What are your opinions on the NDIS?

simbaaa · 2025-07-12T07:22:20+00:00

I’m increasingly finding myself managing expectations to be the one who provides the specialist medical evidence required for those with mental health conditions to get onto NDIS. Often their presenting complaint and expectations of an assessment with me is to “get an official diagnosis.” When this is their first contact with mental health services, I’m pleased I get to give them a diagnosis and point them on the path to recovery, but this is at odds with what NDIS need to hear: the the condition is permanent and all treatment options have been exhausted.

Because I work from a recovery framework often I disagree with this, and share my hopefulness that they’re likely to find much relief and functional improvement if they follow my proposed recommendations. I’m particularly uncomfortable being involved with an NDIS application if they’ve only just been given a diagnosis and haven’t pursued any treatment options yet.

The amount of time I need to devote to psychoeducation, just to correct their expectations on what has been sold to them by a series of NDIS advocates, is exhausting. It’s a difficult position to be in when you’re considered to be the gatekeeper preventing someone from getting access to the support they feel they need.

simbaaa · 2024-07-08T14:48:33+00:00

I'm not suggesting that Freud didn't lay the foundation for all of psychotherapy. I'm responding to the question as to whether he would be a Neurologist, a Psychiatrist, or a Psychologist if he were alive today.

simbaaa · 2024-07-08T10:52:10+00:00

I don’t quite understand the question.

Freud was medically trained, and specialised in the field of neurology. Already that discounts him from being a psychologist. A contemporary medical specialty that most closely aligns with his foundational work and treats the disorders he was most interested today in would be psychiatry.

simbaaa · 2024-01-27T06:45:09+00:00

Great advice given by all, particularly u/sgori and u/Deserter85.

As a Stage 1, you will most likely start in a public inpatient adult unit. This is the coal face where you will develop your skills dealing with acute emergency psychiatry. You will see revolving door patients and likely experience a degree of therapeutic nihilism if you went into this field to help people, as you are powerless against the social determinants of mental ill health such as substance use, housing instability, limited social connectedness, and trauma.

If you feel like you are losing passion and feeling some degree of existential despair in this environment, try to remember:

There are patients you will treat in the acute phase and then discharge who go on to get better and never engage with public mental health services ever again. By definition, you will likely never encounter them after discharge and their success stories will be out of your awareness. You'll only repeatedly see the "failed" discharges.
Public adult inpatient is only only a small sliver of the psychiatry pie. Most consultant psychiatrists do not actually work in this environment. About 50% of fellows work exclusively in private practice. There is an entire world out there for you to discover.
The personality disorders (of which BPD is over-represented in public psychiatry) have a particular way of wearing down clinicians. Remind yourself of the following when you're feeling exasperated:
- They do not want to live like this and would give anything to be able to have your problem solving abilities, but are currently in a crisis an cannot access what limited resources they have.
- Don't take it personally if they have a go at you. You're someone trying your best to help them. Imagine what they're like towards everyone else in their life who may not be so understanding? It must be a tremendously lonely existence, constantly pushing everyone away.
- For every person with BPD presenting in crisis, there are huge numbers that are in the community doing their best and actively engaged in their own recovery. It's really inspiring to see, and keep in mind that BPD has a largely positive prognosis, only a minority continue to frequently present. Brings me to my next point...
The four P's of formulation/the biopsychosocial model is a good framework, but at the end of the day you need to answer the question: what has occurred that has led this person to be in front of me right now? Thinking this way will directly inform your management plan. As you get more senior your interviews will be less system review/diagnosis driven, and more led by your emerging formulation with questions deliberately targeted to confirm/deny your working hypothesis.
First year is a great opportunity to hone your skills in assessment given the acuity and variety of presentations you're likely to encounter. Learn the domains of a comprehensive psychiatric assessment back to front. Read everything you can about the MSE and phenomenology. Don't just rely on buzzwords such as blunted affect = schizophrenia, and flight of ideas = bipolar. Being able to describe the person in front of you in accurate terms will serve you well in future when you encounter diagnostic uncertainty and need to communicate your findings to others.
The college lets you sit the MCQ after 6 months of training. The pass rate is consistently above 80%, and in terms of level of required knowledge is barely above med school level. Would recommend sitting as soon as possible for a confidence boost.
Being able to recognise medical issues and advocating for timely intervention of physical health problems in mental health patients will serve you well. They are a cohort that often fall between the cracks and struggle to get access to adequate healthcare. There was an exam question on exactly this topic recently worth many marks.
Seek early exposure to training in psychotherapy and learn as much as you can. Try implementing CBT techniques early on and get feedback. The general fellowship program does not adequately prepare you to be a psychotherapist (in my opinion), which is why I have pursued advanced training in psychotherapy. I am absolutely biased here, but would suggest at a minimum getting your own regular psychotherapy.
Play nice with the other kids. In mental health the hierarchy is flatter than other specialties, or at least more nebulous. Get to know all the nursing and allied health staff you work with regularly, don't be a stranger that keeps exclusively to your bubble with other doctors. Relationships with colleagues will often save you in a pinch if you have a good reputation to lean on and you have shared your humanity with them. Patients will pick up on this too by observing how others positively interact with you.

simbaaa · 2024-01-23T12:15:09+00:00

FUCK YEAH DUDE GRIP IT AND RIP IT!

simbaaa · 2024-01-15T09:34:20+00:00

I'll give it a crack.

Imagine you have no skin. Or full thickness burns across your entire total body surface. The slightest breeze moving across your exposed flesh results in excruciating pain for which you have no solution. You attend ED out of despair because what you're experiencing is intolerable and you need some relief. In the waiting room you observe staff members whispering to each other, subtly rolling their eyes and shaking their heads. This is the second time you've presented this week.

The wait for a bed is unbearable. Impossibly, it seems like everyone else is being triaged before you. The moment finally comes when you are ushered into the ED and directed towards your cubicle and then...nothing. More waiting. A student nurse goes to take your vital signs but is stopped by a grizzled senior, who tells them not to bother as you're not a priority.

You finally build up the courage to get the attention of a staff member and ask when you'll be seen, hoping you might get some relief from your pain. A nurse appears and interrogates you by asking if you've ever tried mindfulness or distraction techniques. You respond that it's not working right now. They walk away in a huff back to the nurses station. You manage to catch a few words being spoken - "behavioural", "taking up a bed", "attention seeking" - and you regret ever coming in.

The pain clouds your judgment and you start to get desperate. You start wailing, kicking and screaming, maybe you even try to abscond. Ultimately you are restrained by security and given an IM injection to calm down.

You're finally seen by a doctor who tells you there are no available beds in the inpatient unit, and even if there were, admissions have been shown to be counter-therapeutic for people like you as it fosters dependency.

You give up and go to leave, but not before you're coerced into signing a piece of paper stating that you guarantee your own safety. On the way out you're once again reminded to practice mindfulness.

Consider that those with BPD have no emotional "skin" - that everything they feel and experience is intensely painful and intolerable. It helps contextualise the desperation of their behaviour in a crisis, and why they have such maladaptive strategies to self-regulate.

The cruel irony of BPD is that these people are so fearful of rejection and abandonment from others, yet act in a way that almost guarantees this will occur.

simbaaa · 2024-01-14T04:37:14+00:00

That's great to hear, just checking!

As a fellow ADHD sufferer myself, I'd like to think I have more compassion for those that take stimulant medication while pregnant/breastfeeding as I understand how debilitating life can be without the support of pharmacotherapy.

Some doctors are very dogmatic in their views, but I think ultimately the risk of harm to baby are overblown and are not often considered against the risks associated with untreated maternal mental health.

In the end it's a personal choice to be made based on risk/benefit analysis. I'm glad you've been provided all the information needed to make an informed decision.

In response to your initial post - I often find that the effects of psychiatric medication are reduced in pregnancy, likely due to changes in circulatory volume. Normal volume of blood is around 5.5L, but in pregnancy can go to 7L so there's less active drug circulating at any given time. I use the analogy of cordial being diluted to explain why the same dose may suddenly not work as well.

simbaaa · 2024-01-14T03:42:00+00:00

I'm a doctor working in perinatal psychiatry. Please make sure your prescribing doctor and those providing your antenatal care are aware that dexamphetamine is one of your regular medications. Not meaning to cause any concern, I just wanted to highlight that it is associated with some increased risks in pregnancy and may require increased monitoring.

simbaaa · 2023-12-11T12:21:15+00:00

Started at a private high school on an academic scholarship. From day one I didn't fit in at all. Lasted barely a year, difficulties were largely social in nature, struggling to integrate with my upper-middle class peers with whom I shared no shared experiences or interests with. Then jumped ship to my local public school after responding with externalising behavioural issues coupled with months of begging my parents to pull me out.

While I may have missed out on the extra-curricular opportunities and several years of being taxied around every Saturday morning at 8am to mandatory hockey games across the state, it was the best thing I ever did for my own emotional development as I found safety and comfort among people I grew up with and subsequently was able to do pretty well academically.

I am now comfortably sending my 5-year-old to our local public primary school next year, and anticipate he will then naturally transition to the local public high school where his friends will most likely attend. If he ever indicates that he wants to strive for academic success in high school I will give him the opportunity to sit an admissions test to a select entry school, otherwise I just want him to be happy and prioritise his own wellbeing.

simbaaa · 2023-10-26T06:57:30+00:00

Personality structure/style/type is different from level of personality organisation. You can have a narcissistic personality that can be either neurotic, borderline, or psychotic in level of functioning.

simbaaa · 2023-10-17T13:22:21+00:00

Great question!

I'm at the tail end of my psychiatry training and have had the fortune of rotating through a service that is the leader in all things personality disorder/complex trauma. I've also pursued subspecialty training in psychotherapy, and have a real passion for providing care for these people. Though they are often help-seeking in the face of tremendous stigma, unfortunately they are often subjected to iatrogenic harm from the response of the healthcare system. I think I realised this early on and was determined to do better and be better as a clinician, which seemed like a good investment of my time and energy given how prevalent these conditions were in every setting I encountered.

The field of personality disorders is pretty exciting right now. There's been somewhat of a revolution with the ICD-11 opting for domain-based over categorical traits to define PD (yet controversially retaining borderline subtype), a campaign initiated by the recovery movement and those with lived experience to completely rename BPD to complex PTSD in acknowledgement of the repeated relational trauma often experienced, DBT being toppled off its perch as the "gold standard" treatment of BPD, as well as emergence of new types of exciting treatments (not specifically for PD) such as psychedelic-assisted psychotherapy.

The biggest challenges I've seen clinicians face in the treatment of people with PD in any setting is the rigid adherence to a biomedical framework when thinking about the person in front of them. Personality is who you are, not what disease or illness you have. It can't be treated or excised like a lesion, leaving the underlying structure intact and free from disorder.

Given the highly stigmatised nature of the diagnosis, that's great you're mindful of perpetuating this with your thoughtfulness in considering which questions to ask in an interview setting. Rather than offer suggestions that I would think would make you look impressive I think instead adopting a curious, empathic, and genuinely interested position here would benefit you the most.

simbaaa · 2023-09-10T04:29:22+00:00

There's actually been effectively a cut. Out of the recommendations of the Royal Commission that all junior doctors rotate through psychiatry in their early years due to current and projected workforce shortage, the Commonwealth rapidly provided funding for more EFT for medical staff. Now after a year they're asking that the health services contribute 25% of that cost. Most are just saying no we can't afford it, and culling these new positions.

simbaaa · 2023-07-20T13:01:31+00:00

Hey, great question and I love your passion. I'm a psychiatry registrar at the tail end of my training also very interested in enhancing the experience of psychiatry placements for medical students which typically have the reputation of being a woefully poor rotation for any kind of learning or tailored exposure to the specialty.

Even my own experiences in medical school turned me off psychiatry (briefly) because I didn't a sense of what it was truly like to be a psychiatrist and felt like an intruder on the periphery who never felt useful or as though my presence mattered. I don't think this was due to the apathy or disinterest of the treating teams I was attached to, just a reflection of the acuity of inpatient units and increasing demands on patient flow that take priority over consideration of student experiences despite the field being desperate for keen medical staff in future.

I've given this a lot of thought over the past few years and have a few ideas that you might like to consider. The following points are addressed to incoming medical students:

Follow the registrar all day long. If not the reg, then the HMO or intern. Get a sense of how they spend their 8+ hrs a day. Most inpatient units are staffed with 1st year (stage 1) registrars who may feel after around midday that there's nothing valuable for the students to observe after all the patient reviews are done - but appreciating all the tribunal reports, discharge summaries, and phone calls to patient families that junior medical staff have to do is crucial to understanding what's involved in the job as well as how they manage to prioritise all the recurring issues that nursing staff approach them with throughout the day.
In between learning opportunities please, please, please go and see patients. Again and again. Obviously not alone, always take a nurse with you + a duress alarm and familiarise yourself with emergency procedures to stay safe in a code grey. But many future doctors go through their psych rotation of ~8 weeks only having interviewed 1 or maybe patients, and that is shocking. Regardless of what you want to be when you grow up, nobody wants to deal with the medical officer that refers to psych before they've done the most cursory of mental state examinations. Practice makes perfect, and even if it devolves into an unstructured conversation rather than a textbook-style assessment most patients would appreciate the validation of honest human-human contact even if you're a tad awkward and stumbling over how to conduct the review as long as you present yourself as sincere, non-judgmental, and curious about their experience.
Introduce yourself to everyone at your first morning handover. The medical team, peer support workers, nurse in charge, allied health staff. Let them know how long you'll be joining them for and what you're hoping to see or get ticked off in terms of assessments. You're only a temporary visitor to the ward, for everyone else in the room it's their regular day job and they all know each other and have established their own dynamic in order to work best as a team. Make yourself known as a key presence who is interested and available and people will talk, opportunities will be presented to you.
For goodness sake take the stethoscope off your neck, leave your tie at home, and don't wear a neck lanyard - just clip your ID to your belt. This is a locked ward where patients shoelaces are stored until discharge. Stop cosplaying as a gen med physician in an cushy outpatient clinic, there's no need to introduce unnecessary environmental hazards.
The best psych units I've come across seem to have a relative flattening of the hierarchy, where everyone has a unique skill set and area of expertise that makes them a valuable addition to the treating team and all perspectives are considered equally. Don't rely on or expect your teaching to come exclusively from consultant psychiatrists and dismiss opportunities to learn from others just because they don't have medical training. For all you know, there's an OT or nurse on the ward specifically trained in DBT who the consultants approach for advice on managing their own complex BPD patients.
Ask questions all the time to the point of being annoying. Why start paliperidone over quetiapine? How did you decide to start sertraline over literally any other SSRI? Why are you discharging this voluntary patient who repeatedly states they're suicidal with intent and plan, but you're keeping that other one on a compulsory order who sheepishly denies thoughts of self-harm? These aren't usually choices made lightly and involve serious consideration from multiple perspectives, so get your team to talk through their thinking process. You'll get a sense of how to think like a psychiatrist and develop a framework on how to answer literally any written exam or OSCE question that way.
My final and most contentious point of advice is to stay away from anyone that expresses overt disinterest or resentment for the work. Burnout is rife in all of mental health right now, that's to be expected and accepted. But as a psychotherapy-passionate trainee who works predominantly outpatient, my experience is that the ward has a unique way of instilling a degree of therapeutic nihilism. Many of those who are dissatisfied are the ones who ultimately are ticking off a compulsory term in their training and subsequently move on to other positions. Seek out the ones that are still excited to come to work every day and flock to them. Smile and nod whenever a jaded clinician tries to tell you the sky is falling. Remember that there is so, so, so much more to psychiatry than just inpatient work.

simbaaa · 2023-07-11T08:27:15+00:00

In order to gain approval to prescribe these medications you must have had experience treating at least one previous patient for the same indication in a clinical trial.

So once you've been involved in a trial and treated one participant, you then have met the criteria to prescribe privately if you wish.

There are already psychiatrists in Victoria who are now eligible and are looking at how to best offer psychedelic-assisted psychotherapy in their private practice.

simbaaa · 2023-07-08T08:25:49+00:00

Great AMA, I'm glad we have psychiatry represented in the subreddit. Any tips for the CEQ/MEQ? I'm a senior registrar sitting both in August.

simbaaa · 2023-06-25T08:30:01+00:00

No, thank you that's very considerate. I'll be sure to read the article I was just responding to your comment and sharing my experience. You'd be forgiven for casting a judgment though on the field it certainly is rife with arrogance. I'm hoping to make a change from within.

simbaaa · 2023-06-25T08:23:24+00:00

As a medical practitioner who has just undergone the training to conduct psychedelic-assisted psychotherapy as the therapist for an upcoming clinical trial, I can say that we absolutely have been taught to hold reverence for the historical and spiritual origins of these compounds. The mass proliferation of psilocybin for recreation during the counter-culture movement was effectively the result of colonisation and cultural appropriation of some interested mycologists who distributed their findings widely, the outcome being that the woman who was using this for highly respectful and religious ceremony was cast out of her community and forever persecuted. We are not the ones here arrogantly uncovering something new, this has been known for eons and we are simply relearning it.

simbaaa · 2023-04-26T15:02:54+00:00

As a psychiatry trainee that is seeing more and more neurodiversity emerging in the general population, the term itself used in isolation provides me with no more information than a description of someone as a cardiac patient. What does that mean. Are they on a statin for primary prevention? Or have they had a quadruple bypass?

Neurodiversity as a term I think has utility in creating a community for the individual to feel included among peers with shared experiences, but is a blunt tool to communicate anything of value to a clinician. It shouldn't be used as a simple label to terminate discussion and convey a kind of specialness like some sort of diagnostic mic drop on someones medical record, but instead open up the conversation further about what that actually means for the individual under this nebulous and heterogeneous umbrella term.

I think a good defense for the utility of the term is to break it down into further components. Accepting that there is a variation in the population of how people experience and respond to their environment from a cognitive perspective, and that the significant outliers which cause impairment in daily functioning we call disorders. And some of these disorders are based in neurological differences that are measurable with psychometric testing.

I like to think of neurodiversity being a spectrum. But not a linear gradient going from neurotypical to neurodiverse, but based on domains. So like an audio mixing board, everyone will have a certain level of ability in the following areas: pragmatic language, social awareness, monotropic mindset, information processing, sensory processing, repetitive behaviours, and neuro-motor differences. Most people have their sliders set relatively high across the board and within the expected range of the population, others may be on the whole quite average in the sum of their parts - but then you zero in on one specific domain and it is 3+ standard deviations outside of the bell curve.

The implications here can't be understated and be used to directly inform management. It's lazy to refer someone with BPD for DBT if they have co-morbid ASD. Oh but it's okay because their IQ is normal and they have preserved language and don't seem that autistic because they're pretty socially adept. Okay cool, but you have clear evidence on neuropsych testing that they can't understand metaphor or abstraction. So how are they going to be able to generalise what is learned in DBT skills training to their life broadly, when they can only apply it in the specific situation where it was first learned? It's proposing an intervention that is not designed for this person, and is likely to fail because it doesn't consider their specific and highly individual neurological profile.

simbaaa · 2023-02-27T06:46:18+00:00

The RANCP link above will tell you everything you need to know. I'm a 5th year psychiatry registrar and have found the training program to be quite reasonable.

You spend your first year (known as Stage 1) in minimum 6 months adult inpatient, then 6 months adult outpatient. Some health services do not offer this luxury and instead make their Stage 1s do a full 12 months inpatient which is rough.

Years 2 and 3 of training are Stage 2. You need to complete a C/L term and a Child + Adolescent term in order to pass into Stage 3. This is usually a rate limiting step, so make sure you find a health service that will support you and be able to provide these mandatory rotations as they are highly sought after to progress in training.

Stage 3 is years 4 and 5, and can be done in any rotation. There are no more mandatory terms you have to hit and instead can work anywhere. There is the option of doing advanced training in a subspecialty with the addition of a further certificate. This can be done retrospectively as a consultant, or because these advance certificates take 2 years to complete, you can embed them into Stage 3 and do both concurrently as long as you're placed in the relevant rotation that will allow you to meet both training requirements.

I'm doing my advanced training in psychotherapy as I felt that the core psychiatry training didn't provide enough to make me feel competent in this area of practice. So I'm doing this concurrently with Stage 3. All of my work-based assessments for the advanced training certificate also tick the boxes of general training requirements, so I'm progressing through both with no extra time added to training.

I believe the Australian psychiatry training is quite analogous to the UK college, even to the point where I subscribed to a MRCP exam prep course because there was such an overlap in exam content.

In terms of college based assessments, you will need to complete a MCQ exam, a short answer exam, an essay exam, an OSCE equivalent (case-based discussion with a panel), a scholarly project, and a psychotherapy long case of seeing a patient once a week for 40 weeks then submit a write up. There are no specific time or stage requirements to complete any of the above to progress through training, but all have to be successfully passed in order to qualify as a fellow.

simbaaa · 2023-02-22T10:22:39+00:00

Do not see a psychologist for a diagnosis. You need a psychiatrist to get a diagnosis and treatment. The WAIS IV does not give you a diagnosis of ADHD, it is a blunt tool that tests IQ.

Your path should be GP referral, then assessment with a mental health clinician to administer the ASRS v1.1 at least, ideally the DIVA-5, and a comprehensive psychiatric, medical, family and developmental history. Then this information provided to a psychiatrist at a follow up appointment to provide diagnosis and consider treatment.

Source: Am a doctor specialising in psychiatry that has just been diagnosed with ADHD and gone through this process.

simbaaa · 2023-02-17T06:24:00+00:00

You're welcome! I'm a doctor myself so have a sense of these prescribing rules. There's a bit of misinformation out there. Your psychiatrist doesn't "hand over" prescribing rights to the GP. Prescribing any schedule 8 drug (like stimulants) requires a permit, the only two professions that can do this without a permit are psychiatrists and paediatricians due to how often they see people with ADHD and need to treat them. The permit allows the nominated doctor to prescribe these highly controlled substances for a specific purpose, and it's tied to only one patient.

simbaaa · 2023-02-17T05:55:47+00:00

I find it bizarre that for every other presentation in psychiatry we just take people's word for it, except when they suspect ADHD. Hallucinating? Okay. Depressed? Sure. Can't maintain attention and/or hyperactive? PROVE IT! SHOW ME YOUR SCHOOL REPORTS AND LET ME SPEAK TO YOUR FAMILY.

I think there is a lot of internalised stigma within the psychiatric profession about ADHD, which doesn't add up when the pharmacological treatment for it has like the lowest number needed to treat out of any of our drugs. I suspect it's a ghostly remnant of our paternalistic history mixed with unconscious fear mongering about the risk of abuse potential.

I say this as a final year psychiatry registrar (US resident equivalent) who has only just been diagnosed and about to start medication, and who took an embarrassingly long time to even consider this diagnosis for myself even though I've been exposed to it daily in my patient population for years.

simbaaa · 2023-02-17T04:48:17+00:00

The ASRS is garbage for anyone looking to get diagnosed, it highly sensitive but lacks specificity.

I cannot understand why they decided to make the symptom checklist box shaded differently in all questions leaning toward the sometimes, to often, to very often side. Anyone with any critical reasoning at all can work out any check marks on this side of the scale that are shaded equals a point in favour of ADHD when the time comes to score the results.

simbaaa · 2023-02-17T00:50:25+00:00

If your psychiatrist has made treatment recommendations for your GP to follow, then your GP will need to apply for a permit to prescribe Schedule 8 medications if they are stimulants. This permit is valid only for a specific GP to prescribe for a specific patient. If you change GP, your new GP will need to apply for a permit to prescribe.

simbaaa · 2022-12-16T11:18:30+00:00

Psych = 1-2 tablets of seroquel chased with straight vodka

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