most ketamine clinics i see are a complete joke

[annoyedpsychiatrist]

They pop up like crazy around here, and give ketamine out like candy. They also offer other treatments such as vitamin infusions, peptide therapy, and other bull**** treatments (reading the list of treatments they offer from their website). In my state, they're even run by midlevel providers as well. This is becoming super popular here. I had a patient come to me today, clearly under the influence, fixated on me giving him ketamine because he couldn't afford the private ketamine clinics anymore and was tired of having to buy it from his friends who obtain it from various sources. I did not even realize that these clinics are doing intranasal ketamine, but not spravato, no induction or anything, just straight up prescriptions for ketamine, lmao.

I think im starting to slowly lose faith in medicine as we become littered with marijuana and ketamine clinics. Maybe one day well have meth and shrooms clinics.

---

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[Merovinge]

Seeing the gas and FM folks running these clinics without any psychiatry on board is so sad. Whatever FOMO trend is creating more money being pursued is so disappointing. It's one thing when the MBAs do it to pillage the land but seeing MDs do it somehow makes me feel worse.

 

[FlowRate]

This, non-evidence-based naturopathic, non-evidence-based "integrative," "MeRT" treatment, "hormone clinics" (legal steroids), "ADHD specialist clinics" (legal stims), etc. etc. It's all gross. Sure, the part of me that wishes I could optimize my financial situation would love to be earning 2-4x my current salary doing that sort of work, but I wouldn't be able to live with myself otherwise if I did.

Lots of therapists also starting up psilocybin therapy treatments without going through the MAPS training/doing the typical research protocols.

 

[Sushirolls]

These are the moments my thoughts stray to, whatever, people want their magic weed etc, let's just legalize it all. Get rid of the DEA, just... "RELEASE THE KRAKEN!!!"

And we'll be there ready to assist people who want real treatments, and are truly ready after they've run their lives through the grinder. Less effort of motivational interviewing on our part.

Release the kraken... just maybe.

 

[romanticscience]

Lots of therapists also starting up psilocybin therapy treatments

The Perilous Policy of Oregon’s Psilocybin Services

Psilocybin and other psychedelic compounds have the potential to treat psychiatric disorders in a radically different manner than traditional psychopharmaceuticals.[1][1] Their ability to alter neural connectivity in the cortex and to transform an individual’s conscious experience suggests that

jaapl.org

 

[FlowRate]

These are the moments my thoughts stray to, whatever, people want their magic weed etc, let's just legalize it all. Get rid of the DEA, just... "RELEASE THE KRAKEN!!!"

And we'll be there ready to assist people who want real treatments, and are truly ready after they've run their lives through the grinder. Less effort of motivational interviewing on our part.

Release the kraken... just maybe.

Okay not to derail this thread but this is how I feel about stimulants sometimes. Make them a "behind the counter" med like pseudoephedrine. Strict monthly monitored qty limits. Just leave me out of the whole "I was president of Harvard Law Review and have reached senior partner at $biglawfirm$ but just realized I have had ADHD my whole life but my parents didn't want me to get treated when I was a kid. I have trouble doing things and bounce between dishes and laundry and other chores and never get anything done." Song and dance.

 

[erg923]

Okay not to derail this thread but this is how I feel about stimulants sometimes. Make them a "behind the counter" med like pseudoephedrine. Strict monthly monitored qty limits. Just leave me out of the whole "I was president of Harvard Law Review and have reached senior partner at $biglawfirm$ but just realized I have had ADHD my whole life but my parents didn't want me to get treated when I was a kid. I have trouble doing things and bounce between dishes and laundry and other chores and never get anything done." Song and dance.

Hi docs/mods,

Can we start another thread about the disagreement amongst, presumably well trained psychiatrists that argues 1.) ADHD is largely underdiagnosed. 2.) Stimulant are the the most effective treatment/psychotropic we have for any psychiatric disorder in history and outcomes prove it and are "raising the roof" compared to many of our other disorder treatments. 3.) Some over prescribing happens but is inevitable and is nothing to panic about.

Compared to the seemingly equal amount of opinions from presumably well trained psychiatrists, that argues: 1. ADHD is grossly over diagnosed...ADHD is real but somewhat made up. 2. Many people treated for ADHD remain a hot mess of various psychiatric symptoms and dysfunction. 2.) The current trend of prescribing stimulants in this country is "out of control" and poses a significant health risk. 3. Over prescribing is rampant and leads to iatrogenic addition or mental illness.

 

[Sushirolls]

I see what you did there...
But I'm not circling C, all the above.
I'm not circling D, the throw away answer, that ADHD should only be diagnosed by a psychologist doing limited testing, without NeuroPsych fellowships, or ARNPs only equipped with and Adult ADHD rating scale, or patients self diagnosing with TikTok.

The correct answer is still B. *overly diagnosed*

 

[erg923]

I see what you did there...
But I'm not circling C, all the above.
I'm not circling D, the throw away answer, that ADHD should only be diagnosed by a psychologist doing limited testing, without NeuroPsych fellowships, or ARNPs only equipped with and Adult ADHD rating scale, or patients self diagnosing with TikTok.

The correct answer is still B. *overly diagnosed*

It's not a multiple choice test, gramps. Just say what you feel (or can prove preferably). Don't make it more complicated than it needs to be.

 

[SmallBird]

Hi docs/mods,

Can we start another thread about the disagreement amongst, presumably well trained psychiatrists that argues 1.) ADHD is largely underdiagnosed. 2.) Stimulant are the the most effective treatment/psychotropic we have for any psychiatric disorder in history and outcomes prove it and are "raising the roof" compared to many of our other disorder treatments. 3.) Some over prescribing happens but is inevitable and is nothing to panic about.

Compared to the seemingly equal amount of opinions from presumably well trained psychiatrists, that argues: 1. ADHD is grossly over diagnosed...ADHD is real but somewhat made up. 2. Many people treated for ADHD remain a hot mess of various psychiatric symptoms and dysfunction. 2.) The current trend of prescribing stimulants in this country is "out of control" and poses a significant health risk. 3. Over prescribing is rampant and leads to iatrogenic addition or mental illness.

Very specific dichotomy, I don't really find either resonating.

 

[erg923]

Very specific dichotomy, I don't really find either resonating.

Yea man. That's the whole point for the separate thread.

 

[Stagg737]

It's not a multiple choice test, gramps. Just say what you feel (or can prove preferably). Don't make it more complicated than it needs to be.

1. ADHD is under-diagnosed in the sense that many people who probably legitimately have it aren't being treated for it and would benefit from *some* kind of treatment (not necessarily stimulants).

2. ADHD is over-diagnosed in the sense that the primary symptoms that people are distressed by (poor concentration and problems staying on task/finishing tasks) can be caused by many psych disorders or even simple boredom and are easily conveyed to a clinician.

3. There's a lot of crappy diagnosticians or burnt out docs who hear the correct checklist and give a diagnosis without really caring because they're either burnt out or see $$$.

4. Stimulants are one of the best treatment options in our field for patients who are actually correctly diagnosed and are dramatically life altering for those on appropriate regimens. They may also be beneficial for some other disorders which further muddies the waters (depression augmentation).

5. Stimulants have physiologic and psychological effects that people even without certain disorders enjoy or find helpful but have a high abuse/addiction potential and can be very dangerous when not taken appropriately (and sometimes when taken appropriately).

A. Most psychiatrists I know would probably agree with all of the above statements, but find some of them to be far more common/true than others.

B. The standard of care for how we practice is pathetically low, which becomes problematic when meds like stimulants are involved, and frankly a large percentage of MH clinicians frankly aren't good enough to be doing what we do.

C. Society doesn't understand any of this and doesn't really care to. Just fix Timmy. Or Tim if he doesn't live with mommy and daddy anymore.

 

[erg923]

1. ADHD is under-diagnosed in the sense that many people who probably legitimately have it aren't being treated for it and would benefit from *some* kind of treatment (not necessarily stimulants).

2. ADHD is over-diagnosed in the sense that the primary symptoms that people are distressed by (poor concentration and problems staying on task/finishing tasks) can be caused by many psych disorders or even simple boredom and are easily conveyed to a clinician.

3. There's a lot of crappy diagnosticians or burnt out docs who hear the correct checklist and give a diagnosis without really caring because they're either burnt out or see $$$.

4. Stimulants are one of the best treatment options in our field for patients who are actually correctly diagnosed and are dramatically life altering for those on appropriate regimens. They may also be beneficial for some other disorders which further muddies the waters (depression augmentation).

5. Stimulants have physiologic and psychological effects that people even without certain disorders enjoy or find helpful but have a high abuse/addiction potential and can be very dangerous when not taken appropriately (and sometimes when taken appropriately).

A. Most psychiatrists I know would probably agree with all of the above statements, but find some of them to be far more common/true than others.

B. The standard of care for how we practice is pathetically low, which becomes problematic when meds like stimulants are involved, and frankly a large percentage of MH clinicians frankly aren't good enough to be doing what we do.

C. Society doesn't understand any of this and doesn't really care to. Just fix Timmy. Or Tim if he doesn't live with mommy and daddy anymore.

Great job, grampa! Make it a thread! How bout that?

 

[shoomer]

They pop up like crazy around here, and give ketamine out like candy. They also offer other treatments such as vitamin infusions, peptide therapy, and other bull**** treatments (reading the list of treatments they offer from their website). In my state, they're even run by midlevel providers as well. This is becoming super popular here. I had a patient come to me today, clearly under the influence, fixated on me giving him ketamine because he couldn't afford the private ketamine clinics anymore and was tired of having to buy it from his friends who obtain it from various sources. I did not even realize that these clinics are doing intranasal ketamine, but not spravato, no induction or anything, just straight up prescriptions for ketamine, lmao.

I think im starting to slowly lose faith in medicine as we become littered with marijuana and ketamine clinics. Maybe one day well have meth and shrooms clinics.

The ketamine clinics are a huge problem. It's essentially quackery so much of the time because I see patients get them despite obvious contraindications just because whoever's administering the treatment can't turn down a quick buck. Psilocybin clinics will join the club eventually, I'm sure of it.

Okay not to derail this thread but this is how I feel about stimulants sometimes.

Looks like you have derailed the thread successfully lol

 

[SmallBird]

The ketamine clinics are a huge problem. It's essentially quackery so much of the time because I see patients get them despite obvious contraindications just because whoever's administering the treatment can't turn down a quick buck. Psilocybin clinics will join the club eventually, I'm sure of it.


Looks like you have derailed the thread successfully lol

The psilocybin thing is worse in that it might not work for most of the things it's being tried for. Ketamine is quite effective it seems.

 

[FlowRate]

Hi docs/mods,

Can we start another thread about the disagreement amongst, presumably well trained psychiatrists that argues 1.) ADHD is largely underdiagnosed. 2.) Stimulant are the the most effective treatment/psychotropic we have for any psychiatric disorder in history and outcomes prove it and are "raising the roof" compared to many of our other disorder treatments. 3.) Some over prescribing happens but is inevitable and is nothing to panic about.

Compared to the seemingly equal amount of opinions from presumably well trained psychiatrists, that argues: 1. ADHD is grossly over diagnosed...ADHD is real but somewhat made up. 2. Many people treated for ADHD remain a hot mess of various psychiatric symptoms and dysfunction. 2.) The current trend of prescribing stimulants in this country is "out of control" and poses a significant health risk. 3. Over prescribing is rampant and leads to iatrogenic addition or mental illness.

Like Stagg was saying, it's not a dichotomy, it's a dialectic. Both are true. We don't see/aren't directly "bothered" by the undiagnosed patients that aren't presenting to us (and it's fun to treat patients with true ADHD when they do see us) so it's natural to talk (complain) more about the latter, which we are objectively seeing way more of in the past 5 years than ever before (see: spike in rates of stimulant prescribing, increased volume of "ADHD" as chief complaint for adult new patient evals.)

 

[ObsequiousAplomb]

The psilocybin thing is worse in that it might not work for most of the things it's being tried for. Ketamine is quite effective it seems.

The evidence seems to indicate the exact opposite of what you just claimed. Weird.

 

[annoyedpsychiatrist]

Seeing the gas and FM folks running these clinics without any psychiatry on board is so sad. Whatever FOMO trend is creating more money being pursued is so disappointing, completely agree. It's one thing when the MBAs do it to pillage the land but seeing MDs do it somehow makes me worse.

i was thinking the same thing...

The psilocybin thing is worse in that it might not work for most of the things it's being tried for. Ketamine is quite effective it seems.

IV ketamine infusions are great. You feel good temporarily after each one, then when you run out of money/after they drain your bank account dry, you have to go back to facing reality/real life poorly equipped to handle it. So then you illicitly obtain ketamine and other similar things however you can.

When you go to the ER with a nail in your hand, is the most effective treatment to help the patient remove the nail, or to give them pain medications and send them home with the nail in their hand and no way of overcoming that besides temporary relief?

 

[romanticscience]

Well-trained psychiatrists also get upset because we are responsible for treating a condition that has high rates of malingering (how do you confront a person with that; we're not trained for this) with a treatment that also has legal consequences for its diversion/misuse. Also, one of us got shot for not prescribing a controlled substance to a patient who determined "he needed it."

This scenario does not apply to non-prescribing therapists. It really frustrates me because as much as I attempt to be patient-centered or "meet the patient where they are," there are legal ramifications, and the law "is in the room with us." Correct me if I'm wrong, but have psychologists had patients get angry with them after their testing, demanding it to be changed to reflect X diagnosis?

Psychiatrists hate risk, and most (not me) hate the forensic aspects of practice.

Sorry for the rant! I just had a patient want me to send in a prescription early for clonazepam. They said, "Can we just say I need more for anxiety?" When I asked what happened, they said, "I think my friend stole some." After telling them I might have to report that to the DEA, they went radio silent. This is not medicine; this is like pseudo-law enforcement.

 

[vanfanal]

i was thinking the same thing...


IV ketamine infusions are great. You feel good temporarily after each one, then when you run out of money/after they drain your bank account dry, you have to go back to facing reality/real life poorly equipped to handle it. So then you illicitly obtain ketamine and other similar things however you can.

When you go to the ER with a nail in your hand, is the most effective treatment to help the patient remove the nail, or to give them pain medications and send them home with the nail in their hand and no way of overcoming that besides temporary relief?

I like this. Just as ketamine is a dissociative anaesthectic, blocking the pain signals at the level of the sensory cortex; for MH patients it dissociates you from your troubles or stressors. Then bam, back to reality. Hence the short duration of effect.

I’m also appalled by the number of patients I have with addictions who are getting these treatments. Are these ketamine’s clinics not doing a thorough assessment that they can see the patient has a history of substance abuse, they’re on naltrexone or PDMP shows suboxone- more likely they don’t care. They operate like if the patient says they feel depressed then they have depression, simple as that.

I also worry about what will happen with psilocybin therapy. It’s very liable to be misused for the experience and not for therapeutic effect. i hope the regulators can learn lessons from the current day mess that is ketamine and stimulants.

 

[vanfanal]

Well-trained psychiatrists also get upset because we are responsible for treating a condition that has high rates of malingering (how do you confront a person with that; we're not trained for this) with a treatment that also has legal consequences for its diversion/misuse. Also, one of us got shot for not prescribing a controlled substance to a patient who determined "he needed it."

This scenario does not apply to non-prescribing therapists. It really frustrates me because as much as I attempt to be patient-centered or "meet the patient where they are," there are legal ramifications, and the law "is in the room with us." Correct me if I'm wrong, but have psychologists had patients get angry with them after their testing, demanding it to be changed to reflect X diagnosis?

Psychiatrists hate risk, and most (not me) hate the forensic aspects of practice.

Sorry for the rant! I just had a patient want me to send in a prescription early for clonazepam. They said, "Can we just say I need more for anxiety?" When I asked what happened, they said, "I think my friend stole some." After telling them I might have to report that to the DEA, they went radio silent. This is not medicine; this is like pseudo-law enforcement.

Psych is easy and mucho ludcrative if you’re an idiot who doesn’t care.
But being a thoughtful psychiatrist is probably one of the most difficult jobs in medicine, if you don’t have a practice filled with equally thoughtful patients. I don’t think any other specialty deals with something as unpredictable and unquantifiable as human behaviour.

On the bad days, I wish I did something more procedural or rooted in diagnostic studies - just order the work up and follow the algorithm. But on the good days when I have a respectful and thoughtful patient, a nuanced diagnosis and a good treatment plan- it’s the best.

 

[ObsequiousAplomb]

I like this. Just as ketamine is a dissociative anaesthectic, blocking the pain signals at the level of the sensory cortex; for MH patients it dissociates you from your troubles or stressors. Then bam, back to reality. Hence the short duration of effect.

I’m also appalled by the number of patients I have with addictions who are getting these treatments. Are these ketamine’s clinics not doing a thorough assessment that they can see the patient has a history of substance abuse, they’re on naltrexone or PDMP shows suboxone- more likely they don’t care. They operate like if the patient says they feel depressed then they have depression, simple as that.

I also worry about what will happen with psilocybin therapy. It’s very liable to be misused for the experience and not for therapeutic effect. i hope the regulators can learn lessons from the current day mess that is ketamine and stimulants.

Are you sure they aren't saying they are also treating the opioid use disorder with the Ketamine? While not FDA approved, one can certainly justify it in the literature as an off-label treatment.

 

[clausewitz2]

They pop up like crazy around here, and give ketamine out like candy. They also offer other treatments such as vitamin infusions, peptide therapy, and other bull**** treatments (reading the list of treatments they offer from their website). In my state, they're even run by midlevel providers as well. This is becoming super popular here. I had a patient come to me today, clearly under the influence, fixated on me giving him ketamine because he couldn't afford the private ketamine clinics anymore and was tired of having to buy it from his friends who obtain it from various sources. I did not even realize that these clinics are doing intranasal ketamine, but not spravato, no induction or anything, just straight up prescriptions for ketamine, lmao.

I think im starting to slowly lose faith in medicine as we become littered with marijuana and ketamine clinics. Maybe one day well have meth and shrooms clinics.

Well-trained psychiatrists also get upset because we are responsible for treating a condition that has high rates of malingering (how do you confront a person with that; we're not trained for this) with a treatment that also has legal consequences for its diversion/misuse. Also, one of us got shot for not prescribing a controlled substance to a patient who determined "he needed it."

This scenario does not apply to non-prescribing therapists. It really frustrates me because as much as I attempt to be patient-centered or "meet the patient where they are," there are legal ramifications, and the law "is in the room with us." Correct me if I'm wrong, but have psychologists had patients get angry with them after their testing, demanding it to be changed to reflect X diagnosis?

Psychiatrists hate risk, and most (not me) hate the forensic aspects of practice.

Sorry for the rant! I just had a patient want me to send in a prescription early for clonazepam. They said, "Can we just say I need more for anxiety?" When I asked what happened, they said, "I think my friend stole some." After telling them I might have to report that to the DEA, they went radio silent. This is not medicine; this is like pseudo-law enforcement.

You might want to take a gander at the many, many posts over in the psychology forum about PTSD at the VA.

 

[FlowRate]

Well-trained psychiatrists also get upset because we are responsible for treating a condition that has high rates of malingering (how do you confront a person with that; we're not trained for this) with a treatment that also has legal consequences for its diversion/misuse. Also, one of us got shot for not prescribing a controlled substance to a patient who determined "he needed it."

This scenario does not apply to non-prescribing therapists. It really frustrates me because as much as I attempt to be patient-centered or "meet the patient where they are," there are legal ramifications, and the law "is in the room with us." Correct me if I'm wrong, but have psychologists had patients get angry with them after their testing, demanding it to be changed to reflect X diagnosis?

Psychiatrists hate risk, and most (not me) hate the forensic aspects of practice.

Sorry for the rant! I just had a patient want me to send in a prescription early for clonazepam. They said, "Can we just say I need more for anxiety?" When I asked what happened, they said, "I think my friend stole some." After telling them I might have to report that to the DEA, they went radio silent. This is not medicine; this is like pseudo-law enforcement.

My theory for why every "ADHD" npsy eval I've ever seen has said "potentially compatible with ADHD," even when the actual testing does not seem particularly compatible and the npsy already identified many other reasons to have inattention, is that yes, patients do get upset when they pay $4k and don't get their "confirmation" of ADHD.