Hi all, I am working as a psychiatrist. I am happy to answer any questions you may have about the field. Offcourse, I will not be providing any management / treatment of illness as I do not think it is appropriate unless I have assessed a person myself.
For a good online self help resource, people can use MoodGym website.
[AMA] I Am a Shrink (Psychiatrist), Ask Me Anything
DiLs on 13/11/2020 - 22:02
Last edited 15/11/2020 - 08:36
Last edited 15/11/2020 - 08:36
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"This is so embarrassing, my amygdala isn't usually that small, it's a cold day and we've just been swimming at the beach"
I suspect a shrink gf wouldn't want you in their pants anyway
Hi.. I have a fear of cats. As soon as I am within a couple of metres of a cat I start panicking. I’m also afraid of kittens. Please help.
You should discuss with a psychologist / psychiatrist to have exposure therapy. It has very good evidence base.
On exposure therapy what if you know it's going to be bad? Say being the idiot who decided to check on the body level bad? Asking for a friend. Is it sometimes better to be constantly dining with Banquo rather than confront him?
Can 5-THP and L-Tyrosine treat depression or anxiety? Can you share what you know about these over the counter supplements in regards to treating mental health. Cheers.
There is very limited evidence of benefit of complementary treatments for depression. The best these may do is only a small effect. The complementary treatments used are St John's wort, NAC, Zinc, omega 3 fatty acids. Just remember they may add only a very little benefit.
What do you think of Agomelatine as a medication? Have you ever prescribed it for reasons 'off-label'? Do you think there is some decent evidence to suggest it works well for conditions like OCD, when used in conjunction with another SSRI/SNRI medication? P.S - It was causing me to have a liver count so bad, Doctor thought I had hepatitis. I do not believe many Doctors are good with follow up blood exams for medications like these (besides something like Lithium), just my opinion.
Do you believe Mirtazapine is probably the most useful medication to use for a variety of mental health conditions, whether on it's own or in conjunction with another medication? I have noticed allergic reactions (SJS) to this medication in my asian or coloured friends who had by chance been prescribed this medication, more often than not.
Have you ever used Pregabalin off-label to treat mental health conditions? If not, I believe you should consider this.
Have you ever found yourself using Duloxetine for patients? I believe that drug is complete trash and shouldn't even be available on the PBS.
IMO the best medication on the market, still, for Anxiety related disorders is good old Paroxetine. Do you have an opinion on this drug?
Does anyone in this day and age prescribe low dose, as needed SSRI medications for lasting longer in the bedroom? Or is this more a thing where it's only done where someone is requesting it, because they are embarrassed about their pre-mature ejaculations?
I have many questions and comments to make on this area of pharmacology, but there are a few for you!
Agomelatine is a newer antidepressant and not available on PBS because of the limited evidence of efficacy. Yes, it can impact liver.
Mirtazapine can be useful in certain types of depression especially when sleep and appetite is impacted.
Duloxetine when used appropriately also yield good results along with analgesic effects.
SSRIs like paroxetine are good for anxiety.
Tricyclic antidepressants e.g. clomipramine is sometimes used by doctors for premature ejaculation.https://en.wikipedia.org/wiki/Agomelatine
Why are the two linked study references (first line on linked page) at odds with your statement about efficacy?
Don't you think this is more a case of 'only as effective as other medications already available, and the liver monitoring potential downside', instead of it being not as effective? At least in terms of why the PBS won't cover this medication.
I would argue Agomelatine should garner more interest, considering the evidence coming in on a world full of Zombie people (more people lacking sleep than ever, a modern ailment due to modern technology).
Do you do any court work? As in, have paitents reffered to you for assessment as part of their legal proceedings?
Have you had any paitents that have revleaed to you a crime they have committed, or a desire to commit crime? Or have you ever been concerned about a paitent potentially commiting a crime due to their mental state/condition?
I dont do legal work. Yes, patients talk to us about numerous things including any legal issues and you decide how to manage the risk best including involving police.
Do you think old antipsychotics like CPZ still have a place in modern medicine?
What do you think of the move away from seclusion, has the power shift moved to far towards the patient whereby sometimes anything goes on the unit?Yes, old antipsychotics still have a place although newer antipsychotics are preferred. Seclusion and restraint should be avoided wherever safely possible. It is important that consumers feel heard and empowered.
But do you think nursing staff now question when to use seclusion and fear the wrath of not being supported by management or the psychiatrist.
Have you seen levels of abuse escalate over the years as lines become blurred between treating team and patient.There are negatives to both the approaches. We need to find a fine balance between them and it is not easy.
Have you read Thomas Szasz's "The Myth of Mental Illness"? If so I'd love to know what you think of it.
Do you have any advice for a recent high school graduate looking to pursue psychology in the future? What do you love and hate about your job?
Thomas Szasz had a very biased and narrow view of mental health and illness. His basic theory that mental illness does not exist because of lack of an observable pathology does not hold true. By that same logic, there was no illness before the invention of microscope. AIDS was still an illness before we got see the HIV virus.
Just follow your dreams. The emotional component of the job is a bit challenging especially at the start. Improving patient outcomes and their lives is what I love the most.
- Do you write letters back to referring GPs, and what do you think of the general reputation of psychs as being terrible with correspondence back to referrers?
- What are the wish-list of things you would like on a referral (bearing in mind the referrer will have a few minutes at best to write it?)
I believe strong communication and collaboration is very important for improving patient outcomes. It is very important to write letters. Dont think I would agree that psychiatrists have a 'general repuation' of being 'terrible' in correspondence.
In a referral letter, I would love to know the presenting complaints and their history, any previous treatment and response, family history of illness, history of substance use, and risk of serious harm to self or others.Thanks. Certain psychiatrists in our area are notorious for not writing correspondence back, which makes it exceedingly difficult with managing mental health patients. Where are you based broadly if you are comfortable disclosing if you have a private practice？
Agree with this sentiment unfortunately. Working in hospitals it is also often extremely difficult to get any meaningful letter from a patient's private psychiatrist. Like squeezing a dry lemon. Sometimes a meds list at most — compared to other specialists who write long and detailed letters.
Is it true you’ll fix a person up using medication and a psychologist will fix them through talking?
Would you try fixing people through talking before medication?
How does someone know they “need” so see you?
Why would you fix someone diagnosed with ADHD with medication rather than behaviour change strategies?
Different illness need different treatments. Both medicine and psychology can be used cohesively. It also depends on the speed of response required e.g. a severly depressed patient or an aggressive psychotic patient would respond much sooner to medicine than to talk therapy.
Talk therapy is very commonly used without medications to treat illness.
Believe it or not Doctors also take the weekend off sometimes.
I am not the only psychiatrist in Australia. I am also a human just like you and I also have a right to take rest just like you.
hopefully this makes sense as i have some complex not formally diagnosed cognitive impairment
do you feel more training should be completed by psychiatrists (prehaps compulsory) to understand and seperate autism from common misdiagnosis Anxiety, Depression, OCD, ADHD, BPD, etc…?
personally spent 8 years misdiagnosed with schizophrenia…
ASD, sensory issues and medication i'd been put on before assesed impaired my awareness, communication, behavior and understanding. diagnosed by highly experienced consultant psychiatrist who refused to support me with anything other than ADHD/Sz with the impression i'm "just seeking another label"
spent a year free of medication finally able to work for the first time in my life, despite pushing hard couldn't get extra support from community mental health services to help obtain asd diagnosis (expensive assessment), took on far too much then end up with Level 3 'severe' ASD diagnosis
without support waiitng for NDIS, i become housebound stuck in a dark room due to constant blacking out from severe sensory impairment, it's become apparent i'm also experiencing symptoms of myclonic/absent seizures and chronic fatigue that's remained untreated for years due to accessability of doctors and some symptoms maybe past 10 years without autism specific support with communication/understanding like that resulted in my misdiagnosis (seizures = thought blocking | for example)
i lost my ability to be able to communicate needs, progressing to a life threatening state, finally as supports coming through, my needs substantially increased to 100-200k a year, i feel like i'm an extreme example but…
do you feel if government better supported autistic diagnosis in adults that overall expendure could be significantly reduced?
i have some friends with very clear autistic characteristics who don't know what to do but keep seeing psychatrists & other medical doctors with symptoms not improving, due to asd awareness, cost of assessments and waitlists make them inassessabile and feels like they burden mental health services when their needs maybe most appropriately supported within the disability system
i always wonder how prevalent cases like mine could be? and that nobody should have to suffer as long as i have trying to get their needs understood
I think the current training program is very stringent and does not need to be extended any further. ASD is a relatively new diagnosis and people are starting to get hold of it. Even then, the number of specialists with expertise in ASD are very few. I am not sure about the last, it may or may not reduce expenditure but it certainly will help consumers.
how young/old before someone can effectively see a psychologist/Psychiatrist? My 3 yr old concerns me.
I'm unsure if he just really shy/scared of lots of things or if its something more.As an example, he hears dogs bark and he is scared, every time a dog comes towards him quickly he is scared.
If a stranger walks in his general direction sometimes he thinks they are coming towards him and he seems scared.
Once a friendly dog walker i see often kindly stops and allows her pup to be patted. I encouraged him (knowning he is a bit scared) to pat him. I knew he wouldn't but wanted to expose/encourage him, by directing him in the dogs general direction but when the dog moved away i noticed he was just starring into space. He didn't move. I think he might have been petrified thats why he tried to look past the pup?Similar kind of story at playgrounds where another kid might enter his space and want to walk behind/past him. He looks scared/petrified.
We've been considering taking him to GP for referral but avoided going out much due to covid. I know i don't explain his behavior well, hopefully you can provide a guide.
There is no age limit to going to a psychologist or psychiatrist. But I dont think I see this behavior as abnormal. It is not uncommon for such a young child to feel scared of the animal or strangers.
thanks, do you have any tips in helping him be less afraid? I go to playgrounds with him and if he sees another kid there he just stares at them. If there's a few kids playing he just sits out and says he wants to go home.
If you are genuinely concerned, I think it'd be good to talk with a professional. I think it's OK to be concerned and talking with a professional will give you, at the very least, the ease of mind.
@iridiumstem: we mentioned it to our regular check ups and was dismissed. normal for kids, parent thinking too much (i suspect). This was when he was 2 and before covid, we don't really wanna go out to a GP given covid, but will do so when comfortable to do so.
@cloudy: I personally found GPs to be hit or miss when it comes to mental health related stuff from my personal experience. I am not saying that the GP that you are seeing is necessarily bad or anything like that, but eh.
If you are concerned I think a lot of the GPs offer telehealth sessions nowadays and chat with the GP that way (at least I think both my GP and my psychologist offered some form of telehealth service).
@iridiumstem: Thanks, yea, mental health is a tough one. The degree to which one is "normal" shy, or has mental health issues is a spectrum, a spectrum that is always being defined and redefined.
i will certainly look into telehealth, thanks for that suggestion
What would one expect to earn in public vs private as a Psychiatrist?
Numerous factors impact that. As a permanent staff specialist in public sector, we earn something 170,000+ in a year. It increases with every year of experience.
In private, psychiatrists generally ear 300,000+ in a year.
But this is a very simple answer and there are a lot of factors that impact these salaries.
As a locum (short term contracts) you can earn a fair bit.
Thanks for taking the time to do an AMA here, doctor.
Are you aware of any legitimate treatment for existiential angst - that dreary realisation that one and all one's offspring (and indeed every other human on the planet) will ultimately end up feeding worms and pushing up daisies before an indifferent universe?
It's not depression. It's just a small, black annoyance gloating at the back of one's brain, aggravated daily by the joy of religious folk convinced they're in for an eternity of strumming harps on clouds or boffing black-eyed virgins.
You may need someone other than a psychiatrist to answer the question.
Do you ever treat people who are religious? e.g. staunch Catholics, Muslims, Jews.
How do you manage them?They believe that depression is cured by reading their holy texts or praying to God. They are usually never open to change. Do you just pay them lip service and move on?
We work on a biopsychosocial model. Medicine and religion can go together.
But what do you do in cases where religious beliefs are the cause of dysfunction? E.g. damnation anxiety, sin guilt, conflict with science/peers/law/experience, etc.
Man that's a extremely broad topic and there's heaps to talk about. To properly identify someone with their issues you'll need to go by a cases by case diagnosis. In the case of religious beliefs, in general they'll have their own strict rules and codes that they'll abide in their daily lives.
Basically if it becomes conflicting with the worldly experiences that's what will trigger anxiety or stress. Eg. They can't eat meat during a certain period of the month and that's what they were served.
All in all belief in religion is not something considered of a mental illness of any kind. It's specific behaviors that may cause harm to yourself or others.
Best practice is to be educated and learn to self mediate the problem before it becomes an obsession.@nobro25: It seems that religion enjoys a special privileged status in society where it is protected from scrutiny. The obesity epidemic is also handled in the same way by segments of the medical fraternity, rather than addressing the root cause of the dysfunction.
How do you balance removing confirmation bias from your opinions and having a level of empathy to connect on a human level whilst being medically accurate?
You have to maintain humanity and empathy even if you do not agree with someone.
So you can't remove confirmation bias
I have so many questions! All related to me so totally understandable if you don't feel here is the right place to answer them.
I seem to disassociate almost daily. Like I'm in a fog or there is a wall of glass between me and what I'm seeing. If I get stressed, it gets more to the point of trying to figure if I'm in a dream or not, and at time will leave to blanking and not knowing where I am for up to 5 mins (though that's been a while since I've gone that far)… GPs, psychologist and my psychiatrist all seem to brush this off and don't really acknowledge or explain what it is… Surely it's not normal to be living life like that? Or is it?
I was diagnosed with ADHD late in life. Both by a psychologist doing a big long questionnaire and by a psychiatrist who asked me 10 questions and said 'oh wow, you only need 60 points to be diagnosed, you got 80! Very ADHD!'… and signed me up for ritalin…
A year later I was so sick of being so up and down he just changed me to Dex… At no point is he talking to me about my mental health, ADHD or anything other than writing me a script…
I'm grateful I could access medication easier than many people seem to be able too, but I'm a bit frustrated that he isn't interested in addressing ways to improve my ADHD symptoms or general anxiety… He has said my anxiety should disappear once my ADHD is under control.
Told me to stop taking Zoloft but didn't mention how to taper off or anything, despite me asking..
Do I have the right expectations that he should help with my overall mental health? I am reluctant to seek out a new psychiatrist in case they are the same or worse. I have no idea how to screen a new Dr without having to pay…
It seems like an obvious choice to find a new one, but it's very costly and time consuming, which is very hard for someone like me and just a bit overwhelming…
If you got this far thank you for your time!
Dissociation can be part of numerous illnesses. Your psychiatrist or another health professional who has actually assessed you should be able to guide you about the cause and how to minimize them. If you can afford a psychologist, they may spend more time on talking part rather than medicine. Sometimes it is good to trial a new health professional and they may be more helpful.
Why is Wellbutrin (bupropion) still not available in Australia as an antidepressant, only as the anti-smoking drug Zyban? It seems to have side effects preferable to those caused by SSRIs and SNRIs.
Thank you.The evidence as an antidepressant is not that great
What is your opinion on pharmacogenomic-guided prescribing?
Interesting concept but so far only an academic exercise, rarely if ever used in real life practice. May hold future value in treatment resistant cases
Do you regret starting this AMA? lol
Why
So many questions to answer and so many questions to unfold? I thought few of the questions I read were bit… confronting for lack of better words.
As psychiatrists, we often get confrontational questions. Part of our role is to reduce the negative image of mental illness and provide a more true picture.
Hi there,
Do you have to have supervision like other mental health professionals? Also, what is your honest opinion if a pt were to see a psychologist vs/compared to a mental health social worker?
Thanks.You need to remain involved in formal peer review where you discuss complex issues with other psychiatrists. Other than that, you have to do a certain number of continuing professional development activities every years.
Psychologist and social worker both have different skills and expertise to offer.
Is it difficult to disengage with patients once the session is over? How do you hold back from getting personally involved in someone's life so as to remain professional at all times?
Have there been cases where you have personally been involved with a patient's situation because you thought it required intervening?
Good question. You have to be professional at all times. With experience you are able to understand how you can stay neutral and not get emotionally involved with a patient. I think it is very important to remain neutral otherwise you can not help the person. I can't recall me becoming personally involved. I may have felt really bad about someone's situation but didn't get personally involved. You also have resources like peer review where you discuss complex issues / cases with other psychiatrists which helps you a lot in remaining neutral.
But do you ever go home and say, wonder what happened to a client if they didn't return for a while?
Absolutely, you do think hopefully they are safe and well
I have OCD (hand washing). My grandmother had it (father's mother), and mine started in my 20s. This means my OCD is genetic. My father has schizophrenia since 40 years since he was in his 20s. As far as I know, he is the only one who has schizophrenia in past handful generations.
Am I at risk to develop schizophrenia later in life, due to the fact that I already have OCD? I'd seen a study on this once.
Is it likely that my genepool carries these genes of OCD and schizophrenia, which could make my children or grandchildren susceptible to either? On my mother's side no one has any significant psychological problems.
Schizophrenia does have a genetic component and family members are at higher risk than general population. That being said not everyone gets it as well.
Thanks for the response. Last 3 questions. Is there anything I can do in advance to prevent schizophrenia? And do you recommend I see a psychiatrist now, when I am fine?
A major component of me not seeking help is not knowing how to find a psychiatrist I can "trust". I feel skeptical that all psychiatrists are looking out for the best in their patient. Any ideas how to find a "good" psychiatrist?
OCD is easy to cure I'm actually pretty much in control of mine mentally. In a few years I'll take BT and have it under control, I may not even need BT.
Thanks again.
There is no preventive treatment at the moment for schizophrenia. Just take life easy and dont stress that in future you or your offspring may have schizophrenia, that could give you anxiety. If your OCD is in control, that's great news. Just keep following up with the professional who manages that. All the best
Finding a good psychiatrist is usually from word of mouth. Some people rely on Google reviews. Your Gp should know good psychiatrist around. You can also find psychiatrist with specific interests / expertise on RANZCP find a psychiatrist website
@DiLs: Thanks for both replies. Yes I'm not stressed about schizophrenia I'm just wondering if I can need to do something in advance for it. All good. This helped.
Oh gawd no, not another one of these threads, I suspect they just did their university degree and are hyped for working in the industry, and if so here's not the place.
P,s I'll use Google thanks, the one you used for your assignments.
Thank you for your opinion
I'll show you my opinion soon from close observations. Don't worry if it makes no sense
I feel your pain
Thanks for your earlier response to my questions.
in 2015 in Melboure there were three trainee psychiatry registrars that took their lives. This story was deeply shocking and left a big impact on the field and support available in health care industry. My question is, what do you do for self care? and if self care for whatever reason was insufficient - how would you know if you needed your own mental health assessed? I hope that makes senseGood question. Healthcare is a very stressful job. You deal with matters of life and death.
In order to avoid repeating a long post, please check this link.
https://www.ranzcp.org/membership/wellbeing-support-for-memb…Basically you have resources like family, friends, colleagues,GP, employer etc. You have to develop healthy coping strategies and take adequate rest. You have to take regular breaks / holidays etc. And lastly never try to treat yourself. They say a doctor who treats themselves has a fool for a patient.
Thanks again for your response. I am asking a new question and replying in one
Firstly, I agree with everything you said and I will check out the link. As I also work in life and death situations myself, your answers will help me and in turn help others… This is something you should know!
New question: Norman Swan dtr had an accident a few years back and he blamed himself; in an article I read that in his moment of crisis, he dug deep and kept it all inside, using the phrase, " Keep your shit wired tight" Here is an excerpt:
"Some people are left with trauma and if that trauma interferes with their life they need to ask for help, with no fear of stigma, but in the moment of the crisis most people keep their shit wired tight and it's good advice in a crisis."
I know that Holocaust survivors, some never discuss their trauma and some want the world to know what they endured. After writing this I guess I dont have a question, just wanted to share an interesting take on dealing with crisis and trauma. Horses for courses!
It is almost always good to explore and discuss trauma but only when the person themselves feel ready.
Have you diagnosed any adults with ADHD if ya catch my drift, if not how many people come with attention deficits hoping to get medicated ?
Yes after following very stringent criteria we do diagnose adults with ADHD and most of them are wanting as well as needing medication
have you dated or would you date your patient?
No way, utterly inappropriate
Harvey Specter dated his shrink
I'm pretty sure that would be contrary to their guide of ethics too.
Is there evidence that forgiveness works?
I have observed that the trauma keeps popping back up despite forgiveness - so am beginning to think forgiveness is hokum and mostly empty.There is some evidence but more evidence is needed
What are your thoughts on the DSM?
It is just another way of classification. Just like other classifications, it certainly is not perfect. Nonetheless they serve important function in diagnosis and management of a condition.
Is CBT a whole lot of hooey? One thing I've noticed is the theme around it, it's almost like telling the patient "just do it", "be well/happy"!
What do the latest and greatest studies tell us today about it?
CBT when given properly and practiced regularly by a client has a very strong evidence base for numerous illnesses especially depression and anxiety.
What is the average age that psychiatrists retire?
Which subject did you like more in high school, English or Mathematics?
Sorry I dont have data about the retirement age. I liked biology.
Hi there.
Do you believe that unless a fetish interrupts your day to day life and is not illegal; that it is effectively harmless?I'd be curious to know what your thoughts are on a desire for sexual contact that means being unhygenic/unclean/unsanitary but that is consensual.
Cheers!
According to DSM, the most used classification system of mental illness, an illness need either an impairment of functioning or cause distress to individual or others.
That being said paraphilias have been included in classification system of mental illness.
Being unhygienic and unclean may have other harms like infection etc.Cheers, I know the risk of what I play with (and I can guarantee it's not what ANY of you are thinking haha). But I don't feel like it's an issue, I was just curious of what you'd think of fetishes.
Cheers mate.
@rainbowvac - Is it a rainbow colored vacuum cleaner?
@Providence: Haha no, I really should change that handle… I'm not sure I'm comfortable revealing exactly what it is that I'm talking about.
What if she gets into your mind first?