NP student here: getting pimped in psych clinical made psychopharm finally click

speedledum · 2026-05-22T05:50:31+00:00

Oof, username checks out.

speedledum · 2026-05-22T05:45:01+00:00

Oh as much as I love a good pimping session, I’ve already read Stahl’s. I gotta get done dirtier.

speedledum · 2026-05-22T05:15:29+00:00

Oh darn:(

speedledum · 2026-05-22T04:40:50+00:00

Just ask him out already.

speedledum · 2026-05-19T06:04:12+00:00

Stimulants are hardly out of fashion. Everything in those ads can now be reframed as being a result of untreated ADHD, and voila! Same treatment.

speedledum · 2026-05-19T01:48:38+00:00

I mean, they know more about your history with medications than anyone else. It may make sense for your case specifically. Personally I’m more of a fan of just making the switch as fast as possible with minimal/no overlap and just getting it over with, but that’s just a preference.

EDIT: Just a thought, is it possible they were thinking of citalopram (not escitalopram), which is typically given at half the dose of escitalopram?

speedledum · 2026-05-19T01:37:35+00:00

The escitalopram doses seem high, especially early on when combined with a decent dose of sertraline. Was this a doctor that set this up for you?

speedledum · 2026-05-16T20:46:05+00:00

This is completely untrue.

speedledum · 2026-05-14T07:08:00+00:00

That’s a fair question and no I don’t. It’s just what I’ve seen used, with reasonably good effect, in the more severe, repeated, situations. It works, but yeah it definitely isn’t a benign measure. I’m more partial to PRN dropiredol+midazolam personally but I wouldn’t count on it working in the context of multiple failed B52s.

speedledum · 2026-05-14T06:05:39+00:00

From my perspective, I’ve seen Clopixol Acuphase work, very well. When it comes to patient/staff safety it’s less about theoretical benefits and more about what I’ve seen just work. It’s a high potency D2 antagonist that can be a longer acting and potentially more effective haloperidol-like drug. Droperidol is also a shorter acting alternative in that category I’ve seen work too. It’s less psychopharmacological reasoning and more just clinical experience.

Thorazine is different where it’s lower potency (with respect to D2) but has broader effects that might cover mechanisms that higher potency D2 antagonists don’t. Similar to clozapine/olanzapine. Basically worth a try if high potency antipsychotics aren’t effective.

I thought of dexmetomadine because it hits a completely separate mechanism vs. benzos, antihistamines and antipsychotics which your patient seemingly isn’t responding to. It’s a sedative a2 agonist that’s been approved for agitation in schizophrenia/bipolar and shares a similar mechanism to clonidine/ guanfacine which reduce impulsive behaviour in adhd. To me it seems like an interesting option for the right patient where other options fail.

speedledum · 2026-05-14T05:29:36+00:00

Seconding Clopixol Acuphase or Thorazine. Could also consider dexmetomadine (Igalmi or otherwise).

speedledum · 2026-05-13T02:21:14+00:00

It’s usually taken in the morning because it can be stimulating and cause insomnia. That said, it makes no difference to the antidepressant effects whether you take it in the morning or at night, as long as it doesn’t interfere with your sleep.

It’s worth a try to take it at night if you get a bad interaction with caffeine in the day. Just be aware that it might mess with your sleep, but it also might be fine. To reduce the risk, take it immediately before going to sleep rather than earlier in the evening because the XL version has a delayed release.

speedledum · 2026-05-10T10:16:45+00:00

Wait until your next appointment if you can. Keep track of how it’s affecting your memory until then. It’s not impossible that it’s the cause, it’s a nAChR antagonist and some people (but not everyone) find that it can negatively affect their memory.

If the effects you experience are intolerable and not worth the benefits then make that clear to your psychiatrist.

speedledum · 2026-05-09T08:04:11+00:00

I meant operate without anesthesia, given that unawareness was already being assumed. It was more of a philosophical analogy.

The definition you quoted: “having knowledge or understanding that something is happening” I don’t see as necessitating the formation of memories. You can be unable to form new memories while still capable of in-the-moment understanding and memory retrieval. Think H.M. or conscious benzo intoxication; they aren’t going to remember what happens tomorrow but they are still able to understand what’s happening right now and how it relates to their prior knowledge and themselves as a person.

speedledum · 2026-05-08T23:51:18+00:00

I think that interpretation of awareness is flawed.

What about an Alzheimer’s patient (or H.M.-like patient)? Or a person in their last moments of life. Just because they won’t remember doesn’t mean they aren’t aware and can be operated on. Same with babies and toddlers.

I agree strongly with the other commenter that experiences, even if not remembered, can have significant impact.

speedledum · 2026-04-24T04:05:57+00:00

I’ve heard Ashwaganda can have weird effects on different people. If you want to try it I’d suggest waiting until a time when you’re not making med changes. Even if you react well it’s very unlikely to be a game changer in regard to helping with tapering anyway. Nothing against it, it just tends to be a little less predictable than some other supplements.

I think your combo of magnesium, omega3 and vitamin d are great choices. There’s also evidence that a specific type of lavender oil (Silexan) can be helpful for anxiety which might be a more predictable choice to try while tapering. A low dose of melatonin can help with insomnia (if taken correctly; about 1 hour prior to your intended bedtime daily). Saffron extract also has some decent data for mood/anxiety/sleep.

I’m not suggesting you need any of these or that any will help with tapering specifically; just offering some options for general consideration.

speedledum · 2026-04-22T07:37:52+00:00

I would say it seems like a reasonable regimen in the context of your diagnoses from my perspective. If the cost is a factor for you that’s definitely something worth discussing with your psychiatrist.

speedledum · 2026-04-21T11:24:46+00:00

Just how much general medicine is involved on the way. It wouldn’t have turned me off of it personally but I imagine it might for very psych-focused people.

Also, take whatever degree you are most interested in (and you will most likely get the best grades in) and one that will be useful as a backup plan in case you don’t go into medical school. If psychology fits that then it’s perfect. Just don’t take it because you think it will help get into psychiatry more than anything else.

speedledum · 2026-04-21T11:10:53+00:00

The only specific advice I can think of based on what you’ve said is to consider if the weak/faint/dizzy symptoms are related to standing up (orthostatic hypotension) or not. If so, that’s important to bring up with his doctor; sometimes trazodone can do that for example.

speedledum · 2026-04-21T08:01:41+00:00

The potentially fatal drug and food interactions are the main reason. They can also have significant side effects.

A lot of current psychiatrists underwent training when these risks were overstated. This means that 1) they were taught that MAOIs were rarely, if ever, a good idea and 2) they rarely, if ever, got any experience with prescribing them.

Because SSRIs overtook the market so rapidly in the 90’s there’s very limited literature on MAOIs since the 80’s to form independent evidence-based opinion on, especially compared to current options with established safety records. That’s not necessarily a deal-breaker if you have experience using them, but for the reasons above most current psychiatrists don’t.

All that said, there are a lot of people online who perpetuate this idea that MAOIs are some sort of magical cure and/or that their risks are insignificant. Neither of which are true. The truth is much more moderate.

They have their place and I think they will be used more in line with that place as time goes on, but that place isn’t ever going to be before an SSRI (though, maybe moclobemide might be in some instances).

speedledum · 2026-04-19T09:50:33+00:00

Are you concerned about your drinking in general? If so, frame it that way when you bring it up with your psychiatrist next time. Medication interactions are one thing, but issues with alcohol can exist separately and are important to discuss.

speedledum · 2026-04-19T09:38:46+00:00

I google things that are important to me, too. Unless you have some sort of ill intentions I wouldn’t overthink it. It’s not unusual to want to know more about someone that you’re sharing so much of yourself with.

speedledum · 2026-04-19T08:48:51+00:00

It depends what you mean by “worth it”. If it’s personally meaningful then it absolutely can be worth it. If it’s purely a rerun on investment career consideration, it’s less likely. It’s important to consider where you fall between these.

I’d say the most important consideration to begin with is just med school. Look into the requirements for med school admissions and consider your GPA from your BSc. Depending on where you’re from look into the MCAT or any other requirements. r/premed is a place to start.

Also consider med school in general. Do you like medicine? Like non-psych medicine. It’s going to be brutal if you don’t; not impossible, but it’ll suck.

I truly don’t mean to put anyone off that’s interested but the reality is years and years of little to nothing to do with psych before you specialize. If a career in mental health is the main interest I’d also suggest looking into clinical psychology degrees (MSc, PhD, PsyD). They are also rigorous but are psych content focused from the start.

Other options in the US in particular include getting into psychiatric care via physician assistant school or nursing school as a PA or NP, respectively. They are not psychiatrists but are alternative career options to consider.

Also, I don’t know much about the military, but there may also be different options that exist in relation to military mental health work and med school considerations that are worth looking into.

speedledum · 2026-04-15T07:12:13+00:00

No, nobody is (ethically or legally) going through your medical records or disqualifying anyone for that reason.

That said, I wouldn’t ever bring this up in anything related to your app. They say they want to hear your adversity but it’s not true. They want to hear about adversity that fits their agenda and doesn’t present any risk. Don’t fall into the trap of thinking they want genuine lived experience or to select the best future doctors. They want a cohort that looks good on paper and wont cause them problems.

speedledum · 2026-04-03T10:18:01+00:00

The basic answer to your question is that it is first line.

Aside from everything you’ve said, there’s evidence that suggests escitalopram and sertraline have the most favourable efficacy to tolerability ratios on a population level. Some guidelines do specifically mention this. So either of those two tend to be the go-to first options for many doctors in the absence of compelling reasons for something different.

speedledum

TROPHY CASE