Psychiatry under fire from the White House

[jbomba]

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Where are you located that ECT is so easy to get? That is not my experience in multiple large, urban areas. TMS for the average person, not a chance. Who has that kind of time?

This is what I am thinking will happen. The bottom 50% are looking for a savior, and it doesn’t appear they will get it from the current administration, so an AOC or one of the other super progressives, Saunders may be too old, could be the antidote people reach for to save the day.

And this is the problem. We need to get back to some level of normalcy. Living in the extremes is not the answer. AOC is not the answer. Give me a center right, non-maga republican, with socially liberal values, and they have my vote every time.

But Donald Trump is the great divider and he creates extremes on the left as well as the right.

The pendulum swings too far left and right nowadays, and I don't see how things stop at the pace they are on.


But for the record, I take AOC over Trump 100 out of 100 times. Not that I'm at all happy about it.

 

[Cath Up]

Ipse Dixit is never an appropriate response, unless you are parenting your child. I wish I was a parent... one day, I hope.

I am not arguing ipse dixit. Who do you go to for your taxes? A pilot? Who do you go to for legal problems, a gardener? People with expertise possess both real knowledge and gestalt. We ought to have an expert about HEALTH and HUMAN SERVICES in charge of HHS, not someone who thinks vaccines cause autism and people just need to eat healthily. This decade long refrain: “well this [person from industry] doesn’t make sense for government based on prior norms but when you really consider it they could bring a fresh perspective to [industry they have spent their entire career avoiding regulations for]” is just propaganda to enact regulatory capture.

 

[tr]

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

Anything with addictive potential is annoying to prescribe. Both because of the medicolegal concerns and because there will invariably be annoying patient behavior. That doesn't necessarily mean that the risks are 'underestimated,' or that the benefits don't/can't outweigh the risks in any given situation.

 

[2025DandW]

I was digging through data, inflation adjusted salaries from 2005 to today are essentially the same. In 2025 dollars 3-325k a year.

How was it that pay essentially stayed the same?

I have a 2009 MGMA for the mid-West and based on that inflation adjusted salaries should be about $335-350K if I remember correctly,

 

[2025DandW]

I was at a conference last week, and one of the speakers advised caution in the use of valproic acid in MEN under 55, due to the approximately 1.5 risk of neurodevelopment abnormalities (neurodevelopmental abnormalities included autism and adhd and several others); vpa appears to damage sperm Understanding the impact of valproate on male fertility: insights from preclinical and clinical meta-analysis - PubMed . I don't think it's necessarily wrong to have a commission look further into the use of psych drugs in children, although I can understand the concern that the commission might go overboard.

RFK, Jr was certainly an interesting cabinet pick.... with concerns on both the left and right (and the center).

As far as vaccines, as long as he doesn't mess with any vaccine that came out before 9/11/2001, I will be happy.

Obviously, we already have people doing the studies. How do you think they determined the information you presented? How much sense does it make to throw everything out and start all over again?

 

[Mad Jack]

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

What are your supposed concerns that have not been covered by the last 64 years of data? What risk is present that outweighs the benefit of a 31% reduction in substance use in a population that has triple the rate of substance use of the general population when untreated?

What is your actual concern? Death? Disability? Incarceration rates? Those have been studied to death, and all are worse with regard to outcomes than untreated ADHD. So what are you worried about, exactly?

I think there is a case to be made that overdiagnosis of ADHD has led to people being on stimulants that shouldn't be, perhaps a substantial population even. And there are a lot of people who come seeking stimulants for other issues related to cognition that don't have ADHD at all, either because they abuse stimulants and want a legal fix or because they don't understand that many things aside from ADHD can impair cognition (these two types of patients are the reason many adult providers don't want to deal with stimulants, generally). But to say, "oh we haven't studied the risks of stimulants enough" just clearly speaks to one not understanding the already existing deluge of research with regard to stimulant outcomes and safety. How many more dozens of studies do you want than the ones we already have?

 

[allantois]

Best case scenario he limits the prescribing of psychotropics to psychiatrists limiting psychologists and APRNs scope creep.

Worst case scenario psychiatry as a field is decimated and stigmatized.

Really? Most psychotropics in this country are prescribed by PCPs

 

[Crayola227]

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

But the argument here is that it seems we are talking about 2 different populations. One who has the diagnosis and can benefit, and one who maybe evidently does not, the evidence being lack of benefit and harms.

Example, thyroid hormone. If I give it to the right person, it's safe and great. If I have a misdiagnosis, then it will awful.

So it really begs more of a question about differentiating those who can benefit and those who will not. Which certainly is always going to be a very important part of medicine. Presumably the studies showing so much safety did this well. It's always more difficult in practice.

 

[lobstar]

But the argument here is that it seems we are talking about 2 different populations. One who has the diagnosis and can benefit, and one who maybe evidently does not, the evidence being lack of benefit and harms.

Example, thyroid hormone. If I give it to the right person, it's safe and great. If I have a misdiagnosis, then it will awful.

So it really begs more of a question about differentiating those who can benefit and those who will not. Which certainly is always going to be a very important part of medicine. Presumably the studies showing so much safety did this well. It's always more difficult in practice.

I that is perhaps the case. Like, yes, more safety data is basically irrelevant for these people causing MVCs and ending up in the ED all the time with untreated ADHD. Some of the European study data for these outcomes on safety explicitly talk about how the bar for an ADHD diagnosis in say, some small homogeneous European county, is significantly higher than in the US. We know substance use disorders are under-diagnosed, particularly when in the mild range. These chart review studies looking at a CPT code for SUD or a hospitalization or something--that will miss lots of people. I think there's a difference in the populations used for these studies with slam dunk ADHD and what happens on a grander scale in the USA where more or less anybody can have an ADHD diagnosis and a stimulant if they are evaluated a couple times.

 

[trophyhusband]

Tons of jobs, much lower pay was my understanding. This led to much less interest in the field and it being a specialty of last resort for many, as the pay was quite low. Parity, however, is enshrined in law and won't be undone unless the ACA is, which would be quite the undertaking, and even then I would imagine strong advocacy for continued parity

You're assuming that even if the ACA exists that there will be anyone left to enforce its provisions. I would not bet my house on that. Parity is only worthwhile if someone is actually going to enforce it.

My guess is that anything they can get rid of legislatively they'll just ignore enforcement of which effectively makes it useless.

 

[calvnandhobbs68]

You're assuming that even if the ACA exists that there will be anyone left to enforce its provisions. I would not bet my house on that. Parity is only worthwhile if someone is actually going to enforce it.

My guess is that anything they can get rid of legislatively they'll just ignore enforcement of which effectively makes it useless.

Insurance plans are also regulated on a state level though. So yes I could see actual enforcement starting to fall along party lines depending on the state. I guess then giving another group of doctors yet another reason to leave those states lol.

Courts can also impose judgements against insurance plans that fail to comply with provisions if they still stand. See:

Patient Wins Appeal Bringing Back Parity Lawsuit Against UnitedHealthcare

A federal appeals court revived a lawsuit alleging UnitedHealthcare violated federal behavioral health parity and insurance fiduciary laws. On April

bhbusiness.com

 

[VA Hopeful Dr]

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

I don't think many here have issues with kids and ADHD.

It's the adults seeking stimulants that are the issue.

 

[trophyhusband]

Insurance plans are also regulated on a state level though. So yes I could see actual enforcement starting to fall along party lines depending on the state. I guess then giving another group of doctors yet another reason to leave those states lol.

Courts can also impose judgements against insurance plans that fail to comply with provisions if they still stand. See:

Patient Wins Appeal Bringing Back Parity Lawsuit Against UnitedHealthcare

A federal appeals court revived a lawsuit alleging UnitedHealthcare violated federal behavioral health parity and insurance fiduciary laws. On April

bhbusiness.com

State insurance departments don't enforce federal statutes. They enforce their state statues so yes a state can enact and and enforce parity laws at a state level if they were so inclined. But I don't know how many will.

Courts can impose judgements yes but it's generally up to the Executive branch to enforce compliance with those judgements... will they? We'll see.

 

[calvnandhobbs68]

State insurance departments don't enforce federal statutes. They enforce their state statues so yes a state can enact and and enforce parity laws at a state level if they were so inclined. But I don't know how many will.

Courts can impose judgements yes but it's generally up to the Executive branch to enforce compliance with those judgements... will they? We'll see.

I get where you're coming from and that's generally true for federal vs state law but not in these cases basically due to the fact that insurance is overall regulated at the state level still. For example:

Mental Health and Substance Use: State and Federal Oversight of Compliance with Parity Requirements Varies

Before 2008, many health insurance plans provided lower benefits for mental health care than other types of medical care. Congress set parity...

www.gao.gov

"State agencies and the Departments of Labor (DOL) and Health and Human Services (HHS) share responsibility for overseeing compliance with these MH/SU parity requirements among group and individual health plans. These oversight practices vary."

Enforcing Mental Health Parity: State Options to Improve Access to Care

This brief looks at enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 10 states.

www.commonwealthfund.org

"The federal government has provided guidance and tools to help insurers and group health plans meet their responsibilities under the law. But in most cases, state insurance regulators are responsible for monitoring insurer compliance with the MHPAEA within their state’s individual and group markets"

So basically states can take it upon themselves to police enforcement more if they want.

 

[trophyhusband]

I get where you're coming from and that's generally true for federal vs state law but not in these cases basically due to the fact that insurance is overall regulated at the state level still. For example:

Mental Health and Substance Use: State and Federal Oversight of Compliance with Parity Requirements Varies

Before 2008, many health insurance plans provided lower benefits for mental health care than other types of medical care. Congress set parity...

www.gao.gov

"State agencies and the Departments of Labor (DOL) and Health and Human Services (HHS) share responsibility for overseeing compliance with these MH/SU parity requirements among group and individual health plans. These oversight practices vary."

Enforcing Mental Health Parity: State Options to Improve Access to Care

This brief looks at enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 10 states.

www.commonwealthfund.org

"The federal government has provided guidance and tools to help insurers and group health plans meet their responsibilities under the law. But in most cases, state insurance regulators are responsible for monitoring insurer compliance with the MHPAEA within their state’s individual and group markets"

So basically states can take it upon themselves to police enforcement more if they want.

So yes and no. I should have been more precise. The states cannot regulate self-funded insurance plans which more and more large employers are moving to... those are regulated by DOL. As of 2017 about 60% of employees under employer provided plans were self-funded and it's probably higher now.

But other employer plans and individual plans are jointly regulated. If they remove the marketplace subsidies these plans will be a smaller and smaller part of the market.

So the states can try to enforce it on a small portion of the market but then you're just going to be creating confusion on what plans it actually applies to and maybe chase companies away from your state.

Basically I wouldn't count on states to save you.

 

[clausewitz2]

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

I think this has a lot more to do with the interpersonal dynamics of clinical visits associated with patients who are very fixated on being prescribed a particular molecule and adult-trained psychiatrists who don't feel particularly well-equipped to assess the legitimate need for that molecule in the first place. This is not the same as a rational and careful assessment of long-term risks. That is to say, it's because these clinical encounters can be super annoying, not because the drugs are super toxic at therapeutic doses.

I don't mind so much having to explain to someone why I'm not going to prescribe stimulants to them but then I feel competent assessing ADHD in adults, have my own clear protocol about how to treat it, and I don't have to worry about Press-Gainey scores or any of that nonsense. I also work in OCDland a lot so I'm very comfortable being therapeutically withholding, so there's probably a temperament issue as well.

 

[Mad Jack]

I don't think many here have issues with kids and ADHD.

It's the adults seeking stimulants that are the issue.

I think a lot of the problem is that kids with ADHD become adults with ADHD, and a great number of adult providers struggle with what to do with them

 

[Stagg737]

Midwestern Doc on Substack has written very nice (and extremely lengthy) articles on SSRIs. I would encourage a read. Here's are links:

The Hidden Dangers of Antidepressants and Why They're So Hard To Stop Taking

Unveiling the Depression Industry

www.midwesterndoctor.com

What They Don’t Tell You About Anxiety and The Dangers of Benzodiazepines

The forgotten treatments for anxiety and the immense dangers of inappropriately prescribed benzodiazepines

www.midwesterndoctor.com

The Dark Side of Antidepressants

Why are SSRIs so dangerous?

www.midwesterndoctor.com

The FDA's War Against Sleep

Exploring the Critical Importance of Sleep and the Treatments for Insomnia

www.midwesterndoctor.com

We don't need a psychiatrist skeptic attorney to tell the public that we're a corrupt profession, we've done that for ourselves already:

https://www.psychiatriapolska.pl/pdf-80136-81413?filename=Industry_corrupted.pdf

Edward Shorter has written a beautiful treatise on antidepressants before SSRIs, Shorter, Edward. Before Prozac: The troubled history of mood disorders in psychiatry. Oxford University Press, 2008. I would encourage a read.

How many other chairperson's of the American Psychiatric Association conducted experiments on human beings without their knowledge or consent? I know of just one, for now, Donald Ewen Cameron. Do we not deserve criticism for our failure to acknowledge the injustices we've done, as a profession, on our people? I cannot fault RFK Jr.

I'm sorry, but this person you're quoting is awful. I just skimmed the article on "the FDA's war against sleep" and it's absolutely BS. Arguing that pretty much every sleep medication out there is bad and that GHB, aka the date rape drug, should be the main thing we use and that it's super safe compared to other meds. I skimmed their main blog and it's full of memes about the dangers of SSRIs including how they cause school shootings. This doc should be ashamed of themselves for promoting this crap.

 

[calvnandhobbs68]

I'm sorry, but this person you're quoting is awful. I just skimmed the article on "the FDA's war against sleep" and it's absolutely BS. Arguing that pretty much every sleep medication out there is bad and that GHB, aka the date rape drug, should be the main thing we use and that it's super safe compared to other meds. I skimmed their main blog and it's full of memes about the dangers of SSRIs including how they cause school shootings. This doc should be ashamed of themselves for promoting this crap.

Yeah idk if this was satire or what posting this junk because you only have to scroll a couple posts down on that substack to find:

Dismantling The Common Lies Used To Push Vaccines

How the System Continually Manipulates Us and How We Can Now Overcome It.

substack.com

 

[Stagg737]

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.

I think efforts in regards to dangers of prescribing stimulants would be much better directed at creating standards for more robust practices for diagnosing ADHD and diagnoses that actually warrant using stimulants than actually targeting stimulants. The number of times I've seen patients with "ADHD" and our low standards for diagnostic accuracy (as a whole in the field) is pretty sad.

 

[tr]

I think efforts in regards to dangers of prescribing stimulants would be much better directed at creating standards for more robust practices for diagnosing ADHD and diagnoses that actually warrant using stimulants than actually targeting stimulants. The number of times I've seen patients with "ADHD" and our low standards for diagnostic accuracy (as a whole in the field) is pretty sad.

Or go entirely the other way and make them legal over the counter like cannabis.
Nobody's asked me about medical marijuana since legalization.

 

[annoyedpsychiatrist]

Midwestern Doc on Substack has written very nice (and extremely lengthy) articles on SSRIs. I would encourage a read. Here's are links:

The Hidden Dangers of Antidepressants and Why They're So Hard To Stop Taking

Unveiling the Depression Industry

www.midwesterndoctor.com

What They Don’t Tell You About Anxiety and The Dangers of Benzodiazepines

The forgotten treatments for anxiety and the immense dangers of inappropriately prescribed benzodiazepines

www.midwesterndoctor.com

The Dark Side of Antidepressants

Why are SSRIs so dangerous?

www.midwesterndoctor.com

The FDA's War Against Sleep

Exploring the Critical Importance of Sleep and the Treatments for Insomnia

www.midwesterndoctor.com

We don't need a psychiatrist skeptic attorney to tell the public that we're a corrupt profession, we've done that for ourselves already:

https://www.psychiatriapolska.pl/pdf-80136-81413?filename=Industry_corrupted.pdf

Edward Shorter has written a beautiful treatise on antidepressants before SSRIs, Shorter, Edward. Before Prozac: The troubled history of mood disorders in psychiatry. Oxford University Press, 2008. I would encourage a read.

How many other chairperson's of the American Psychiatric Association conducted experiments on human beings without their knowledge or consent? I know of just one, for now, Donald Ewen Cameron. Do we not deserve criticism for our failure to acknowledge the injustices we've done, as a profession, on our people? I cannot fault RFK Jr.

Midwestern Doc on Substack has written very nice (and extremely lengthy) articles on SSRIs. I would encourage a read. Here's are links:

The Hidden Dangers of Antidepressants and Why They're So Hard To Stop Taking

Unveiling the Depression Industry

www.midwesterndoctor.com

What They Don’t Tell You About Anxiety and The Dangers of Benzodiazepines

The forgotten treatments for anxiety and the immense dangers of inappropriately prescribed benzodiazepines

www.midwesterndoctor.com

The Dark Side of Antidepressants

Why are SSRIs so dangerous?

www.midwesterndoctor.com

The FDA's War Against Sleep

Exploring the Critical Importance of Sleep and the Treatments for Insomnia

www.midwesterndoctor.com

We don't need a psychiatrist skeptic attorney to tell the public that we're a corrupt profession, we've done that for ourselves already:

https://www.psychiatriapolska.pl/pdf-80136-81413?filename=Industry_corrupted.pdf

Edward Shorter has written a beautiful treatise on antidepressants before SSRIs, Shorter, Edward. Before Prozac: The troubled history of mood disorders in psychiatry. Oxford University Press, 2008. I would encourage a read.

How many other chairperson's of the American Psychiatric Association conducted experiments on human beings without their knowledge or consent? I know of just one, for now, Donald Ewen Cameron. Do we not deserve criticism for our failure to acknowledge the injustices we've done, as a profession, on our people? I cannot fault RFK Jr.

1. I have never had an issue tapering anyone off an SSRI.
2. I have never seen a single person snort zoloft, or buy zoloft off the street
3. Wtf are you talking about.


Im just going to be blatant and up front. Whether i agree with trump or disagree ill leave that at the door. RFK Jr is crazy as hell. He should not be allowed anywhere near medicine. He is a fking *****. The idea that he has any power is a literal joke. We should feel embarrassed a country that he is in a position of power, that someone with literally zero scientific knowledge influences the spread of misinformation.

I am worried because he is both crazy and stupid which is a dangerous combination, and I could see him doing something that makes psychiatry harder. Absolutely.

 

[annoyedpsychiatrist]

Or go entirely the other way and make them legal over the counter like cannabis.
Nobody's asked me about medical marijuana since legalization.

if stimulants were OTC, there would be mass shortages, riots in stores, people would be buying them all to scalp them, etc. You wouldnt be able to keep them on the shelf, lol. Its already close to being OTC with how theyre prescribed now by incompetent providers, but that would be the final nail in the coffin

 

[tr]

if stimulants were OTC, there would be mass shortages, riots in stores, people would be buying them all to scalp them, etc. You wouldnt be able to keep them on the shelf, lol. Its already close to being OTC with how theyre prescribed now by incompetent providers, but that would be the final nail in the coffin

It's a thorny issue for sure. I'm not sure there's a good answer. I was all for legal MJ, but I don't love how it's turned out, with every corner of NYC stinking of skunkweed, adolescent use rates skyrocketing and psychosis rates following close behind.

Association between non-medical cannabis legalization and emergency department visits for cannabis-induced psychosis - Molecular Psychiatry

A major public health concern of cannabis legalization is that it may result in an increase in psychotic disorders. We examined changes in emergency department (ED) visits for cannabis-induced psychosis following the legalization and subsequent commercialization (removal of restrictions on...

www.nature.com

At the same time, I would say that alcohol and cannabis are both significantly more harmful and less beneficial (obviously) than amphetamines, so I don't see the argument for having the former two be available and the latter be restricted.

 

[Stagg737]

It's a thorny issue for sure. I'm not sure there's a good answer. I was all for legal MJ, but I don't love how it's turned out, with every corner of NYC stinking of skunkweed, adolescent use rates skyrocketing and psychosis rates following close behind.

Association between non-medical cannabis legalization and emergency department visits for cannabis-induced psychosis - Molecular Psychiatry

A major public health concern of cannabis legalization is that it may result in an increase in psychotic disorders. We examined changes in emergency department (ED) visits for cannabis-induced psychosis following the legalization and subsequent commercialization (removal of restrictions on...

www.nature.com

At the same time, I would say that alcohol and cannabis are both significantly more harmful and less beneficial (obviously) than amphetamines, so I don't see the argument for having the former two be available and the latter be restricted.

Was going to say that legalizing amphetamines would certainly help my production numbers as an ER/C/L psychiatrist. A nearby state legalized weed right after I became an attending and the rates of THC-induced psychosis I saw afterwards skyrocketed. Went from something I almost never saw to something I see weekly, sometimes multiple times per week. I think the same will happen if we legalize amphetamines in many places. Legalizing amphetamines probably wouldn't make a huge difference where I'm at since meth is bountiful, but in areas that don't have bountiful access to meth I could see things being disastrous.

I have to disagree with the bolded a bit. While amphetamines have greater benefits for the right patient than alcohol or cannabis, I don't think it's that much safer than alcohol and definitely far more harmful than cannabis. Early studies on amphetamines (including meth) from post-WW2 Japan are pretty d***ing with many patients developing chronic or permanent psychoses. Today I see far more meth-induced problems in the ER and it's almost always more severe and problematic than with cannabis unless synthetics are involved, in which case all bets are off.

 

[Crayola227]

Or go entirely the other way and make them legal over the counter like cannabis.
Nobody's asked me about medical marijuana since legalization.

Might actually help some of the meth problems?

 

[Crayola227]

1. I have never had an issue tapering anyone off an SSRI.
2. I have never seen a single person snort zoloft, or buy zoloft off the street
3. Wtf are you talking about.


Im just going to be blatant and up front. Whether i agree with trump or disagree ill leave that at the door. RFK Jr is crazy as hell. He should not be allowed anywhere near medicine. He is a fking *****. The idea that he has any power is a literal joke. We should feel embarrassed a country that he is in a position of power, that someone with literally zero scientific knowledge influences the spread of misinformation.

I am worried because he is both crazy and stupid which is a dangerous combination, and I could see him doing something that makes psychiatry harder. Absolutely.

Look at Scientology. As a field psychiatry is often the first casualty of medicine, likely owing to its somewhat subjective nature. If I don't know I'm crazy & I don't believe in crazy, there's nothing to stop my not believing in treatment for crazy besides death.

People tend to better connect stopping antibiotics and their raging infection coming back.

Although nothing stops the Christian Scientists either besides the law. But perhaps soon we won't have to worry about such things.

I love theocracy.

 

[lockian]

Importantly, to everyone saying they are merely going to "investigate" the harms of medication - they are not going to do any new research. They are planning to do this in 100 days. You can't conduct any research in 100 days. All they're going to do is cherry pick the existing data to support their messed up beliefs.

Also, please hear me out. SSRIs, SNRIs and other antidepressants *can be* quite miserable to get off of, and no, they don't always last the "standard" 6-8 weeks; sometimes they last much longer. However, I bring this up to say that the answer is not to ban them or restrict them, but rather the opposite. Banning them or restricting is going to make all hell break lose, both from the decompensation standpoint and the withdrawal standpoint.

Unfortunately, this is an issue that was not very covered well in my residency program, but since graduating I *have* had patients who (unlike RFK) have been on both opioids and antidepressants and compared SSRI/SNRI withdrawal to opioid withdrawal, in terms of the sheer physical misery of it. I also *have* tried to get people off SSRIs and while in some cases it goes reasonably well, at other times even with a slow and cautious taper over many months or even years, people eventually get to a point where they have intolerable withdrawal. (Usually they're fine until a certain dose and then they get all sorts of new and strange otherwise unexplained symptoms). It has been humbling to learn that withdrawal spans a lot more symptoms than the FINISH mnemonic, in fact: I've seen awful things like persistent genital arousal, akathisia, new onset cognitive impairment and insomnia that nothing will touch. Usually what happens is I tell the patient to re-increase the dose, things improve, and I propose going down slower with the aid of a liquid formulation or compounded prescription. Most people say no; they're content to be on meds indefinitely if the alternative is withdrawal or an excruciatingly slow taper.

Maybe in the grand scheme these cases aren't the most common scenario, but they exist. We may not even know the true likelihood of discontinuation syndrome because how many people are going to go off voluntarily if the med has worked for them, and how many psychiatrists would actually recommend it?

Yes, there are problems with antidepressants, but obviously trying to ban them or even increase the regulation is not the answer.

I am terrified of what if going to happen to patients if SSRI's and other psychotropics are going to be another one of this administration's scapegoats. I am trying very hard not to catastrophize, but ngl, it's hard.

 

[clausewitz2]

Was going to say that legalizing amphetamines would certainly help my production numbers as an ER/C/L psychiatrist. A nearby state legalized weed right after I became an attending and the rates of THC-induced psychosis I saw afterwards skyrocketed. Went from something I almost never saw to something I see weekly, sometimes multiple times per week. I think the same will happen if we legalize amphetamines in many places. Legalizing amphetamines probably wouldn't make a huge difference where I'm at since meth is bountiful, but in areas that don't have bountiful access to meth I could see things being disastrous.

I have to disagree with the bolded a bit. While amphetamines have greater benefits for the right patient than alcohol or cannabis, I don't think it's that much safer than alcohol and definitely far more harmful than cannabis. Early studies on amphetamines (including meth) from post-WW2 Japan are pretty d***ing with many patients developing chronic or permanent psychoses. Today I see far more meth-induced problems in the ER and it's almost always more severe and problematic than with cannabis unless synthetics are involved, in which case all bets are off.

Yes but those studies were looking almost exclusively at heavy IV users of amphetamines. That's going to be different than modal use in an OTC world, which I imagine is going to be PO. Alcohol can be purchased legally and yet the vast majority of users are not necking Everclear on the daily.

 

[Crayola227]

It's a thorny issue for sure. I'm not sure there's a good answer. I was all for legal MJ, but I don't love how it's turned out, with every corner of NYC stinking of skunkweed, adolescent use rates skyrocketing and psychosis rates following close behind.

Association between non-medical cannabis legalization and emergency department visits for cannabis-induced psychosis - Molecular Psychiatry

A major public health concern of cannabis legalization is that it may result in an increase in psychotic disorders. We examined changes in emergency department (ED) visits for cannabis-induced psychosis following the legalization and subsequent commercialization (removal of restrictions on...

www.nature.com

At the same time, I would say that alcohol and cannabis are both significantly more harmful and less beneficial (obviously) than amphetamines, so I don't see the argument for having the former two be available and the latter be restricted.

Wait, cannabis is more harmful than amphetamines? Are you including meth as an amphetamine here?

 

[calvnandhobbs68]

Also, please hear me out. SSRIs, SNRIs and other antidepressants *can be* quite miserable to get off of, and no, they don't always last the "standard" 6-8 weeks; sometimes they last much longer. However, I bring this up to say that the answer is not to ban them or restrict them, but rather the opposite. Banning them or restricting is going to make all hell break lose, both from the decompensation standpoint and the withdrawal standpoint.

Unfortunately, this is an issue that was not very covered well in my residency program, but since graduating I *have* had patients who (unlike RFK) have been on both opioids and antidepressants and compared SSRI/SNRI withdrawal to opioid withdrawal, in terms of the sheer physical misery of it. I also *have* tried to get people off SSRIs and while in some cases it goes reasonably well, at other times even with a slow and cautious taper over many months or even years, people eventually get to a point where they have intolerable withdrawal. (Usually they're fine until a certain dose and then they get all sorts of new and strange otherwise unexplained symptoms). It has been humbling to learn that withdrawal spans a lot more symptoms than the FINISH mnemonic, in fact: I've seen awful things like persistent genital arousal, akathisia, new onset cognitive impairment and insomnia that nothing will touch. Usually what happens is I tell the patient to re-increase the dose, things improve, and I propose going down slower with the aid of a liquid formulation or compounded prescription. Most people say no; they're content to be on meds indefinitely if the alternative is withdrawal or an excruciatingly slow taper.

From my end, the discontinuation symptoms aspect is even less relevant in kids even though this EO is targeted primarily in pediatrics.

I'll often cross titrate a kid who's been on a particular SSRI/SNRI for months/year+ onto another one in 3-7 days or taper a kid completely off in a couple weeks and they'll have no issue. Hell, half the time when it's stopped the kid shows up and tells me they just stopped taking it a month ago. I think part of it are kids are more resilient and recover faster from most things than adults in general but I also think they get less in their own heads about side effects and don't really "expect" discontinuation symptoms as much.
Ah to be a kid again.

 

[Ceke2002]

So once the razor gang's been through and 'fixed everything' (whatever that looks like, considering dude in charge of health stuff is a freaking nutjob) what then? Like I seriously don't get the end game with all of this, unless the end game is some eugenics like, "Some of you may die, but that's a sacrifice I'm willing to make (/meme)" scenario. So you get rid of, or seriously restrict the use of certain Psychiatric drugs, make food safer or healthier or whatever the plan is, get rid of the environmental toxins (somehow I can't see this being 'get rid of actual toxins' so much as 'get rid of vaccinations'), and what then? Is this current government under the delusion that everything will be fixed by just getting rid of things, or are they actually going to bother to do things like subsidise therapy visits, provide school children with subsidised healthy meal options, spend the money needed to clean up contaminated land areas, re-open Polio wards, etc etc. And what happened to all the 'I don't trust the Government to run anything' folks? I'm seeing a lot of now former friends (their choice, not mine) who have done a heel turn face and are now seemingly in love with the idea of big government making the big decisions. Sorry, WUT?!

 

[Stagg737]

Yes but those studies were looking almost exclusively at heavy IV users of amphetamines. That's going to be different than modal use in an OTC world, which I imagine is going to be PO. Alcohol can be purchased legally and yet the vast majority of users are not necking Everclear on the daily.

True, but if it's available OTC what is going to stop people from using significant quantitites or transitioning to something harder once they're far enough into the addiction cycle? ETA: Or just buying it over the counter and then mainlining it?

I've encountered plenty of suburban moms who've used IV heroin after developing dependence from prescription opiates. Regardless, I'd still disagree that typical cannabis use is going to be more dangerous than amphetamines.

 

[OldPsychDoc]

Disappointed OPD. From what I've seen and conceptualized of your historic posts you've usually maintained a decency in your posts that show a tempered nature - even when I've disagreed with them. Hope this is a blip in your usually posting quality.

Most of those posts were pre-45, pre-pandemic, and definitely pre-unelected Space Nazi. Playing by the rules and not pushing back is how these fascists ended up in control of our government--ignoring laws, conflicts of interest, and the Constitution at their whim.
(God...remember when even the conservatives were at least decent people? I miss John McCain...even Dubya!)

What you're seeing isn't a "blip"--expect it to be the start of new trend.
As Helen Mirren said, "If I could give my younger self one piece of advice, it would be to use the words “**** off” much more frequently."
If that disappoints you, I'm happy to have done so.

 

[brosa]

I mean I make 500k a year and work 32 hrs a week currently. Not many similar non medicine jobs like this.

Yeah, but this not the norm. There is a huge bias on the internet, everyone on Reddit knows a psychiatrist making 500k+ not working much. I am graduating now and had a very hard time finding good jobs. Friend of mine did sign a 400k one, but he will work way more than 32h a week.

 

[annoyedpsychiatrist]

what psych job is 500k for 32 hours a week and how do i obtain this.

 

[calvnandhobbs68]

what psych job is 500k for 32 hours a week and how do i obtain this.

I mean if in PP around me if you bill 90% 99214+90833s 30min followups and work 48 weeks a year for 32 hours a week you'd clear 500+ easy but that's before overhead and everything.

 

[lockian]

From my end, the discontinuation symptoms aspect is even less relevant in kids even though this EO is targeted primarily in pediatrics.

I'll often cross titrate a kid who's been on a particular SSRI/SNRI for months/year+ onto another one in 3-7 days or taper a kid completely off in a couple weeks and they'll have no issue. Hell, half the time when it's stopped the kid shows up and tells me they just stopped taking it a month ago. I think part of it are kids are more resilient and recover faster from most things than adults in general but I also think they get less in their own heads about side effects and don't really "expect" discontinuation symptoms as much.
Ah to be a kid again.

A couple of things:
--Right now they're "assessing" the issues in kids (I say "assessing" in quotes because I don't trust this administration and I'm sure they'll only find what they want to find) but who is to say that adults aren't next? It may end up similar to gender affirming care. Ban it for kids outright, and restrict and regulate the heck out of it until it's functionally unaccessible for adults.

--Tapering someone off a drug and cross tapering are different. Ideally the new drug should "plug the hole" and reduce discontinuation symptoms - though in my experience it's not a guarantee.

--You might be right about kids being more resilient, but I'd chalk up the explanation more to neuroplasticity and ability to adapt to being on a drug and then adapt to being off of it, as well as less time being on drugs overall. Discontinuation syndrome, as far as I understand, is a response to the nervous system trying to adapt to being without the drug.

--I take issue with the implication that discontinuation effects are from being "in your own head" about the effect of the drug. (If I misunderstood, I'm sorry, please correct me). I've seen people who were very motivated and very well recovered from their original symptoms, and with very good coping skills still get absolutely miserable discontinuation syndrome. I've had someone literally end up in the hospital for medical reasons and it ended up being withdrawal from stopping a low dose of a med that's "probably not even doing anything." I mean I *guess* there could be a very subconscious effect of "I need this drug" but I am skeptical of that. The issue with such claims is that they're difficult to disprove. In my experience, however, it's more a question of how long the person has been on psychotropic drugs. I've also seen cases where tapering off once, twice goes just fine but then the third (or nth time) the body says "nope." I've also seen people get increasingly med sensitive over a lifetime of tapers and med changes, and I've seen people cavalierly go off medications thinking "they don't need them" and having been *completely unaware* that discontinuation syndrome exists, and develop the same predictable pattern of symptoms.

Unfortunately, though, these issues are not as well studied as they should be, anything we say is just based on personal practice experience and speculation. I wish I had the spoons to find a way to do research in this area - it's very interesting. But sadly, based on what I've seen in clinical practice I've stopped asking patients if they ever see themselves going off meds. I'll agree to help the patient do it safely if that's what they want, but otherwise the risk of decompensation and withdrawal is too great.

 

[Stagg737]

what psych job is 500k for 32 hours a week and how do i obtain this.

I mean if in PP around me if you bill 90% 99214+90833s 30min followups and work 48 weeks a year for 32 hours a week you'd clear 500+ easy but that's before overhead and everything.

Or cash only PP. At $400/hr 30 hours per week for 45 weeks is $540k gross. Same rate at 32 hrs/week for 48 weeks/yr and it's ~$615k gross, which should clear well over $500k after overhead.

Or just provide crappy care and and be a dermatologist churning through 40 patients in an 8 hour day.

 

[jbomba]

I mean if in PP around me if you bill 90% 99214+90833s 30min followups and work 48 weeks a year for 32 hours a week you'd clear 500+ easy but that's before overhead and everything.

Around here that combo generated around 230 for a solo doc. Do the math and it's way more than 500k.

 

[lockian]

or are they actually going to bother to do things like subsidise therapy visits, provide school children with subsidised healthy meal options, spend the money needed to clean up contaminated land areas, re-open Polio wards, etc etc

No, they're not, and we all know they're not. The EO actually implies what they're going to do with language like "fresh thinking," "eliminating conflicts of interest," transparency," and "the availability of expanded treatment options." In far right circles, there is talk about how supplements and alternative treatments are unfairly edged out by the medical system and the FDA. So yeah, it's all going to be sketchy supplements that are touted as the cure-all by people like Musk without any medically rigorous evidence to back it up. Because actual medical research is "all in someone's pocket," doncha know.

 

[Stagg737]

No, they're not, and we all know they're not. The language of the EO actually implies what they're going to do with language like "fresh thinking," "eliminating conflicts of interest," transparency," and "the availability of expanded treatment options." In far right circles, there is talk about how supplements and alternative treatments are unfairly edged out by the medical system and the FDA. So yeah, it's all going to be sketchy supplements that are touted as the cure-all by people like Musk without any medically rigorous evidence to back it up. Because actual medical research is "all in someone's pocket," doncha know.

People can already get these anyway. Unless the goal is just to get CMS to cover them (which one could then make an argument about inappropriate use of taxpayer dollars) then what's the problem? Unless you're suggesting they're going to just completely replace SSRIs and other psych meds with supplements. That would be a problem but imo would eventually self-correct anyway.

 

[lockian]

Unless you're suggesting they're going to just completely replace SSRIs and other psych meds with supplements.

Yes, that's exactly what I'm concerned about, and I am not sure how it would self correct, unfortunately.

 

[Stagg737]

Yes, that's exactly what I'm concerned about, and I am not sure how it would self correct, unfortunately.

You think when 10%+ of the population is on SSRIs and they get pulled along with the meds for bipolar, schizophrenia, and ADHD and we see rates of MH exacerbations skyrocket that there's not going to be a course correction?

 

[lockian]

The problem with the state of politics these days is that telling yourself (and others) "you're catastrophizing" doesn't work anymore. Things that seemed outlandish until recently, such as Roe V Wade being overturned, DEI ending, widespread deportations, etc. are actually happening. It's not the stuff of catastrophic thinking anymore.

 

[lockian]

You think when 10%+ of the population is on SSRIs and they get pulled along with the meds for bipolar, schizophrenia, and ADHD and we see rates of MH exacerbations skyrocket that there's not going to be a course correction?

Rationally, I do. But the people currently in power are not rational. There's going to be a lot of bad things happening, and they might easily just not care or write it off. For instance, gender affirming care is literally lifesaving, as the alternative is a high incidence of suicide attempts. Does anyone care about this who's in power now? I doubt it, and I doubt it's going to change. Now, of course, trans people are 1% of the population at best, so there may be a difference.

However, see my post above this.

 

[Stagg737]

The problem with the state of politics these days is that telling yourself (and others) "you're catastrophizing" doesn't work anymore. Things that seemed outlandish until recently, such as Roe V Wade being overturned, DEI ending, widespread deportations, etc. are actually happening. It's not the stuff of catastrophic thinking anymore.

The problem here is that the things you listed only seem outlandish or to be catastrophes to some people. Meanwhile others wanted those policies/events or at least considered them not a big deal by enough people for this election outcome to occur. Conservatives have been talking about the end of Roe v Wade, ending DEI, and being harder on immigration since before Trump.

Rationally, I do. But the people currently in power are not rational. There's going to be a lot of bad things happening, and they might easily just not care or write it off. For instance, gender affirming care is literally lifesaving, as the alternative is a high incidence of suicide attempts. Does anyone care about this who's in power now? I doubt it, and I doubt it's going to change. Now, of course, trans people are 1% of the population at best, so there may be a difference.

However, see my post above this.

When the masses speak, a dictator has to appease them somehow. Even if only around 5% of people per year have SMI, almost 50% of people experience a MH problem in their lifetime and around a quarter of the country has a MH problem in any given year. The gov would either have to impose restrictions that don't have a significant impact or they'll eventually have to correct things, and when a major course correction occurs the pendulum often swings hard and fast.

 

[bGMx]

Stagg, I don't know what your political predilections are, and I am definitely taking things out of context, so don't consider this necessarily disagreeing with you. This is more for me to get my thoughts out.

I think the current administration, and now christian-nationalist/technocrat/neomonarchist/oligarchic (aka MAGA) approach is to make the government as small as possible, and it is therefore believable that one end point is for private business to handle SMI and MH... which of course won't go well, because the intuition that the invisible hand will help people who would... probably die without a safety net... is wrong.

I suspect things get real bad, and if the current administration successfully pulls a fast one on the citizenry (by bribing w/ $5,000 dollar Trump checks, focusing on the woke crisis which is not actually existential but feels serious because "they're trying to make us all trans-marxists!", stunts like "saving astronauts from Biden", calling judges "politicians", etc), and they win the midterms, we're talking about decades of suffering that will fundamentally change everything. Other countries can't trust us anymore, and our government has convinced the US voting block that the biggest issue... the reason everything is difficult right now... is race, abortion, and gender.

Maybe they keep SSRIs around, maybe they defund psychiatry and Jeff Bezos convinces these immoral crooks our leadership that Amazon One will make the world healthier if they remove the "red tape" that currently organizes our mental health institutions bureaucracies, and you get events like this where Amazon says their virtual healthcare is superior despite an obvious death via negligent care. Bezos was right behind Trump, next to Elon, on inauguration day. Do we really think the pharmaceutical lobbies, physician lobbies, and hospital lobbies can beat the organization, willpower, and scheming, of a handful of billionaires? Collective action struggles in the short term versus someone with minimal values and a love of money/power. That is why America was the shining city on the hill: a small group of aristocrats put the power back in the hands of the people.

I suspect our wards and panels either get overrun by unsolvable problems, or we get kicked out of our seat; either way, things aren't looking peachy. Our new administration, and those who work so readily with him, are disconnected from everyday Americans in every way, and they are making decisions for all of us, patients and physicians alike. RFK straight faced drinks methylene blue while robbing the good common people of America, framing it as "just asking questions" and "Europe bans food coloring" and then simultaneously abandoning Europe as an ally. We need to call it for what it is at this point, there is no catastrophizing, because when it gets to physicians, the rest of America will be in dire straights. There is too much to lose, and we probably will have to lose a lot before people start waking up.

TLDR: My point is this: if we (antiMAGA) don't win the midterms, things will likely become unrecognizable. Question is: will MAGA propaganda work enough to convince people that it is still Biden's fault in the 2026 midterms (see: race, gender, abortion (aka sex))? Will it already be too late given concerted government actions to undermine democracy and implement the wet dream of the Heritage Foundation? Or will things be that bad already that it is undeniable Trump is a major ****, and then the pendulum swings hard the other way.

 

[GoSpursGo]

This thread has crossed the line on political discussions, which are generally not allowed on the main forums. Accordingly this thread is being closed.