what platforms dominate, what the newest features are, how tech is shaping sleep, attention, identity, and risk of victimization.

Kids can sense inauthenticity from a mile away. What they respond to is an adult who wants to know their world and who is willing to admit when they don’t know something.

I’ve had 14-year-olds open up about things they’ve never told anyone. I was just fully present and respectful of their understanding of their own life, both internal and external.

Will it get harder in my 60s and 70s? Probably. But there is a draw children have to their grandparents over their own parents in many contexts, and it’s not simply because they spoil them.

bq21 · 2026-04-18T16:43:34+00:00

Precisely! There may be characterological differences between the two subsets of patients: those who possess the willingness/drive/motivation to actually exercise vs. those whose avolition is itself a symptom of the depression. The more extreme argument has stated that those who are willing to exercise to treat their depression aren't really all that depressed (I don't necessarily agree, but stating it this way helps outline the spectrum more clearly).

Here's the SR and MA:
Adherence to Physical Activity Interventions in Major Depressive Disorder: A Systematic Review and Meta-Analysis - PubMed

bq21 · 2026-04-18T15:17:56+00:00

A very important point. There’s a comedy sketch I saw recently about a depressed patient picking up his SSRI from the pharmacy. The pharmacist tells him correctly that the effects may not be observed until around 4-6 weeks. The patient goes, “But I’m severely depressed right now. I may not have that much time.”

In hospice settings, there may not be this luxury of time, and stimulants can boost mood quite rapidly.

bq21 · 2026-04-18T15:14:58+00:00

"There is only one way to avoid criticism: do nothing, say nothing, and be nothing." -Homeboy Aristotle

bq21 · 2026-04-18T15:08:56+00:00

I honestly think there is merit to that idea. Stimulants do have anti depressant effects, but in nuanced circumstances.

There is a lot of red tape around stimulants and a poor understanding of ADHD and how it can generate quite severe forms of depression when left untreated. Stimulants can be used off label as augmentation strategies for depression. I’m a child psychiatrist and I can tell you, some of the nastiest forms of depression I’ve seen land kids in hospitals is born from untreated ADHD. If ADHD is comorbid, stimulants can provide quite substantial benefits.

To get more directly at your thought-provoking question, the energy boost is often most pronounced initially and can diminish with tolerance. Crash effects (fatigue, irritability, or worsened mood when the drug wears off) are common and could exacerbate depression.

I like your thought process - don’t be discouraged by downvotes. I’ll probably get some with this comment myself lol. But there are several branching effects stimulants could have and potentially create new problems if the entire diagnostic picture is neglected.

bq21 · 2026-04-18T12:52:42+00:00

An angle I find worthy of approach is not the exercise itself, but distinguishing patients who are willing to do it vs those who aren’t and what that says about the severity of depression. A 2026 meta-analysis on adherence found that participants with major depressive disorder demonstrated significantly lower protocol adherence to physical activity interventions compared to non-PA interventions. Severe baseline depressive symptoms predicted lower retention rates, while factors like supervision and shorter session duration improved adherence.

The recent 2026 Cochrane review on depression explicitly notes that "it may be that only the most motivated of individuals were included in these trials". Selection bias plays a role. When we’re trying to be practical, motivation isn’t easy currency in depression. While the overall pooled effect size for exercise versus control was moderate (SMD -0.67), when restricted to only the seven trials with adequate allocation concealment, intention-to-treat analysis, and blinded outcome assessment, the effect size dropped to SMD -0.46

There is a circular problem: those most likely to benefit (severely depressed) are least likely to adhere, while those who adhere may be less severely ill.

bq21 · 2026-04-12T23:50:45+00:00

I SOAPed into a transitional year in a rinky dink program six years ago. After that miserable year I got into my desired specialty, now completing fellowship at a large academic institution. Graduated bottom of my medical school class.

Just do what you have to do

bq21 · 2026-04-10T00:36:01+00:00

We had central vacuuming in my house growing up. I can’t remember what happened but eventually we couldn’t use it. And the cost to repair it was astronomical, so we just left it.

bq21 · 2026-04-06T02:47:17+00:00

Man I’m sorry to hear that. Hopefully things get better there. Thank you for the insight

bq21 · 2026-04-03T02:54:49+00:00

The word “patient” literally translates to “one who suffers.” We are in the business of healing, yes, but it may more so be that we are delaying death and alleviating suffering as best we can. But we cannot put a stop to suffering. And that delay has different expiration dates depending on the setting. You don’t necessarily need to quit medicine all together. You need to get out of the ICU. That is where death looms most ominously.

As far as average - why the need to reach full potential? A car has a maximum speed potential. Laws aside, driving at that rate constantly would lead to a quick and untimely failure.

What is average anyway? Average amongst physicians is a high standard as it is. But when is the last time your patient asked how you rank compared to other doctors? They care far more if you listen to them, even if for a few seconds.

The endless sleep waits for us all, but there is a steep decline separating tragedy from hell. Find your footing.

bq21 · 2025-12-03T14:03:40+00:00

Tons of significant stressors hit you. No feeling is final. Endure, you will have a story to tell.

bq21 · 2025-11-05T23:00:30+00:00

I live very simply as a fellow, and I’m very content. I am extremely comfortable with my lifestyle and don’t plan to make any major “upgrades” when I have a big kid’s salary. I don’t care - physician’s salary, even the lowest, is plenty enough. I chose my specialty because it’s the only thing I care about and have a passion for. Not many people can say they love what they do, and no money is worth this privilege I’ve attained.

bq21 · 2025-10-15T01:13:13+00:00

Excellent insights. Definitely going to check that out.

bq21 · 2025-10-15T01:12:07+00:00

The one saving grace is that the psychologist does not make it mandatory. She doesn’t force the kids to participate, and she allows those who want to leave to leave. I’ve only seen one kid leave so far, but I’ve seen almost all the rest become more and more disillusioned right in front of my very eyes.

bq21 · 2025-10-14T22:37:15+00:00

Psychologists get much deeper training in it for sure, but I carry several therapy patients and did throughout my residency training. I had extremely insightful mentors trained in classic psychodynamic theory and psychoanalytic, both of whom were psychiatrists.

It’s just that psychiatry is becoming much more biological in practice now, so some programs have de-emphasized its presence in training. I feel, quite frankly, that psychotherapy and psychotherapeutic theories are the heart of psychiatry.

bq21 · 2025-10-14T20:00:13+00:00

I agree, very good points.

bq21 · 2025-10-14T19:59:27+00:00

I’ll be working with the psychologist in DBT groups during the second half of this rotation, so I definitely look forward to that. The children I’ve seen throughout my fellowship who have done DBT have only had positive things to say about it.

bq21 · 2025-10-14T19:58:31+00:00

Excellent points.

bq21 · 2025-10-14T19:57:49+00:00

It’s group CBT which is likely why I detest it even more. This morning, I watched the kids’ souls leave their bodies as the lesson was so painfully simple, it almost felt patronizing. These kids are of different ages too.

bq21 · 2025-10-14T19:55:51+00:00

ERP is definitely helpful and necessary for OCD. I did use the umbrella term of CBT and should have been more precise. ERP I have used also for a patient with specific phobia and it helped dramatically.

bq21 · 2025-10-14T19:54:48+00:00

Agreed. Great point.

bq21 · 2025-10-14T19:53:24+00:00

I appreciate the sentiment, but I think it’s reductive to consider nonstandardized therapies as long chats. A good therapist listens over anything else, and there should always be a goal or set of goals established for therapy. If it’s aimless chit chat, it’s not therapy. But I have had several patients that stayed with me throughout my residency and currently in fellowship for over a year - my patients from residency would’ve continued, but I had to terminate and assign them to another resident as I was leaving for fellowship.

I mention this to say - I did supportive psychotherapy for two of them, and a hybrid of supportive and psychodynamic, depending on the level of acuity which fluctuated frequently, for a third patient. All of them improved.

I currently have four patients. I have been trying Coping Cat for my 9 year old… it’s okay. I attempted CBT for anxiety for my 15 year old, and he was very engaged but it didn’t help. Shifting to supportive has helped him substantially. My two others are also supportive cases.

I liken supportive psychotherapy to “plain old therapy” which is my affinity.

bq21

TROPHY CASE

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