Arjun Nanda, MD
@arjunknanda
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Child Psychiatrist. Medical Team Lead @MCBH_together . I post about the future of mental health. Views are my own.
Monterey, CA
Joined March 2009
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The Benevolent Childhood Experiences (the opposite of the ACEs) try to capture the positive things in a childhood that can enhance long term outcomes in mental health.
Important to evaluate the good things that can happen in a child’s life rather than just the negatives.
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@jmrphy
It’s gotten to the point where I instinctively click the tweet that comes up because I know it’ll disappear into the ether after a second
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Blinding in an MDMA trial is going to be difficult. Expectancy bias equally so.
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Depersonalization and derealization are incredibly common in people with psychiatric conditions, particularly those with depression and a history of interpersonal abuse.
Why don’t we learn more about this in psychiatric training? Prevalence of 50% in depression is astounding.
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@andyohlbaum
Genuinely concerned that you’re not recognizing the implications of developing this sort of technology. What is the goal here? Replace human connection with a human-AI connection? This isn’t a problem that needs to be fixed.
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Up to 80% of people with schizophrenia smoke cigarettes. Why?
I’ve always had a soft spot for the self-medication hypothesis. Nicotine improves cognition (vital in schizophrenia) and reduces side effects from antipsychotics.
That pesky increased mortality from cigs sucks tho.
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@JonHaidt
Social media warps kids’ minds. I see kids who are “terminally online” and many are addicted to their phones (cannot control use, withdrawal anxiety). How terrible is it that we all collectively understand this and yet continue on with the status quo. Thank you for your work.
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@JonHaidt
The data is damning. Economic and social improvements (while incredibly advantageous) do not equate to robust mental health. Even Anthony Bourdain killed himself.
The focus for improving this crisis should be on fostering resiliency and real connection.
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I just found out that there are psychiatrists that do their note while the patient is in the room… talking to them…
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Being a “perfect parent” isn’t good for your kid
The “good enough mother” (Winnicott, 1953) is the mother who meets her child’s needs adequately, but not perfectly. This helps the child build resilience and adjust to imperfections inherent in the world.
Cut yourself some slack
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@LinusEkenstam
This is “Psychotherapy Simulator”. It helps therapists improve their therapy through role play. It role-plays a client scenario and provides feedback on the session. It’s helped me with a few cases already.
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@ClementLeeMD
Psychiatry
MS: Depression involves a multifaceted interplay of neurobiological processes, cognitive-emotional states, and sociocultural stressors.
Resident: A combination of your genes, environment, and personality traits make you depressed
Attending: life is suffering
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Excellent jumping-off point in psychiatry: the new DSM5 cross-cutting screening measure. 23 questions that screens for most psychiatric disorders - and gives a direction on where to dig deeper. Great stuff from
@CarleneMac
@APApsychiatric
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20% of people with a suicide attempt did not have a psychiatric disorder at the time.
I had a handful of patients like this in residency. They come in after a suicide attempt and don’t actually meet criteria for a psychiatric disorder. We watch them for a bit, try to understand
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@LoriGottlieb1
Everyone is up in arms about the confidentiality debacle, but will no one mention the fact that she’s giving advice in therapy?
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@cremieuxrecueil
@JSchleiderPhD
Anecdotally I see this with my patients too. Summer break truly is a break from their struggles. Such a tragedy that the place of learning where kids spend the majority of their day is also the place that makes them want to die.
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@CarlatPsych
@US_FDA
@chrisaikenmd
As always, these RCTs look at 6 or 8 weeks of data and say “this is safe” ➡️ FDA approval. No long term data? That suicidality rate? Come on guys. We need better options. There needs to be a systematic overhaul.
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The BCEs were revised in 2023 to capture even more of this data. Note that 10 more items were added, which include food, education, sleep, safety, acceptance, time in nature, medical access, pride, and being taught to stand up for oneself.
Thanks to
@QuantPsychiatry
for the tip!
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@ChrisPalmerMD
If they are a danger to themselves, to others, or are "gravely disabled", yes. Otherwise, no. Their housing situation should not affect that decision unless it contributes to one of the first three criteria.
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@CBCNews
I'm sure this comment section will be filled with sage wisdom.
Just a friendly reminder that this vaccine literally prevents cancer.
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@chamath
Healthcare is also in a fairly abysmal state back in Canada. Artificially restricting the supply of physicians now means that very few people can actually go see an outpatient doctor. They’re desperately trying to bring physicians back but we’ve already left for greener pastures.
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@hubermanlab
@Stanford
@StanfordMed
About 47% of those who develop cannabis-induced psychosis “convert” to schizophrenia or bipolar disorder.
About 1/200 people who smoke high potency THC develop cannabis-induced psychosis.
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Our clinic’s no-show rates dropped after switching from text reminders to calls from social workers.
Community mental health needs to be a high-touch system to be effective for patients. Technology is best used on the back end to support in-person contact.
True story: At CNBC, in a prior career, I covered an upstart health plan that really believed that tech - specifically machine learning/AI - would be the core lever to drive behavioral change for its Medicare population. That would improve outcomes & drive down costs. The plan
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@ClementLeeMD
Psychiatry related:
- Drug Holiday
- 5250
- Countertransference
- Immature Defense
- I Assess For Capacity And You Can Too
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@cremieuxrecueil
Always bank on laziness. The internet, AI, whatever - these tools are used by students to maximize laziness, not necessarily educational achievement. Those who succeeded without those tools will succeed with them, and those who didn’t, won’t.
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@ChrisPalmerMD
I’m concerned by the fact that the FDA approved it for that age group based on this data. The suicidality is a significant risk.
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I published a GPT, “Psychotherapy Simulator”. It role-plays a patient scenario and provides feedback on the session with the goal of improving a therapist’s understanding of themselves and the case. It’s trained on psychodynamic texts.
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All antidepressants lead to weight gain. Some more than others.
In order of most weight gain to least:
Escitalopram
Paroxetine
Duloxetine
Venlafaxine
Citalopram
Sertraline <-> Fluoxetine
Bupropion
Interestingly bupropion also has the highest amount of discontinuation at 6 mo
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Hi everyone I would like to direct your attention to this novel treatment for depression
#mentalhealth
#anus
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@CBCNews
It is crucial that this is done right. My heart goes out to those who are waiting for MAID, but a government-funded life-ending system needs to be done correctly, or not at all.
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Postpartum depression is caused in part by inflammation, which is why brexanolone works.
Inflammation is also highly correlated with suicidal behavior.
We should see if brexanolone can treat acute suicidality 👀
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@LinusEkenstam
Read through 5 different research papers and have a discussion on the underlying principles of those studies.
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Yes, mental disorders can be socially transmitted among teens.
At the 1 year follow up, the risk of having a mental disorder increased by 9% if they had one diagnosed classmate, and by 18% if they had more than one diagnosed classmate.
Now that is scary. And intuitive.
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@wallisweaver
@WayneHoy
You’re saying that potential risk is more than actual benefit? What risk do you find is greater than the push towards EV and making humanity multiplanetary? You just listed off character traits, not actual risks.
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- At least one caregiver with whom you felt safe
- At least one good friend
- Beliefs that comforted you
- Liked going to school
- At least one teacher who cared for you
- Good neighbors
- Had an adult who supported or advised you
- Opportunities to have a good time
- Liked
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Being a psychiatrist on X is so wild. Psychiatry tries to navigate the extreme tides of the human psyche, while many vocal people here have waded in gentle waters and call themselves experienced sailors.
I’m not referring to the obvious crowd. I’m talking about tech bros et al.
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I’m considering starting a podcast to interview people who are at the forefront of innovative technology in mental health.
Would any of my (relatively few) followers be interested in that?
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Using rTMS after two antidepressant failures leads to better outcomes than switching meds again.
The question is, why should we have to wait for two failed antidepressant trials?
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Powerful perspective. Arm yourself with science to fight the failings of society
“If science ceases to be a rebellion against authority, then it does not deserve the talents of our brightest children. We should try to introduce our children to science today as a rebellion against poverty, ugliness, militarism, economic injustice”—Professor Freeman Dyson, 2006
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@are4201
Gives us actionable things to work towards rather than things to avoid. That mental shift can be powerful and encouraging for both families and health professionals.
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@SterlingCooley
@andyohlbaum
Not good enough of a reason to allocate money, time, and resources to develop it. Plenty of reasons to raise concerns given societal impacts.
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Super fascinating. Given chatGPTs tone I wonder if it will always look at the inkblots through a positive lens.
Here is the first output on the ChatGPT Rorschach test, I have more than 100 now.
The discovery we made is both robust and fascinating.
I now have a psychological model of the ChatGPT corpus and training.
ChatGPT3.5 output:
“The image appears to be a symmetrical inkblot
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@AmyGDalaMD
My wife and I try to split it up - one of us boards early and sets everything up on the plane, the other parent is with the child walking on the treadmill/conveyor belt thing in the terminals
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There’s a lot of attention on the muscarinic receptors in schizophrenia recently, especially with the development of new meds that bypass the D2 blockade system.
This new study shows KAR-XT reduces schizophrenia symptoms significantly and is well tolerated.
Big if true
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The problem with an AI therapist is that talking about your thoughts and feelings is largely unstructured and not optimal for prompt engineering. My psychotherapy GPT reframes well but is unable to look deeper into the meaning of my statements or ask the most salient question.
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@LinusEkenstam
This is “Psychotherapy Simulator”. It helps therapists improve their therapy through role play. It role-plays a client scenario and provides feedback on the session. It’s helped me with a few cases already.
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Does anyone in private practice regret making that decision? I’m strongly considering it in the next year but planting myself in one place with little option to relocate or have an escape plan is the thing holding me back.
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@freyaindiaa
The question that therapy may ask is: why are they treating the people around them poorly? It may come from insecurity, fear, family culture to name a few. Most therapists should not be giving advice but rather holding their hand as they understand and change themselves.
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AI chatbots for therapy can be problematic. Full video in next post. Don’t mind the YouTube comments
My thoughts: AI therapy will provide lower quality care than a good human therapist but will dramatically increase access. It will also maximize engagement which is anti-therapy
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Therapists watching themselves on video during supervision
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@sjessielondon
I've found that every BPD patient I show the DSM criteria to reacts with a “wow, that's me” and feels seen. Sometimes having the diagnosis is itself therapeutic.
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@naval
1. Tons of garbage data. Low quality, pharma funded, significant bias
2. Each patient has a unique medical history that is not duplicated in even vast amounts of data
3. Negative studies not published
4. Medical decisions are often based not on research but on experience
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Mental health awareness month:
Adverse childhood experiences like abuse and neglect take years off peoples lives. It dramatically increases their chance of developing chronic health conditions and completing suicide. 16% of Californians have >4 ACEs (1/6 people).
Be kind.
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The fragmentation of psychiatric care leads to worse outcomes and a more costly system for all parties.
Detox diagram - as promised. Confirmed with ED and acute care psych MDs. Note fragmentation of services, payors, and quality due to rationing and lack of standardization.
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@AviSchiffmann
The simplest solution is usually the correct one.
A relationship will with an AI will never be as deep as it would be with a human because they can never share the same experience of life, while another human can.
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The image shows how delusions seen in the first episode of psychosis often return if future episodes occur. This means that tracking delusional content can be helpful in predicting psychotic episodes.
Link in next tweet.
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@jonathanstea
No kidding. This guy needs to take his platform seriously. There is a wild amount of misinformation circulating on this site right now
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@dustinthedad
@andyohlbaum
Agree. Understanding and working through friction in relationships is difficult. Learning how to adjust yourself to a potential partner is difficult. This is the easy way out and nothing good comes out of that.
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@dawso007
Aside from the pharma shill trope:
- psychiatrists diagnose and prescribe for normal human emotion
- psychiatrists don’t do therapy
- psychiatrists aren’t real doctors
Would argue that the first point is the most important to refute.
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@JonathanShedler
Therapy tries to read between the lines - which AI chatbots are currently not capable of. It only goes off info in the prompt
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Day 105 using AI as a psychiatrist: I got a complex patient from another doc. I did my assessment and inputted pertinent (+ non-identifying) info in GPT4. Asked for a differential and treatment plan. It put a dx on my radar that neither I nor the prior doc thought of. Pretty cool
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Well here’s an interesting idea. Should we use psychedelics as a prophylaxis for mental health disorders? It could build resilience and adaptability in people given its ability to increase neuroplasticity
Article in next post
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Just a reminder - cannabis/THC is not a benign drug, especially at high potency. 1/200 people develop psychosis requiring medical intervention. 47% of people with cannabis-induced psychosis end up developing schizophrenia or bipolar disorder.
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@G_S_Bhogal
Because "mental retardation" was still actively used for a diagnosis i.e. it described an individual with a low IQ. The term mental retardation has now been replaced with intellectual disability.
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@RCarhartHarris
Seems old school but I dictate into Notes (iOS) and get chatGPT to clean it up. So far it’s worked 100% of the time.
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The data on meditation confirms what Hindus have known for >3500 yrs - that it is deeply transformative, easily accessible, and the truest way to reach a higher level of consciousness.
We (in the West) should be learning this and teaching it to patients.
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My least favorite airline,
@AirCanada
, cancelled our return flight because we missed one leg of our trip - now we’ll have to pay over double what we paid initially because of their nonsense policies. Lesson learned - stay away from Air Canada.
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A longer duration of untreated psychosis means more negative and positive symptoms, lower chance of remission, and worse overall functioning. Need to catch it early, and treat it early.
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The best intervention for poor sleep is simple: sleep hygiene.
I discuss this with my patients because their sleep often sucks, and if followed religiously, it is game changing. It helps with both falling asleep and staying asleep.
My favorites are point 3, 6, and 10.
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