# Psychiatry Letter


## Posts

- [Pharmacogenetic testing: A waste of time for predicting response](https://www.psychiatryletter.com/pharmacogenetic-testing-a-waste-of-time-for-predicting-response/): [et_pb_section][et_pb_row][et_pb_column type=”4_4″][et_pb_text] Q: I was wondering if you’ve used genetic testing to help choose an antidepressant. I have one patient who is requesting it but hasn’t actually “failed” any antidepressant trials. She doesn’t like the idea of waiting several weeks just to find out something may not work. Cost is not an issue for her and frankly even if I don’t order it I think she’ll probably do it anyways. My understanding is that those tests are really more about how quickly you metabolize drugs which isn’t really the same thing efficacy.How would you go about counseling someone on this? […]
- [Lithium orotate over the counter for bipolar illness?](https://www.psychiatryletter.com/lithium-orotate-over-the-counter-for-bipolar-illness/): Q: I have a question about Lithium Orotate 10 mg or other low dose. I have a few patients who cannot accept their manic depressive diagnosis but they would accept Lithium Orotate OTC low dose. I suggested it to one after doing the usual labs and EKG. She said it is helping her and she continues to refuse Lithium Carb as well as Bipolar diagnosis. I do not push either as she is slowly questioning it herself. Is Lithium orotate 10 mg ok if a patient refuses carbonate? PL: Lithium orotate 5 mg/d is equivalent to lithium carbonate 25 mg/d. […]
- [Carbamazepine: The most overlooked mood stabilizer](https://www.psychiatryletter.com/carbamazepine-the-most-overlooked-mood-stabilizer/): An underappreciated medication Use the slow release form Best clinical uses Formulations, mechanisms, dosing, and pharmacokinetics Drug interactions Side effects Medical risks An underappreciated medication Carbamazepine is an underappreciated drug.  Its lack of weight gain should put it at the fore of mood stabilizer options in groups concerned about weight, such as young women.  Since lamotrigine is less effective in the long-term for manic episode prevention than for depression, and since it is acutely ineffective for mixed or manic symptoms, carbamazepine would seem to have an important niche in the young woman with predominantly mixed episode symptoms, or with a […]
- [Truths and Fallacies of Psychopharmacology](https://www.psychiatryletter.com/truths-and-fallacies-of-psychopharmacology/): Truths of Psychopharmacology 1. Your treatment is as good as your diagnosis. 2. Treat diseases, not symptoms. 3. All drugs are guilty until proven innocent. 4. All drugs are toxic; only the dosing and indication makes them therapeutic. 5. Always have an exit strategy. 6. Most psychiatric drugs are symptomatic, not disease-modifying. The clearest exception is lithium. 7. Older drugs are more effective than newer drugs. 8. Newer drugs are more tolerable than older drugs. 9. Treatment “resistance” usually reflects either misdiagnosis or an invalid diagnosis. 10. Course, not symptoms, reveals the diagnosis.   Fallacies of Psychopharmacology 1. More is […]
- [Pleae dose lithium just once daily - Really.](https://www.psychiatryletter.com/pleae-dose-lithium-just-once-daily-really/): Question: Dr. Ghaemi recommends Lithium once daily dosing over twice daily to minimize renal side effects, based on studies like this one: Singh, Lokesh Kumar, et al. “Improving tolerability of lithium with a once-daily dosing schedule.” American Journal of Therapeutics 18.4 (2011): 288-291. What are your thoughts on this article that recommends twice daily dosing: Mendelsohn, Alex. “Lithium story: eight guidelines, eight recommendations.” The Lancet Psychiatry 10.5 (2023): 321-322. PL: This essay above is written by a patient in the UK who is a physicist. He makes a big deal about the pharmacokinetics of lithium, but what he and most […]
- [Treatment of anxiety "disorders"](https://www.psychiatryletter.com/treatment-of-anxiety-states/): Obsessive-compulsive disorder Panic disorder Generalized anxiety treatment Post-traumatic stress disorder Anxiety is the “fever” of psychiatry.  Fever is a completely nonspecific symptom, which happens in many illnesses, and frequently without any illness.  Fever “disorders” are meaningless.  Similarly, anxiety is a nonspecific symptom, which is quite common, sometimes related to other illnesses, and sometimes just part of one’s personality.  Most anxiety “disorders” are not scientifically valid illnesses.  In other words, the key concept here is a diagnostic hierarchy. If anxiety happens as part of other illnesses, then anxiety is not itself a separate illness.  (Just as fever occurring with pneumonia is […]
- [Post-traumatic stress disorder (PTSD)](https://www.psychiatryletter.com/post-traumatic-stress-disorder-ptsd/): Diagnostic hierarchy and Post-traumatic stress disorder  Trauma: Too broad a concept Treatment A DSM misnomer As discussed elsewhere, post-traumatic stress disorder (PTSD) is an anxiety condition which arises after severe and often repeated trauma, usually of violent nature (physically or sexually). The classic example is military trauma, after exposure to the violence and carnage of war.  The classic civilian example is repetitive childhood sexual trauma at the hands of one’s caregivers or parents or other adults. Diagnostic hierarchy Again the concept of diagnostic hierarchy is central, and this condition should not be diagnosed when apparent PTSD symptoms only happen in the context […]
- [Antidepressants in bipolar depression: Ineffective at best, harmful at worst](https://www.psychiatryletter.com/antidepressants-in-bipolar-depression-ineffective-at-best-harmful-at-worst/): Antidepressants,  in the PL view, should not be used in bipolar illness. The only studies in which they have been compared to mood stabilizers find that mood stabilizers alone are as effective as antidepressants for the acute major depressive episode in bipolar disorder (reviewed here). Further, repeated studies show that antidepressants are ineffective in prevention of future depression (as meta-analyzed here).  Thus, if after using one or two mood stabilizers, an antidepressant is added for an acute major depressive episode in bipolar disordre, it should be tapered off after improvement from the acute depression, in the view of PL, not […]
- [The Antidepressant Efficacy Controversy](https://www.psychiatryletter.com/the-antidepressant-efficacy-controversy/): In recent years, there has been some controversy about whether or not antidepressants are as effective as many had thought. One group – mostly on the outside of the psychiatric profession –  argues that antidepressants are only slightly more effective than placebo, if at all.  Another group – in the psychiatric professional mainstream – believes that antidepressants are effective to a marked degree. The PL view is that both groups are mistaken.  The antidepressant (AD) critics argue that there was only a small benefit in a meta-analysis of all AD randomized clinical trials (RCTs) in major depressive disorder (MDD). This […]
- [Amphetamines: A Critique](https://www.psychiatryletter.com/amphetamines-a-critique/): The views presented here are described with citations to primary data in our review, downloadable below (1). Amphetamines, including all versions of methylphenidate, are antidepressants, and thus share all of the risks described elsewhere with those agents in bipolar illness.  In the largest study of amphetamines in adults with bipolar disorder, we found a 40% manic switch rate, even with mood stabilizers.  These are highly mood destabilizing agents.   I also will comment that their use for purported adult ADHD is often, in my view, incorrect, because the manic symptom of distractibility or the depressive symptom of poor concentration is then […]
- [Hippocratic Psychopharmacology](https://www.psychiatryletter.com/hippocratic-psychopharmacology/): Hippocratic psychiatry NOT “First, do no harm” Nature heals Non-Hippocratic psychiatry Rules for a Hippocratic Psychopharmacology Holmes’ Rule stated Holmes’ Rule explained Example of Holmes’ Rule: Antidepressants in bipolar illness Osler’s Rule stated Osler’s rule explained Summary  NOT “First, do no harm” It’s a lie:  Hippocrates never said, “First, do no harm.” That phrase was invented by a 19th century English physician and falsely attributed to Hippocrates. Here’s the truth:  Hippocrates said, “As to diseases, try to help, or at least not harm.” There’s a huge difference between the two statements. “First, do no harm” implies a general conservatism about treatment: Be […]
- [Childhood ADD: A Critique](https://www.psychiatryletter.com/childhood-add-a-critique/): Childhood ADHD Inattention in diagnosis of Childhood ADHD Social factors Identifying the real entity Treatment Inattention in diagnosis The diagnosis of ADHD is typically made when a person has marked inattention, or distractibility, along with “executive dysfunction”, or disorganization.  “Hyperactivity” is not, in our view, a scientifically valid central part of this diagnosis.  In children, an inability to sit still in a classroom occurs secondary to the main problem of inattention.  There is no “increased energy” and “decreased need for sleep” which would reflect a primary problem with having excessive energy compared to the general population; that increased energy and decreased […]
- [Adult ADD: A Critique](https://www.psychiatryletter.com/adult-add-a-critique/): The adult ADHD diagnosis Mood and anxiety factor Explanations A separate condition? Not worth the risks Summary The adult ADHD diagnosis As noted in the post on childhood ADD, the diagnosis of Attention Deficit Hyperactivity Disorder is typically made when a person has marked inattention, or distractibility, along with “executive dysfunction”, or disorganization.  In adults, there is usually not an inability to sit still in classrooms (mistakenly labeled “hyperactivity”)  since most adults are no longer in school; rather the executive dysfunction is typically the primary complaint.  Most adults receive amphetamines as symptomatic treatments for inattention. Symptom-oriented treatment, although very popular, […]
- [Mixed depression](https://www.psychiatryletter.com/mixed-depression/): Depression with psychomotor excitation is not just a “major depressive episode”      Clinicians use the word “depression” loosely. The DSM concept of a “major depressive episode” combines very different kinds of depressive states:  Take melancholic: there is no reactivity of mood, which means that the patient is just plain sad all the time –  not angry or anxious or anything else.  There is marked anhedonia, meaning the patient has basically no interests at all, and is often unable to get out of bed or function at all. Now take its opposite: “mixed depression”, where the patient his highly reactive […]
- [Psychiatric Diagnosis: Beyond DSM](https://www.psychiatryletter.com/psychiatric-diagnosis-beyond-dsm/): In the Hippocratic tradition, clinicians should treat diseases, not symptoms. Diagnosis thus becomes extremely important, which entails careful attention to be as scientific as possible in our diagnostic system. As discussed elsewhere, the DSM approach has failed in this regard for the past three decades. One cannot, therefore, solely rely on DSM diagnoses in the practice of clinical psychopharmacology. A more scientific approach is needed. The solution is scientific research on clinical diagnoses, an approach that is based on a century of medical research, and has been well established and accepted psychiatric research for the past half-century. This approach involves […]
- [Understanding anxiety](https://www.psychiatryletter.com/understanding-anxiety/): Anxiety is the “fever” of psychiatry. Fever is a completely nonspecific symptom, which happens in many illnesses, and frequently without any illness. Fever “disorders” are meaningless. Similarly, anxiety is a nonspecific symptom, which is quite common, sometimes related to other illnesses, and sometimes just part of one’s personality. Most anxiety “disorders” are not scientifically valid illnesses. In other words, the key concept here is a diagnostic hierarchy, as explained here. If anxiety happens as part of other illnesses, then anxiety is not itself a separate illness. (Just as fever occurring with pneumonia is not a separate fever “disorder”). Let’s examine […]
- [Bipolar illness: Treatment](https://www.psychiatryletter.com/bipolar-illness-treatment/): The basic principle of treating bipolar illness is simple: Maximize mood stabilizers; avoid antidepressants. The corollary is: Antipsychotics are not mood stabilizers. So treatment means taking true mood stabilizers, defined as drugs which have been proven to prevent depressive or manic episodes. There are only four such agents: lithium, valproic acid (divalproex, Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal). All patients with bipolar illness should be on at least one of these four agents. Antidepressants should be avoided. In the best-designed and largest studies, they are proven ineffective in acute bipolar depression, meaning for immediate short-term benefit of depressive symptoms in […]
- [Understanding depression](https://www.psychiatryletter.com/understanding-depression/): “Depression” is not a diagnosis. It is a syndrome, a collection of signs and symptoms, like fever. It can happen in different diseases, and it can happen without any disease – just like fever. The biggest mistake made today is to treat “depression” with “antidepressants”, as if we should always treat fever with “antifever” drugs (antipyretics) like Tylenol, without caring about any diseases that might be causing fever and treating those diseases (such as penicillin for pneumonia). This doesn’t mean that antidepressants don’t “work”, in the same sense that we don’t say that Tylenol doesn’t “work” for fever. Antidepressants provide […]
- [SSRI, SNRI - It's the SAME.  Just say "SRI"](https://www.psychiatryletter.com/ssri-snri-its-the-same-just-say-sri/): Doctor: I’m giving you Cymbalta (duloxetine). Patient: I got manic and suicidal on SSRIs. Is it an SSRI? Doctor: Don’t worry. It’s a SNRI. Patient: Oh. This 19 year old male had experienced worsened suicidality twice previously with fluoxetine and sertraline. He knew “SSRIs” were bad for him but he had never heard of “SNRIs”. It’s not just a minor issue to use a false phrase like “SSRIs”. These agents are not “selective” and thus they should simply be called “SRIs”, or serotonin reuptake blockers. If we did so, we would realize that there is no difference between all these […]
- [Curbside Consult: Spontaneous remission in bipolar illness](https://www.psychiatryletter.com/curbside-consult-spontaneous-remission-in-bipolar-illness/): Q. I saw a patient this week for an initial evaluation who has a historical diagnosis of bipolar disorder (likely type II). She was initially diagnosed while in graduate school at age 28, and experienced what was deemed to be a hypomanic episode, in the midst of her graduate studies and while completing, ironically enough, a mindfulness-based stress reduction course. She was reportedly put on lamotrigine, titrated up to an unknown dose (she thinks it was at least 100mg) and remained on that until her mood stabilized. She eventually discontinued the lamotrigine and reportedly has remained well for the last […]
- [Curbside consult: Antidepressant-withdrawal mania](https://www.psychiatryletter.com/curbside-consult-antidepressant-withdrawal-mania/): Q. I have an 18 year old female with a history of depression who had been stable on citalopram. She had never had a manic/hypomanic episode. She complained of diminished libido and chose to switch to bupropion rather than add a medication to address it. We decided to start bupropion and taper citalopram gradually from 20 mg daily. She called me two weeks later. She reported since she started bupropion she has been experiencing palpitation, in addition to feeling depressed, tearful, irritable, with racing thoughts, increased rate of speech, and her sleep schedule which was previously well regulated has flipped […]
- [QA:  The "Treatment Overlap" speech and giving an ultimatum in clinical care](https://www.psychiatryletter.com/qa-the-treatment-overlap-speech-and-giving-an-ultimatum-in-clinical-care/): Question: If you see a new patient and you’re recommending discontinuation of amphetamines due to side effects (like high anxiety) and it leads to patients considering discontinuing care with you, how much will you work with them and prescribe for the time being? A 12 year old had this scenario; on his first visit, his mother was demanding a refill of methylphenidate 50 mg/d which he had been receiving from his prior psychiatrist. Lots of issues in the family so I hate for them to leave my care as the boy could use serious help. Answer: This is a difficult […]
- [QA: Borderline personality that goes away and lamotrigine deficiency syndrome](https://www.psychiatryletter.com/qa-borderline-personality-that-goes-away-and-lamotrigine-deficiency-syndrome/): Question: In one of the last lectures I attended, our lecturer expressed his views, that borderline personality disorder to him, isn’t really a personality disorder.. and that he prefers the psychodynamic view of the condition, in that.. it’s more like a state of functioning, that is in between neurotic and psychotic states. His evidence behind that view was that BPD patients often respond greatly to dialectical behavior therapy (DBT), and that’s why it’s unlikely to be a personality disorder if it can be resolved to such a great extent. Answer: The origin of the concept of “borderline” personality was that […]
- [Are delusions rational?](https://www.psychiatryletter.com/are-delusions-rational/): A few decades ago, the Harvard psychologist Brendan Maher made an unusual claim. People with delusions use the same rational process as non-delusional people. The distinction between being “psychotic” – that is, having delusions or hallucinations – and being non-psychotic was not qualitative, but quantitative. Delusional people are just more irrational than normal people. This experimental result is confirmed with the many studies on the cognitive biases of normal thinking, such as the famous example of confirmation bias (you believe a viewpoint based on your recent observations that confirm that viewpoint, while paying less attention to observations that don’t confirm […]
- [Invalidity of Adult ADD](https://www.psychiatryletter.com/adult-add/): The diagnosis of ADD is typically made when a person has marked inattention, or distractibility, along with “executive dysfunction”, or disorganization. In adults, there is usually not an inability to sit still in classrooms (mistakenly labeled “hyperactivity”) since most adults are no longer in school; rather the executive dysfunction is typically the primary complaint. An initial observation is that it is clearly false to assume that ADD persists into adulthood. This assumption is based on restrospective studies that are of worse quality than prospective studies which find the reverse. The rise in diagnosis of adult ADHD fully coincides with marketing […]
- [Living with uncertainty](https://www.psychiatryletter.com/living-with-uncertainty/): When I was in psychiatry residency, one of the consistent teachings we received was that we needed to learn to become comfortable with uncertainty. And that we had to transfer that idea to our patients, because life is uncertain. In later years, I wondered how much of that emphasis on uncertainty, coming from our Freudian teachers, had to do with the shortcoming of their knowledge; I think they misunderstood much of psychiatry. But it’s true; at some point, we reach the end of our knowledge, and the beginning of uncertainty. (My favorite philosopher Karl Jaspers talked a lot about this.) […]
- [The diagnostic hierarchy concept: Why is it missing in psychiatry?](https://www.psychiatryletter.com/the-diagnostic-hierarchy-concept-why-is-it-missing-in-psychiatry/): The concept of diagnostic hierarchy was explained for psychiatry a century ago by the German psychiatrist Karl Jaspers. The idea is that not all diagnoses are created equal; some are more important or more primary than others. For instance, alcohol-induced psychosis, not schizophrenia, should be diagnosed in the setting of delirium tremens. I would suggest that the concept also is implicit more generally in the standard “medical model” which we are taught in medical school and which the average internist applies without much conscious cogitation – the principle of differential diagnosis. As is well known by the average physician, the […]
- [How to mislead with meta-analysis:  Lithium and suicide](https://www.psychiatryletter.com/how-to-mislead-with-meta-analysis-lithium-and-suicide/): A recent paper on lithium and suicide is an excellent example of how to mislead with meta-analysis. It is pseudoscience at its finest. The authors are major critics of the pharmaceutical industry; they claim that drugs are over-hyped.  What pharmaceutical company makes profit on lithium? It was introduced as a generic drug from its very beginning in the US in 1970. The authors’ opposition to lithium shows that they’re opposed to psychiatric drugs per se, not just because of the influence of the pharmaceutical industry.  They can’t let even lithium – the most effective psychiatric medication in human history – get away.  “The idea […]
- [What is psychotic depression?](https://www.psychiatryletter.com/what-is-psychotic-depression/): Q. Is psychotic depression yet another form of depression? Or is psychotic depression the same as manic depression? What is the difference between the two? I know that depression is qualified as neurosis and manic depression as psychosis. What about psychotic depression then? Or is psychotic depression just another term for depression still? PL. This answer is too brief to be definitive, but it will get the idea across. “I know that depression is qualified as neurosis and manic depression as psychosis.” This is not true. The two phrases neurosis and psychosis are misleading and not helpful. Psychosis scientifically (not […]
- [The Serotonin hypothesis debunked? Not really - It never meant anything](https://www.psychiatryletter.com/serotonin-hypothesis-debunked/): The serotonin hypothesis of depression, which became popular from the 1990s until now, is false, and has been known to be false for a long time, and never was proven to begin with. The norepinephrine hypothesis of depression, which preceded the serotonin hypothesis in the 1960s to the 1980s, also was false, and has been known to be false for a long time, and never was proven to begin with. The same holds for the dopamine hypothesis of schizophrenia, which began in the 1960s and 1970s, and more generally for he “chemical imbalance” metaphor for all mental illness. All these are major […]
- [How to mentor](https://www.psychiatryletter.com/how-to-mentor/): Judge what you say by what your hearer can appreciate.  You’ll be surprised how much people appreciate being taught a little, and how much they resent being taught too much.
- [Mood Temperaments: A basic explanation](https://www.psychiatryletter.com/mood-temperaments-a-basic-explanation/): [et_pb_section fb_built=”1″ _builder_version=”4.16″ global_colors_info=”{}”][et_pb_row _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”]    Temperament reflects the biological component of personality; it is about half genetic, and appears to be basically stable from childhood into later life.  Mood temperaments can be conceived as basically mild versions of depressive or bipolar illness, with three major varieties: Hyperthymia  Hyperthymia reflects mild constant manic symptoms.  These people are energetic, active, workaholics, life-of-the-party, highly sociable, very funny, curious and even sometimes impulsive, sometimes risk-takers.  They can be very charismatic, creative, and productive. Often they are successful professionally, wealthy, and […]
- [Explaining Suicide](https://www.psychiatryletter.com/explaining-suicide/): Explaining Suicide Complex, but not unpredictable Fill up a small baseball stadium, like Fenway Park in Boston, with people. About 41,000 persons. Those are the number of people who kill themselves every year in the US. That comes out to over 100 persons daily, about 5 persons per hour. The World Health Organization estimates that about 1 million people in the world commit suicide yearly. Suicide is to psychiatry what mortality is to medicine: our ultimate goal and responsibility in treating psychiatric illnesses. We may or may not succeed in making people happier, or more functional, or more satisfied with their […]
- [Antidepressants in bipolar depression: Common practice, poor science](https://www.psychiatryletter.com/antidepressants-in-bipolar-depression-common-practice-poor-science/): Antidepressants in bipolar depression: Common practice, poor science The context The use of antidepressants in bipolar depression is extremely common and yet it has little scientific evidence to support it. In fact, antidepressants are the most commonly used class of medications in bipolar illness, given to about 50% of patients treated for that diagnosis in the United States. In contrast, the most proven effective treatment in bipolar illness, lithium, is given to less than 10% of patients treated for that diagnosis in the United States. This common practice occurs despite the fact that there are very few randomized clinical trials (RCTs) that support benefit […]
- [Akathisia: Not exactly what you think](https://www.psychiatryletter.com/akathisia-not-exactly-what-you-think/): Akathisia: Not exactly what you think   Importance of akathisia Akathisia can sometimes be sufficient reason to change the neuroleptic medication, when lowered dosing or addition of beta-blockers, as described below, are either ineffective or not indicated. In any case, akathisia should never be allowed to fester; this side effect calls for immediate and quick relief. One-half of all EPS About one-half of extrapyramidal side effects (EPS) represent akathisia. If akathisia is missed, one-half of the cases of EPS will be misinterpreted as other conditions. Conservative estimates indicate that about 25% of patients treated with traditional neuroleptics develop akathisia. About […]
- [Addictions: How to understand them](https://www.psychiatryletter.com/6954-2/):   Addictions:  How to understand them Two types: primary and secondary Addictions come in two basic types:  those which exist independent of other psychiatric conditions, and those additions which are caused by other psychiatric conditions.  The first kind can improve with addictive behavior treatment, such as 12-step approaches.  The second kind can also improve that way, but is more likely to improve if the underlying psychiatric illnesses which cause or promote addictive behaviors are treated. In other words, the concept of  a diagnostic hierarchy is again relevant. If the addictive behavior happens as part of other illnesses, then it is not itself […]
- [Going underground](https://www.psychiatryletter.com/going-underground/): Q: I wanted to ask about integrating the things you teach into my learning and practice as an upcoming resident. Lots of what you say is in conflict with what is traditionally taught, and I feel that I will just end up getting confused and my preceptors will perceive a lack of knowledge if I used some of the principles taught by you on the website/podcast (ex. Giving Lithium for a patient with MDD who has suicidal ideation with plan). My preceptors will probably just think I am dumb and reject a suggestion like this one, despite the evidence. Do […]
- [A 17 year old female refuses olanzapine…](https://www.psychiatryletter.com/a-17-year-old-female-refuses-olanzapine/): Q: I have a 17 y/o girl that refuses to take olanzapine because at the John Hopkins clinic she was given a list of medications that she should avoid because they can increase QTC. She has a mitral valve prolapse, asymptomatic but causes a heart murmur. I don’t have any negative experience with olanzapine and QTC, but it is listed in the package insert as a moderate possibility. In all the years after that first encounter with this medication my only concern has been the metabolic syndrome. I Rx 5 mg of olanzapine and d/c the previous medications. She came […]
- [A Reading List for Psychiatry](https://www.psychiatryletter.com/a-reading-list-for-psychiatry/): Here is a reading list that I’ve prepared for advanced psychiatric residents who have done rotations with me. I would recommend it for those interested in psychiatry either during medical school or during psychiatry residency or in the first 5-10 years after psychiatry residency. It probably will make the most sense in the latter years of psychiatry residency or afterwards, but the books should not be read once and left aside in any case. They should be read and then read again, at least in part, a few years later with more clinical and life experience. I’ve included my own […]
- [Harvard Psychiatry Residency Notes - Circa Early 1990s](https://www.psychiatryletter.com/harvard-psychiatry-residency-notes-circa-early-1990s/): Some time ago, on a prior blog, I began transcribing some of my residency notes from my years at McLean Hospital and Massachusetts General Hospital in 1991-1994. A transfer of websites led to loss of the original blog posts, but here I will begin to rewrite parts of those notes. I plan to add to this blog post gradually, so that the notes are updated over time in this same post. 1993: At the Massachusetts General Hospital (MGH) Consultation/Liaison Program: In the MGH consultation/liaison suite, where sat the offices of Drs. George Murray and Edwin (Ned) Cassem, both Jesuit priests […]
- [The New Canon of Psychiatry: What It Means](https://www.psychiatryletter.com/the-new-canon-of-psychiatry-what-it-means/): Summary of the canon of psychopharmacology So what does the canon of psychopharmacology teach us? An important lesson is that even though the studies were conducted outside the realm of the pharmaceutical industry, by academic centers and with government funding, in each case the researchers seemed strongly biased toward the most positive favorable spin they could give to the drugs being studied. This result stands out especially because the studies found, each in its own way, that the drugs being studied were less effective than had been presumed before these studies were conducted. Many of the more complex questions the […]
- [The New Canon of Psychiatry: STEP-BD for Bipolar Depression](https://www.psychiatryletter.com/the-new-canon-of-psychiatry-step-bd-for-bipolar-depression/): The conventional wisdom: STEP-BD for bipolar depression CATIE was the largest (about 1500 patients) and most ambitious of the three canons of psychopharmacology; it failed to show that most patients even stay on their medications for a year in schizophrenia. STAR*D was about half the size of CATIE (around 750 patients), but still large, and showed benefit acutely but again most patients did not stay well with their medications for a year with depression. STEP*BD was smaller again, about half the size of STAR*D, but very different in its goals. The efficacy of lithium and other mood stabilizers for long-term […]
- [The New Canon of Psychiatry: STAR*D for Depression](https://www.psychiatryletter.com/the-new-canon-of-psychiatry-stard-for-depression/): The conventional wisdom: STAR*D for depression The second large canon of psychopharmacology is the STAR*D study, a large sequential large randomized clinical trial (RCT) of over 1000 patients with an acute depressive episode of so-called major depressive disorder (Rush et al., 2006b). Before STAR*D, there were few RCTs comparing antidepressants to each other, and hardly any looking at outcomes after multiple failed trials. The main outcome was to assess whether there was a difference between switching antidepressants versus combining them as adjuncts, after failure of initial antidepressant monotherapy. The STAR*D protocol was as follows: First 1439 patients were treated openly […]
- [The New Canon of Psychiatry: CATIE](https://www.psychiatryletter.com/the-new-canon-of-psychiatry-catie/): The conventional wisdom: CATIE for schizophrenia Here is the official line on the design and results of this study: CATIE was a one year study of schizophrenia, in which a large sample of about 1500 patients were recruited at about 50 clinical trial sites (exact numbers are n=1493in 57 sites). They were randomized double-blind to one of five drugs: olanzapine, risperidone, quetiapine, ziprasidone, and perphenazine. The first four agents were second-generation dopamine blockers, and the last agent was a first-generation traditional dopamine blocker. There was no placebo arm. The basic question was whether second-generation dopamine blockers are more effective than […]
- [The New Canon of Psychopharmacology: How We Got CATIE, STARD, and STEPBD](https://www.psychiatryletter.com/the-new-canon-of-psychopharmacology-how-we-got-catie-stard-and-stepbd/): In the mid-1990s, an incredible thing happened. The National Institute of Mental Health (NIMH) decided to fund major clinical psychopharmacology studies. About 90% of NIMH is for other purposes, so the world of clinical psychopharmacology always has suffered from neglect in academic research. The field has relied on the pharmaceutical industry for its largest and most definitive studies, with all the limitations already discussed. NIMH leadership, almost always laboratory researchers without background in clinical psychopharmacology, has tended to see this problem as a solution. Government funding wasn’t needed where private industry funding was present. By now it should be obvious […]
- [How to Analyze a Study: Lithium for prevention of suicide, the VA RCT](https://www.psychiatryletter.com/how-to-analyze-a-study/): The recent VA study on lithium provides a good example about why it is important to analyze research studies for yourself. Don’t rely on what the authors tell you, and don’t rely on the journal reviewers to vet the study sufficiently. The VA study concluded that lithium had no benefit for suicidality in general in patients with bipolar illness or “major depression.” The accompanying commentary pointed out that there is a large literature otherwise, and commented on the lithium levels being on the lower end of the usual therapeutic range, and attrition in the study. What the paper did not […]
- [Does lithium improve suicidality? A new VA study](https://www.psychiatryletter.com/does-lithium-improve-suicidality-a-new-va-study/): Suicide-related outcomes in veterans with major depression or bipolar disorder JAMA Psychiatry, Katz et al, 2021 This recent study reported that lithium did not differ from placebo in prevention of suicide-related outcomes over one year in 519 patients. The study was stopped early due to this lack of difference in interim analysis. The authors are to be commended for making the effort to conduct such an important and difficult study. Their extensive efforts in data collection deserve the highest quality of data analysis and scientific interpretation. If the study had positive results, it would have been surprising, but definitive. Lithium […]
- [How do you treat melancholic depression?](https://www.psychiatryletter.com/how-do-you-treat-melancholic-depression/): Q; Never heard of chronic involutional melancholia. I give some activating drugs like venlafaxine or duloxetine for new onset of melancholia and do check-up for signs of any type of dementia and consider lithium and other brain supplements for dementia prevention. PL: Kraepelin used the phrase “involutional melancholia” to describe middle age and later onset severe depression. It was chronic in its course, ie, it didnt come and go, it just stayed. Our view is that it likely reflects what now is called vascular depression, which has middle and later onset, and is chronic. The “melancholic” features are not central […]
- [What is Bipolar Depression? What is Melancholia?](https://www.psychiatryletter.com/what-is-bipolar-depression-what-is-melancholia/): Q: I’m confused on the melancholia concept. You said that melancholia and mixed depression are more episodic and severe, but then you described melancholia as a component of unipolar depression, identified as chronic involutional melancholia. What is the difference between melancholia as part of manic-depressive illness (MDI) and unipolar? Also, is bipolar depression as a psychomotor retardation illness a melancholic presentation? PL: The question is misstated because DSM concepts remain so strong. MDI means bipolar illness plus unipolar depression. Unipolar depression does not mean non-bipolar depression, because there are other depressive conditions that are neither unipolar nor bipolar, meaning they […]
- [Four antidepressants and still not well](https://www.psychiatryletter.com/four-antidepressants-and-still-not-well/): Q. The following patient was referred to me and is unfortunately a very typical case of the standards of current practice: Patient states he/she is seeking tools for continued good health. Patient willing to discontinue some medications, needs medication evaluation & management. Psychiatric diagnoses are PTSD, Depression, Anxiety, Insomnia. Psychiatric Medications: Venlafaxine ER 150mg QD, Buproprion XL 300mg + 150mg QD, Hydroxyzine 50mg QID PRN, Amitriptyline 100mg HS, Adderall 20mg BID (prescribed for two years for motivation, not ADHD) , Clonazepam 1 mg QID PRN, Prazosin 2 mg QID PRN My recommendations were: 1- taper down prazosin mg by decreasing […]
- [What is a disease-modifying drug?](https://www.psychiatryletter.com/what-is-a-disease-modifying-drug/): Question: I would like to ask you one question regarding your differentiation between “symptomatic” drugs like monoamine-agonists or dopamine-inhibitors and second messenger modulators, the latter showing some ability to modify the disease process as such. From my clinical point of view I can very much confirm the fact, that lithium and valproate are one of the best drugs we have in the long-term run. My question would be: Why is that actually? I can find no huge difference in the way both classes of the drugs work in terms of mode of action. So called antidepressants work via GPCRs, modulating […]
- [Keeping Up with the Literature: Read the Journals and the Old Books](https://www.psychiatryletter.com/keeping-up-with-the-literature-read-the-journals-and-the-old-books/): What journals should you read? How do you keep up with the scientific literature? The best advice comes from William Osler: Let the old men read the new books; you students should read the journals, and the old books. So that’s the advice, and there are two pieces to it: Read the journals. And read the old books. The journals Which journals should you read? My advice is to pick one general journal and one specialty journal, and read every article in it every month. You should read the title and/or abstract of each article. Then pick 2-3 articles per […]
- [Research and Practice: Twins, Not Opposites](https://www.psychiatryletter.com/research-and-practice-twins-not-opposites/): I never have understood clinicians who see clinical research as unrelated or even opposed to what they do. This attitude – that clinical research and clinical practice are opposites – even is enshrined in the US government’s official federal policy regarding research ethics (the 1976 “Belmont Report”). That policy stipulates that Institutional Review Boards (IRBs) have to give approval for research, with the standard aspects of informed consent forms and such. What is deemed clinical research is based on the criterion that the researcher is making decisions based on obtaining knowledge, not based on what is in the patient’s best […]

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- [Private clinical-dialogue-with-dr-nassir-ghaemi](https://www.psychiatryletter.com/private-clinical-dialogue-with-dr-nassir-ghaemi/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” admin_label=”Header” module_class=”cust-wave-hero-sec” _builder_version=”4.17.3″ _module_preset=”default” background_color=”rgba(218,245,251,0.9)” background_image=”https://drghaemi.com/psy-old/wp-content/uploads/2022/05/andrew-neel-cckf4TsHAuw-unsplash.jpg” background_blend=”overlay” background_enable_video_mp4=”off” z_index=”99″ custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”150px||150px||false|false” custom_padding_tablet=”150px||||false|false” custom_padding_phone=”100px||60px||false|false” bottom_divider_height=”80px” locked=”off” global_colors_info=”{}”][et_pb_row make_equal=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” background_enable_image=”off” background_position=”bottom_right” max_width=”1240px” custom_padding_tablet=”” custom_padding_phone=”0px||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ module_class=”ds-vertical-align” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||||false|false” custom_padding_tablet=”|0px|||false|false” custom_padding_phone=”|0px|||false|false” custom_padding_last_edited=”on|phone” global_colors_info=”{}”][et_pb_text _builder_version=”4.27.2″ _module_preset=”default” header_font=”Crimson Text||||||||” header_text_align=”center” header_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_font_size=”70px” background_layout=”dark” max_width_last_edited=”off|desktop” custom_margin_tablet=”” custom_margin_phone=”||20px||false|false” custom_margin_last_edited=”on|phone” custom_padding_tablet=”” custom_padding_phone=”” custom_padding_last_edited=”on|phone” header_text_align_tablet=”” header_text_align_phone=”center” header_text_align_last_edited=”on|phone” header_font_size_tablet=”50px” header_font_size_phone=”30px” header_font_size_last_edited=”on|phone” header_line_height_tablet=”” header_line_height_phone=”1.2em” header_line_height_last_edited=”on|tablet” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_text_color%22%93}”] Clinical Dialogue with Dr. Nassir Ghaemi [/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||100px||false|false” custom_padding_tablet=”||60px||false|false” custom_padding_phone=”||40px||false|false” global_colors_info=”{}”][et_pb_row _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_shop type=”product_category” include_categories=”37″ columns_number=”3″ icon_hover_color=”RGBA(255,255,255,0)” hover_overlay_color=”RGBA(255,255,255,0)” show_rating=”off” show_sale_badge=”off” module_class=”cust-product-grid” _builder_version=”4.27.2″ _module_preset=”default” title_font=”Crimson […]
- [Articles](https://www.psychiatryletter.com/articles/): On this page, PL provides pdf access to important articles published by the PL editor and editorial board members that may be of interest to its readers. The bipolar spectrum: Conceptions and misconceptions, SN Ghaemi 2014 Critique of invalidity of adult ADHD and harms of amphetamines, DE Vergne et al 2011 Misdiagnosis of affective temperaments as adult ADHD, SN Ghaemi et al 2023 Improving psychiatric drug discovery – SN Ghaemi, 2022 Symptomatic versus disease-modifying effects of psychiatric drugs – SN Ghaemi 2022 Clinical Research Diagnostic Criteria (CRDC) as an alternative to DSM, applied to bipolar illness – SN Ghaemi et […]
- [From Research To Practice](https://www.psychiatryletter.com/from-research-to-practice/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” admin_label=”Header” module_class=”cust-wave-hero-sec” _builder_version=”4.17.3″ _module_preset=”default” background_color=”rgba(218,245,251,0.9)” background_image=”https://drghaemi.com/psy-old/wp-content/uploads/2022/05/national-cancer-institute-NFvdKIhxYlU-unsplash.jpg” background_blend=”overlay” background_enable_video_mp4=”off” z_index=”99″ custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”150px||150px||false|false” custom_padding_tablet=”150px||||false|false” custom_padding_phone=”100px||60px||false|false” bottom_divider_height=”80px” locked=”off” global_colors_info=”{}”][et_pb_row make_equal=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” background_enable_image=”off” background_position=”bottom_right” max_width=”1240px” custom_padding_tablet=”” custom_padding_phone=”0px||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ module_class=”ds-vertical-align” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||||false|false” custom_padding_tablet=”|0px|||false|false” custom_padding_phone=”|0px|||false|false” custom_padding_last_edited=”on|phone” global_colors_info=”{}”][et_pb_text _builder_version=”4.20.4″ _module_preset=”default” header_font=”Crimson Text||||||||” header_text_align=”center” header_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_font_size=”70px” background_layout=”dark” max_width_last_edited=”off|desktop” custom_margin_tablet=”” custom_margin_phone=”||20px||false|false” custom_margin_last_edited=”on|phone” custom_padding_tablet=”” custom_padding_phone=”” custom_padding_last_edited=”on|phone” header_text_align_tablet=”” header_text_align_phone=”center” header_text_align_last_edited=”on|phone” header_font_size_tablet=”50px” header_font_size_phone=”30px” header_font_size_last_edited=”on|phone” header_line_height_tablet=”” header_line_height_phone=”1.2em” header_line_height_last_edited=”on|tablet” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_text_color%22%93}”] From Research to Practice Webinar [/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||100px||false|false” custom_padding_tablet=”||60px||false|false” custom_padding_phone=”||40px||false|false” global_colors_info=”{}”][et_pb_row _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_shop type=”product_category” include_categories=”35″ columns_number=”3″ orderby=”price-desc” icon_hover_color=”RGBA(255,255,255,0)” hover_overlay_color=”RGBA(255,255,255,0)” show_rating=”off” show_sale_badge=”off” module_class=”cust-product-grid” _builder_version=”4.20.4″ _module_preset=”default” title_font=”Crimson […]
- [About](https://www.psychiatryletter.com/about/): The Psychiatry Letter is a community of clinicians who want to practice in a scientific and humanistic way, focusing on research data, not the conventional wisdom. PL was founded as a digital and print newsletter in 2016 and now is a website that provides webinars and free educational information for clinicians, patients, and families. Join us to improve psychiatric practice. PL was founded by Dr. Nassir Ghaemi with the assistance of an advisory board. The current board and their disclosures are provided here. Founder: Nassir Ghaemi MD MPH, Professor of Psychiatry, Tufts University; Lecturer on Psychiatry, Harvard Medical School – […]
- [Psychopharmacology Update 2023](https://www.psychiatryletter.com/psychopharmacology-update-2023/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” admin_label=”Header” module_class=”cust-wave-hero-sec” _builder_version=”4.17.3″ _module_preset=”default” background_color=”rgba(218,245,251,0.9)” background_image=”https://drghaemi.com/psy-old/wp-content/uploads/2022/05/andrew-neel-cckf4TsHAuw-unsplash.jpg” background_blend=”overlay” background_enable_video_mp4=”off” z_index=”99″ custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”150px||150px||false|false” custom_padding_tablet=”150px||||false|false” custom_padding_phone=”100px||60px||false|false” bottom_divider_height=”80px” locked=”off” global_colors_info=”{}”][et_pb_row make_equal=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” background_enable_image=”off” background_position=”bottom_right” max_width=”1240px” custom_padding_tablet=”” custom_padding_phone=”0px||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ module_class=”ds-vertical-align” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||||false|false” custom_padding_tablet=”|0px|||false|false” custom_padding_phone=”|0px|||false|false” custom_padding_last_edited=”on|phone” global_colors_info=”{}”][et_pb_text _builder_version=”4.17.6″ _module_preset=”default” header_font=”Crimson Text||||||||” header_text_align=”center” header_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_font_size=”70px” background_layout=”dark” max_width_last_edited=”off|desktop” custom_margin_tablet=”” custom_margin_phone=”||20px||false|false” custom_margin_last_edited=”on|phone” custom_padding_tablet=”” custom_padding_phone=”” custom_padding_last_edited=”on|phone” header_text_align_tablet=”” header_text_align_phone=”center” header_text_align_last_edited=”on|phone” header_font_size_tablet=”50px” header_font_size_phone=”30px” header_font_size_last_edited=”on|phone” header_line_height_tablet=”” header_line_height_phone=”1.2em” header_line_height_last_edited=”on|tablet” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_text_color%22%93}”] Psychopharmacology Update 2023 [/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||100px||false|false” custom_padding_tablet=”||60px||false|false” custom_padding_phone=”||40px||false|false” global_colors_info=”{}”][et_pb_row _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_shop type=”product_category” include_categories=”34″ columns_number=”3″ icon_hover_color=”RGBA(255,255,255,0)” hover_overlay_color=”RGBA(255,255,255,0)” show_rating=”off” show_sale_badge=”off” module_class=”cust-product-grid” _builder_version=”4.20.4″ _module_preset=”default” title_font=”Crimson Text|600|||||||” title_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ title_font_size=”20px” […]
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- [Education](https://www.psychiatryletter.com/education/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” admin_label=”Header” module_class=”cust-wave-hero-sec” _builder_version=”4.17.3″ _module_preset=”default” background_color=”rgba(218,245,251,0.9)” background_image=”https://drghaemi.com/psy-old/wp-content/uploads/2022/06/alfons-morales-YLSwjSy7stw-unsplash-2.jpg” background_blend=”overlay” background_enable_video_mp4=”off” z_index=”99″ custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”150px||150px||false|false” custom_padding_tablet=”150px||||false|false” custom_padding_phone=”100px||60px||false|false” bottom_divider_color=”#002272″ bottom_divider_flip=”horizontal” locked=”off” global_colors_info=”{}”][et_pb_row make_equal=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” background_enable_image=”off” background_position=”bottom_right” max_width=”1240px” custom_padding_tablet=”” custom_padding_phone=”0px||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ module_class=”ds-vertical-align” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||||false|false” custom_padding_tablet=”|0px|||false|false” custom_padding_phone=”|0px|||false|false” custom_padding_last_edited=”on|phone” global_colors_info=”{}”][et_pb_text _builder_version=”4.17.3″ _module_preset=”default” header_font=”Crimson Text||||||||” header_text_align=”center” header_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_font_size=”70px” background_layout=”dark” max_width_last_edited=”off|desktop” custom_margin_tablet=”” custom_margin_phone=”||20px||false|false” custom_margin_last_edited=”on|phone” custom_padding_tablet=”” custom_padding_phone=”” custom_padding_last_edited=”on|phone” header_text_align_tablet=”” header_text_align_phone=”center” header_text_align_last_edited=”on|phone” header_font_size_tablet=”50px” header_font_size_phone=”30px” header_font_size_last_edited=”on|phone” header_line_height_tablet=”” header_line_height_phone=”1.2em” header_line_height_last_edited=”on|tablet” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_text_color%22%93}”] Educational Articles [/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][/et_pb_section]
- [TEMPS scale](https://www.psychiatryletter.com/temps-scale/): TEMPS-patient version TEMPS scoring guide revised PL 2021 Here is a 50-item self-report version of the TEMPS scale to assess mood temperaments. It should be given to patients before an initial evaluation, and reviewed during the evaluation and correlated with clinical history. A scoring guide developed for clinical practice also is provided based on later research.
- [PL Referral Center](https://www.psychiatryletter.com/pl-referral-center/): [et_pb_section fb_built=”1″ admin_label=”section” _builder_version=”4.16″ global_colors_info=”{}”][et_pb_row admin_label=”row” _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text admin_label=”Text” _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”] PL Referral Center Clinicians or families or people seeking an evaluation often ask for referrals who may take an approach similar to the one described on this website. PL has obtained permission from these clinicians to list them as possible referrals. Availability and fees will differ from clinician to clinician. The practice of Dr. Nassir Ghaemi, PL founder, can be found at www.drghaemi.com   He is located in Cambridge, Massachusetts, and is licensed in that state as well […]
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- [Webinar](https://www.psychiatryletter.com/webinar/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” admin_label=”Header” module_class=”cust-webinar-hero-sec” _builder_version=”4.17.3″ _module_preset=”default” background_color=”rgba(218,245,251,0.95)” background_enable_image=”off” background_blend=”overlay” background_video_mp4=”https://drghaemi.com/psy-old/wp-content/uploads/2022/05/pexels-cottonbro-5486225-2.mp4″ z_index=”99″ width=”100%” custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”150px||150px||false|false” custom_padding_tablet=”150px||||false|false” custom_padding_phone=”100px||30px||false|false” bottom_divider_height=”80px” locked=”off” global_colors_info=”{}”][et_pb_row make_equal=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.17.3″ _module_preset=”default” background_enable_image=”off” background_position=”bottom_right” max_width=”1240px” custom_padding_tablet=”” custom_padding_phone=”0px||||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ module_class=”ds-vertical-align” _builder_version=”4.17.3″ _module_preset=”default” custom_padding=”||||false|false” custom_padding_tablet=”|0px|||false|false” custom_padding_phone=”|0px|||false|false” custom_padding_last_edited=”on|phone” global_colors_info=”{}”][et_pb_text _builder_version=”4.17.3″ _module_preset=”default” header_font=”Crimson Text||||||||” header_text_align=”center” header_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_font_size=”100px” background_layout=”dark” max_width_last_edited=”off|desktop” custom_margin_tablet=”” custom_margin_phone=”||20px||false|false” custom_margin_last_edited=”on|phone” custom_padding_tablet=”” custom_padding_phone=”” custom_padding_last_edited=”on|phone” header_text_align_tablet=”” header_text_align_phone=”center” header_text_align_last_edited=”on|phone” header_font_size_tablet=”60px” header_font_size_phone=”30px” header_font_size_last_edited=”on|phone” header_line_height_tablet=”” header_line_height_phone=”1.2em” header_line_height_last_edited=”on|tablet” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_text_color%22%93}”] Webinars [/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_row custom_padding_last_edited=”on|tablet” _builder_version=”4.17.3″ _module_preset=”default” custom_padding_tablet=”0px||0px||false|false” custom_padding_phone=”0px||0px||false|false” locked=”off” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.17.3″ _module_preset=”default” header_2_font=”Crimson Text||||||||” header_2_text_align=”center” header_2_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_2_font_size=”60px” module_alignment=”center” custom_margin=”||0px||false|false” header_2_font_size_tablet=”42px” header_2_font_size_phone=”38px” header_2_font_size_last_edited=”on|phone” header_2_line_height_tablet=”” header_2_line_height_phone=”1.2em” header_2_line_height_last_edited=”on|phone” […]
- [Akiskal Video](https://www.psychiatryletter.com/akiskal-video/): [et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” module_class=”cust-hagop-sec” _builder_version=”4.17.3″ _module_preset=”default” custom_margin=”||||false|false” custom_margin_tablet=”-150px||||false|false” custom_margin_phone=”-150px||||false|false” custom_margin_last_edited=”off|desktop” custom_padding=”100px||100px||false|false” custom_padding_tablet=”100px||||false|false” custom_padding_phone=”40px||60px||false|false” locked=”off” global_colors_info=”{}”][et_pb_row custom_padding_last_edited=”on|tablet” _builder_version=”4.17.3″ _module_preset=”default” custom_padding_tablet=”0px||0px||false|false” custom_padding_phone=”0px||0px||false|false” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.17.3″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.17.3″ _module_preset=”default” header_2_font=”Crimson Text||||||||” header_2_text_align=”center” header_2_text_color=”gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91″ header_2_font_size=”60px” module_alignment=”center” custom_margin=”||0px||false|false” header_2_font_size_tablet=”42px” header_2_font_size_phone=”26px” header_2_font_size_last_edited=”on|phone” header_2_line_height_tablet=”” header_2_line_height_phone=”1.2em” header_2_line_height_last_edited=”on|phone” locked=”off” global_colors_info=”{%22gcid-cc3d4aba-dae1-410c-976b-c9d3c4e0bb91%22:%91%22header_2_text_color%22%93}”] Hagop Akiskal: An Appreciation [/et_pb_text][et_pb_text _builder_version=”4.17.3″ _module_preset=”default” text_font=”Karla||||||||” text_text_color=”#000000″ text_font_size=”20px” text_line_height=”1.8em” text_orientation=”center” custom_margin=”||30px||false|false” custom_margin_tablet=”||30px||false|false” custom_margin_phone=”||30px||false|false” custom_margin_last_edited=”on|tablet” hover_enabled=”0″ text_font_size_tablet=”” text_font_size_phone=”14px” text_font_size_last_edited=”on|phone” locked=”off” global_colors_info=”{}” sticky_enabled=”0″] Shown here with Athanasios Koukopoulos (right) [/et_pb_text][et_pb_code _builder_version=”4.17.3″ _module_preset=”default” box_shadow_style=”preset1″ box_shadow_blur=”30px” box_shadow_color=”rgba(0,34,114,0.3)” global_colors_info=”{}”][/et_pb_code][/et_pb_column][/et_pb_row][/et_pb_section]
- [Home](https://www.psychiatryletter.com/home/): [et_pb_section fb_built=”1″ _builder_version=”4.27.2″ _module_preset=”default” global_colors_info=”{}”][/et_pb_section]
- [Sample Page](https://www.psychiatryletter.com/sample-page/): This is an example page. It’s different from a blog post because it will stay in one place and will show up in your site navigation (in most themes). Most people start with an About page that introduces them to potential site visitors. It might say something like this: Hi there! I’m a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like piña coladas. (And gettin’ caught in the rain.) …or something like this: The XYZ Doohickey Company was founded in 1971, […]


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