Psychofarm Podcast

Antipsychotic medications are not interchangeable, and the tradeoffs between efficacy, metabolic burden, movement side effects, sedation, and adherence can be huge. In this episode, we build an antipsychotic tier list and rank medications including clozapine, olanzapine, haloperidol, risperidone, lurasidone, quetiapine, aripiprazole, and more. Along the way, we connect receptor pharmacology to practical clinical pearls, including food requirements, smoking effects, prolactin, akathisia, EPS, weight gain, long-acting injectables, and clozapine monitoring. We also discuss how medication choice shifts across schizophrenia, bipolar disorder, bipolar depression, and mood symptoms. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

What should patients know when they are diagnosed with depression? In this episode, psychiatrists Dr. Malzberg and Dr. Fu cover what they wish every patient knew from the start. They explain why a depression diagnosis is a useful shorthand rather than a fixed identity, how biological, psychological, and social factors feed into each other, and how medication, therapy, and lifestyle changes work together. You will hear practical first steps like behavioral activation, a steady wake time, morning sunlight, and cutting back on alcohol and cannabis, plus what to do if treatment stalls and how to decide who to tell. It is an hour of clear psychoeducation for patients and a resource clinicians can share. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Diagnosing bipolar disorder is rarely as simple as finding a clear episode of hypomania. Dr. Phelps explains why bipolarity is better understood across a mood spectrum and walks through the clues that can help distinguish bipolar depression from unipolar depression: age of onset, family history, course of illness, treatment response, cyclicity, and collateral history. We also dig into mixed states, the “four A’s” of anxiety, anger, agitation, and attention problems, antidepressant activation, the HCL-32, and the Bipolarity Index. The larger theme is diagnostic humility: uncertainty is often appropriate, and treatment decisions should reflect both the strength of the evidence and the risks of getting the diagnosis wrong. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Lindsay Clancy postpartum psychosis and the insanity defense are examined through a forensic psychiatry lens in this episode. We discuss how psychiatrists distinguish psychosis from malingering, whether someone can be psychotic while still appearing organized, command hallucinations, delusions, altruistic filicide, and what criminal responsibility actually asks. We also look at Dr. Philip Resnick’s testimony, Clancy’s psychiatric treatment, fragmented care, collateral information, and the limits of ruling out bipolar disorder after a brief evaluation. Finally, we explore why the case has produced such intense public reactions and why psychiatry often requires tolerating uncertainty rather than forcing complex patients or cases into simple categories. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

We put the Seinfeld cast on the proverbial couch, not to slap diagnoses on fictional characters, but to show why personality formulation can tell us far more than a psychiatric label.Is George a vulnerable narcissist, borderline, or something more complicated? Does Jerry’s obsession with cleanliness and order actually resemble OCD or an obsessive-compulsive personality style? Could Kramer meet criteria for antisocial personality disorder despite being charming, affectionate, and largely nonviolent? And is Elaine secretly the healthiest person in the group?Along the way, we explore flanderization, narcissism, borderline personality organization, obsessive-compulsive personality traits, psychopathy versus antisocial personality disorder, gambling disorder, and the DSM-5 Alternative Model for Personality Disorders. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Mood stabilizers for bipolar disorder can be confusing because lithium, lamotrigine, Depakote, carbamazepine, and oxcarbazepine have very different strengths, risks, and clinical roles. In this episode, two psychiatrists break down how they think about maintenance treatment, lithium dosing and monitoring, common side effects, lab levels, toxicity counseling, and medication interactions. They also compare Depakote for mania, lamotrigine for bipolar depression, carbamazepine’s interaction burden, and the potential role of oxcarbazepine. Along the way, they discuss combination treatment, diagnostic uncertainty, pregnancy and fertility considerations, rash counseling, and why effective bipolar care requires focusing on long-term episode prevention rather than the symptom of the day. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Anxiety medications tier list: two psychiatrists rank the treatments they actually use for generalized anxiety disorder… and the ones they avoid. The discussion covers first-line SSRIs, why buspirone may be underrated, when benzodiazepines can help or harm, and how to think about mirtazapine, hydroxyzine, propranolol, gabapentin, pregabalin, quetiapine, and bupropion. Just as important, the episode argues that “anxiety” is not a diagnosis: re-diagnosis, mindfulness, CBT and ACT principles, exercise, reducing caffeine or stimulants, and understanding avoidance may matter more than adding another prescription. The result is a practical, opinionated guide to anxiety treatment that combines evidence, clinical experience, side effects, dependence risk, and long-term recovery. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Unfortunately no Dr. Fu today, but Dr. Malzberg speaks with the wonderful psychiatrist Dr. Mary Ellen Eller, who walks through what modern electroconvulsive therapy actually looks like and when clinicians should consider it. The episode covers ECT history, stigma, seizure monitoring, memory concerns, side effects, and the real-world logistics patients face during a treatment course. It also explores where ECT fits in the algorithm for severe depression, depression with psychosis, catatonia, bipolar mania. The result is a grounded, clinician-friendly guide to a misunderstood treatment. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Psychiatrists rank antidepressants for major depressive disorder, including SSRIs like sertraline, escitalopram, fluoxetine, and paroxetine; SNRIs like venlafaxine and duloxetine; and atypical options like bupropion and mirtazapine. They also cover lithium, low-dose aripiprazole, trazodone, esketamine, stimulants, benzodiazepines, TCAs, and MAOIs, with emphasis on diagnosis, side effects, withdrawal, weight gain, sexual dysfunction, anxiety, insomnia, and why “which antidepressant is best” depends on the patient. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Psychotherapeutic techniques are the subject of this episode, as the conversation lays out six memorable therapy mantras for better diagnosis, formulation, and treatment. Rather than focusing on abstract theory, the discussion shows how clinicians can stay close to patient material, clarify vague symptom language, notice countertransference, rewind key moments, and make links that improve both psychotherapy and medication management. It’s a practical lesson in interviewing: ask simpler questions, tolerate not knowing too quickly, observe contradictions, and avoid getting lost in content when the process is where the diagnostic data actually lives. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

In this episode, Dr. Fu and Dr. Malzberg share practical systems for time protection: start on time, end on time, finish documentation inside the visit, and use tools like AI scribes and quiet typing gear. They also lay out clear messaging rules so emails, texts, and forms do not become off-the-clock clinical care, plus the value of emergency slots. The deeper work is emotional: process the job with mentors or supervision, know your limits, and build a real life outside medicine so you can stay effective for the long game. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Subtle psychosis can be missed when you rely on checklists or slip into an interrogator stance. We break down a clinician-friendly approach to detecting psychosis early: use countertransference as a signal, mirror emotion without agreeing with delusions, and clarify the patient’s narrative without derailing it. You’ll also get an OLDCARTS-style framework for taking a voice-hearing history (onset, location, duration, character, and more), plus practical alliance moves for paranoia. We close with how to bridge the treatment gap once you’re seeing the pattern clearly. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

How do you actually evaluate a “delusion” in the room, especially when the belief could be plausible, culturally reinforced, or tied to mood or substances? In this episode, we break down a practical approach to psychosis language, why “fixed false belief” is often insufficient, and the interview questions that help clarify origin, certainty, flexibility, and function. We also use the TALD framework to expand beyond the usual linear vs circumstantial vs tangential model of thought disorder, then apply everything to a case vignette where a single supplement becomes the explanation for an entire life collapse. Educational and clinically focused.TALD: https://ars.els-cdn.com/content/image/1-s2.0-S0920996414005933-mmc1.docxUnderstanding Delusions Paper: https://journals.lww.com/inpj/fulltext/2009/18010/understanding_delusions.2.aspx This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com