Maxwell Zachary Price, BA

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

We appreciated Dr. Nasrallah’s recent editorial¹ that implicated smartphones, social media, and video game addiction, combined with the pandemic, in causing default mode network (DMN) dysfunction. The United States Surgeon General’s May 2023 report echoed these concerns and recommended limiting the use of these platforms.² While devices are accelerants on a raging fire of mental illness, we observe a more insidious etiology that kindled the flame long before the proliferation of social media use during the pandemic. I (MZP) call this the “borderlinization” of society.

Imagine living somewhere in America that time had forgotten, where youth did not use smartphones and social media or play video games, and throughout the pandemic, people continued to congregate and socialize. These are the religious enclaves throughout New York and New Jersey that we (MZP and RLP) serve. Yet if devices were predominantly to blame for the contemporary mental health crisis, we would not expect the growing mental health problems we encounter. So, what is going on?

Over the past decade, mental health awareness has permeated all institutions of education, media, business, and government, which has increased compassion for marginalized groups. Consequently, people who may have previously silently suffered have become encouraged and supported in seeking help. That is good news. The bad news is that we have also come to pathologize, label, and attempt to treat nearly all of life’s struggles, and have been exporting mental disease around the world.³ We are losing the sense of “normal” when more than one-half of all Americans will receive a DSM diagnosis in their lifetime.⁴

Traits of borderline personality disorder (BPD)—such as abandonment fears, unstable relationships, identity disturbance, affective instability, emptiness, anger, mistrust, and dissociation⁵—that previously were seen less often are now more commonplace among our patients. These patients’ therapists have “validated” their “victimization” of “microaggressions” such that they now require “trigger warnings,” “safe spaces,” and psychiatric “diagnosis and treatment” to be able to function “normally.” These developments have also positioned parents, educators, employers, and psychiatrists, who may share “power and privilege,” to “walk on eggshells” so as not to offend newfound hypersensitivities. Interestingly, the DMN may be a major, reversible driver in BPD,⁶ a possible final common pathway that is further impaired by devices starting to creep into our communities and amplify the dysfunction.

Beyond treating individual patients, we must consider mandating time away from devices to nourish our DMN. During a 25-hour period each week, we (MZP and RLP) unplug from all forms of work and electronics, remember the past, consider the future, reflect on self and others, connect with nature, meditate, and eat mindfully—all of which are DMN functions. We call it Shabbat, which people have observed for thousands of years to process the week before and rejuvenate for the week ahead. Excluding smartphones from school premises has also been helpful⁷ and could be implemented as a nationwide commitment to the developing brains of our youth. Finally, we need to look to our profession to promote resilience over dependence, distress tolerance over avoidance, and empathic communication over “cancellation” to help heal a divisive society.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

We appreciated Dr. Nasrallah’s recent editorial¹ that implicated smartphones, social media, and video game addiction, combined with the pandemic, in causing default mode network (DMN) dysfunction. The United States Surgeon General’s May 2023 report echoed these concerns and recommended limiting the use of these platforms.² While devices are accelerants on a raging fire of mental illness, we observe a more insidious etiology that kindled the flame long before the proliferation of social media use during the pandemic. I (MZP) call this the “borderlinization” of society.

Imagine living somewhere in America that time had forgotten, where youth did not use smartphones and social media or play video games, and throughout the pandemic, people continued to congregate and socialize. These are the religious enclaves throughout New York and New Jersey that we (MZP and RLP) serve. Yet if devices were predominantly to blame for the contemporary mental health crisis, we would not expect the growing mental health problems we encounter. So, what is going on?

Over the past decade, mental health awareness has permeated all institutions of education, media, business, and government, which has increased compassion for marginalized groups. Consequently, people who may have previously silently suffered have become encouraged and supported in seeking help. That is good news. The bad news is that we have also come to pathologize, label, and attempt to treat nearly all of life’s struggles, and have been exporting mental disease around the world.³ We are losing the sense of “normal” when more than one-half of all Americans will receive a DSM diagnosis in their lifetime.⁴

Traits of borderline personality disorder (BPD)—such as abandonment fears, unstable relationships, identity disturbance, affective instability, emptiness, anger, mistrust, and dissociation⁵—that previously were seen less often are now more commonplace among our patients. These patients’ therapists have “validated” their “victimization” of “microaggressions” such that they now require “trigger warnings,” “safe spaces,” and psychiatric “diagnosis and treatment” to be able to function “normally.” These developments have also positioned parents, educators, employers, and psychiatrists, who may share “power and privilege,” to “walk on eggshells” so as not to offend newfound hypersensitivities. Interestingly, the DMN may be a major, reversible driver in BPD,⁶ a possible final common pathway that is further impaired by devices starting to creep into our communities and amplify the dysfunction.

Beyond treating individual patients, we must consider mandating time away from devices to nourish our DMN. During a 25-hour period each week, we (MZP and RLP) unplug from all forms of work and electronics, remember the past, consider the future, reflect on self and others, connect with nature, meditate, and eat mindfully—all of which are DMN functions. We call it Shabbat, which people have observed for thousands of years to process the week before and rejuvenate for the week ahead. Excluding smartphones from school premises has also been helpful⁷ and could be implemented as a nationwide commitment to the developing brains of our youth. Finally, we need to look to our profession to promote resilience over dependence, distress tolerance over avoidance, and empathic communication over “cancellation” to help heal a divisive society.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

We appreciated Dr. Nasrallah’s recent editorial¹ that implicated smartphones, social media, and video game addiction, combined with the pandemic, in causing default mode network (DMN) dysfunction. The United States Surgeon General’s May 2023 report echoed these concerns and recommended limiting the use of these platforms.² While devices are accelerants on a raging fire of mental illness, we observe a more insidious etiology that kindled the flame long before the proliferation of social media use during the pandemic. I (MZP) call this the “borderlinization” of society.

Imagine living somewhere in America that time had forgotten, where youth did not use smartphones and social media or play video games, and throughout the pandemic, people continued to congregate and socialize. These are the religious enclaves throughout New York and New Jersey that we (MZP and RLP) serve. Yet if devices were predominantly to blame for the contemporary mental health crisis, we would not expect the growing mental health problems we encounter. So, what is going on?

Over the past decade, mental health awareness has permeated all institutions of education, media, business, and government, which has increased compassion for marginalized groups. Consequently, people who may have previously silently suffered have become encouraged and supported in seeking help. That is good news. The bad news is that we have also come to pathologize, label, and attempt to treat nearly all of life’s struggles, and have been exporting mental disease around the world.³ We are losing the sense of “normal” when more than one-half of all Americans will receive a DSM diagnosis in their lifetime.⁴

Traits of borderline personality disorder (BPD)—such as abandonment fears, unstable relationships, identity disturbance, affective instability, emptiness, anger, mistrust, and dissociation⁵—that previously were seen less often are now more commonplace among our patients. These patients’ therapists have “validated” their “victimization” of “microaggressions” such that they now require “trigger warnings,” “safe spaces,” and psychiatric “diagnosis and treatment” to be able to function “normally.” These developments have also positioned parents, educators, employers, and psychiatrists, who may share “power and privilege,” to “walk on eggshells” so as not to offend newfound hypersensitivities. Interestingly, the DMN may be a major, reversible driver in BPD,⁶ a possible final common pathway that is further impaired by devices starting to creep into our communities and amplify the dysfunction.

Beyond treating individual patients, we must consider mandating time away from devices to nourish our DMN. During a 25-hour period each week, we (MZP and RLP) unplug from all forms of work and electronics, remember the past, consider the future, reflect on self and others, connect with nature, meditate, and eat mindfully—all of which are DMN functions. We call it Shabbat, which people have observed for thousands of years to process the week before and rejuvenate for the week ahead. Excluding smartphones from school premises has also been helpful⁷ and could be implemented as a nationwide commitment to the developing brains of our youth. Finally, we need to look to our profession to promote resilience over dependence, distress tolerance over avoidance, and empathic communication over “cancellation” to help heal a divisive society.

In his recent editorial (“A ‘guest editorial’ … generated by ChatGPT?” Current Psychiatry, April 2023, p. 6-7, doi:10.12788/cp.0348), Dr. Nasrallah asked for feedback on the ChatGPT-generated editorial on myths surrounding psychiatry. I found the “product” equivalent to a diligent high schooler’s homework assignment. ChatGPT lacks the nuance of a historical perspective, one that has observed the ever-changing enthusiasms (from Freud’s “cure” for posttraumatic stress disorder through dopamine, then 5HT, now glutamate and psychedelics) because mental illness is so difficult to treat. For the guest editorial on myths, a little googling would have yielded the same content, if not a similar list of myths. Surely such an editorial would never be accepted in any psychiatry journal; maybe in Reader’s Digest!

Sara Hartley, MD
Berkeley, California

I just read the “guest editorial” generated by ChatGPT. Thank you for this article. Although this is truly an amazing advancement in artificial intelligence (AI), I feel this guest editorial was very basic. It did not read like scientific writing. It read more like it was written at an 11th- or 12th-grade level, though I am fully aware that the question was simple, and thus the answer was not very deep. I can’t deny that if I had been tested, chances are good I would have fallen among the 32% of my peers who would not have recognized it as AI. I appreciate that you (and your team) are working on a protocol regarding how to include content generated by or with the help of AI. God knows if (most likely, when) people with evil minds will use AI to spread false information that may dispute the accredited scientific data and research that guide the medical world and many other fields. I wonder if AI can serve as a search engine that is better or easier to use than PubMed (for example) and the other services we use for research and learning.

Alex Mustachi, PMHNP-BC
Suffern, New York

I wanted to let you know how much I enjoyed reading your recent editorial on AI and scientific writing. Sharing the 4 AI-generated “articles” with readers (“For artificial intelligence, the future is finally here,” Current Psychiatry, April 2023, p. 8-11,29, doi:10.12788/cp.0354) was a delightfully clever/engaging exercise. Other journals need to take a more proactive/targeted stand on this very important issue.

Martha Sajatovic, MD
Cleveland, Ohio

Continue to: The AI-generated samples...

The Al-generated samples were fascinating. As far as I superficially noted, the spelling, grammar, and punctuation were correct. That is better than one gets from most student compositions. However, the articles were completely lacking in depth or apparent insight. The article on anosognosia mentioned it can be present in up to 50% of cases of schizophrenia. In my experience, it is present in approximately 99.9% of cases. It clearly did not consider if anosognosia is also present in alcoholics, codependents, abusers, or people with bizarre political beliefs. But I guess the “intelligence” wasn’t asked that. The other samples also show shallow thinking and repetitive wording—pretty much like my high school junior compositions.

Maybe an appropriate use for AI is a task such as evaluating suicide notes. AI’s success causes one to feel nonplussed. Much more disconcerting was a recent news article that reported AI made up nonexistent references to a professor’s alleged sexual harassment, and then generated citations to its own made-up reference.¹ That is indeed frightening new territory. How does one fight against a machine to clear their own name?

Linda Miller, NP
Harrisonburg, Virginia

References

1. Verma P, Oremus W. ChatGPT invented a sexual harassment scandal and named a real law prof as the accused. The Washington Post. April 5, 2023. Accessed May 8, 2023. https://www.washingtonpost.com/technology/2023/04/05/chatgpt-lies/

Thank you, Dr. Nasrallah, for your latest thought-provoking articles on AI. Time and again you provide the profession with cutting-edge, relevant food for thought. Caveat emptor, indeed.

Lawrence E. Cormier, MD
Denver, Colorado

Continue to: We read with interest...

We read with interest Dr. Nasrallah’s editorial that invited readers to share their take on the quality of an AI-generated writing sample. I (MZP) was a computational neuroscience major at Columbia University and was accepted to medical school in 2022 at age 19. I identify with the character traits common among many young tech entrepreneurs driving the AI revolution—social awkwardness; discomfort with subjective emotions; restricted areas of interest; algorithmic thinking; strict, naive idealism; and an obsession with data. To gain a deeper understanding of Sam Altman, the CEO of OpenAI (the company that created ChatGPT), we analyzed a 2.5-hour interview that MIT research scientist Lex Fridman conducted with Altman.¹ As a result, we began to discern why AI-generated text feels so stiff and bland compared to the superior fluidity and expressiveness of human communication. As of now, the creation is a reflection of its creator.

Generally speaking, computer scientists are not warm and fuzzy types. Hence, ChatGPT strives to be neutral, accurate, and objective compared to more biased and fallible humans, and, consequently, its language lacks the emotive flair we have come to relish in normal human interactions. In the interview, Altman discusses several solutions that will soon raise the quality of ChatGPT’s currently deficient emotional quotient to approximate its superior IQ. Altruistically, Altman has opened ChatGPT to all, so we can freely interact and utilize its potential to increase our productivity exponentially. As a result, ChatGPT interfaces with millions of humans through RLHF (reinforcement learning from human feedback), which makes each iteration more in tune with our sensibilities.² Another initiative Altman is undertaking is to depart his Silicon Valley bubble for a road trip to interact with “regular people” and gain a better sense of how to make ChatGPT more user-friendly.¹

What’s so saddening about Dr. Nasrallah’s homework assignment is that he is asking us to evaluate with our mature adult standards an article that was written at the emotional stage of a child in early high school. But our hubris and complacency are entirely unfounded because ChatGPT is learning much faster than we ever could, and it will quickly surpass us all as it continues to evolve.

It is also quite disconcerting to hear how Altman is naively relying upon governmental regulation and corporate responsibility to manage the potential misuse of future artificial general intelligence for social, economic, and political control and upheaval. We know well the harmful effects of the internet and social media, particularly on our youth, yet our laws still lag far behind the fact that these technological innovations are simultaneously enhancing our knowledge while destroying our souls. As custodians of our world, dedicated to promoting and preserving mental well-being, we cannot wait much longer to intervene in properly parenting AI along its wisest developmental trajectory before it is too late.

Maxwell Zachary Price, BA
Nutley, New Jersey

Richard Louis Price, MD
New York, New York

References

1. Sam Altman: OpenAI CEO on GPT-4, ChatGPT, and the Future of AI. Lex Fridman Podcast #367. March 25, 2023. Accessed April 5, 2023. https://www.youtube.com/watch?v=L_Guz73e6fw

2. Heikkilä M. How OpenAI is trying to make ChatGPT safer and less biased. MIT Technology Review. Published February 21, 2023. Accessed April 5, 2023. https://www.technologyreview.com/2023/02/21/1068893/how-openai-is-trying-to-make-chatgpt-safer-and-less-biased/

Disclosures

The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

In his recent editorial (“A ‘guest editorial’ … generated by ChatGPT?” Current Psychiatry, April 2023, p. 6-7, doi:10.12788/cp.0348), Dr. Nasrallah asked for feedback on the ChatGPT-generated editorial on myths surrounding psychiatry. I found the “product” equivalent to a diligent high schooler’s homework assignment. ChatGPT lacks the nuance of a historical perspective, one that has observed the ever-changing enthusiasms (from Freud’s “cure” for posttraumatic stress disorder through dopamine, then 5HT, now glutamate and psychedelics) because mental illness is so difficult to treat. For the guest editorial on myths, a little googling would have yielded the same content, if not a similar list of myths. Surely such an editorial would never be accepted in any psychiatry journal; maybe in Reader’s Digest!

Sara Hartley, MD
Berkeley, California

I just read the “guest editorial” generated by ChatGPT. Thank you for this article. Although this is truly an amazing advancement in artificial intelligence (AI), I feel this guest editorial was very basic. It did not read like scientific writing. It read more like it was written at an 11th- or 12th-grade level, though I am fully aware that the question was simple, and thus the answer was not very deep. I can’t deny that if I had been tested, chances are good I would have fallen among the 32% of my peers who would not have recognized it as AI. I appreciate that you (and your team) are working on a protocol regarding how to include content generated by or with the help of AI. God knows if (most likely, when) people with evil minds will use AI to spread false information that may dispute the accredited scientific data and research that guide the medical world and many other fields. I wonder if AI can serve as a search engine that is better or easier to use than PubMed (for example) and the other services we use for research and learning.

Alex Mustachi, PMHNP-BC
Suffern, New York

I wanted to let you know how much I enjoyed reading your recent editorial on AI and scientific writing. Sharing the 4 AI-generated “articles” with readers (“For artificial intelligence, the future is finally here,” Current Psychiatry, April 2023, p. 8-11,29, doi:10.12788/cp.0354) was a delightfully clever/engaging exercise. Other journals need to take a more proactive/targeted stand on this very important issue.

Martha Sajatovic, MD
Cleveland, Ohio

Continue to: The AI-generated samples...

The Al-generated samples were fascinating. As far as I superficially noted, the spelling, grammar, and punctuation were correct. That is better than one gets from most student compositions. However, the articles were completely lacking in depth or apparent insight. The article on anosognosia mentioned it can be present in up to 50% of cases of schizophrenia. In my experience, it is present in approximately 99.9% of cases. It clearly did not consider if anosognosia is also present in alcoholics, codependents, abusers, or people with bizarre political beliefs. But I guess the “intelligence” wasn’t asked that. The other samples also show shallow thinking and repetitive wording—pretty much like my high school junior compositions.

Maybe an appropriate use for AI is a task such as evaluating suicide notes. AI’s success causes one to feel nonplussed. Much more disconcerting was a recent news article that reported AI made up nonexistent references to a professor’s alleged sexual harassment, and then generated citations to its own made-up reference.¹ That is indeed frightening new territory. How does one fight against a machine to clear their own name?

Linda Miller, NP
Harrisonburg, Virginia

References

1. Verma P, Oremus W. ChatGPT invented a sexual harassment scandal and named a real law prof as the accused. The Washington Post. April 5, 2023. Accessed May 8, 2023. https://www.washingtonpost.com/technology/2023/04/05/chatgpt-lies/

Thank you, Dr. Nasrallah, for your latest thought-provoking articles on AI. Time and again you provide the profession with cutting-edge, relevant food for thought. Caveat emptor, indeed.

Lawrence E. Cormier, MD
Denver, Colorado

Continue to: We read with interest...

We read with interest Dr. Nasrallah’s editorial that invited readers to share their take on the quality of an AI-generated writing sample. I (MZP) was a computational neuroscience major at Columbia University and was accepted to medical school in 2022 at age 19. I identify with the character traits common among many young tech entrepreneurs driving the AI revolution—social awkwardness; discomfort with subjective emotions; restricted areas of interest; algorithmic thinking; strict, naive idealism; and an obsession with data. To gain a deeper understanding of Sam Altman, the CEO of OpenAI (the company that created ChatGPT), we analyzed a 2.5-hour interview that MIT research scientist Lex Fridman conducted with Altman.¹ As a result, we began to discern why AI-generated text feels so stiff and bland compared to the superior fluidity and expressiveness of human communication. As of now, the creation is a reflection of its creator.

Generally speaking, computer scientists are not warm and fuzzy types. Hence, ChatGPT strives to be neutral, accurate, and objective compared to more biased and fallible humans, and, consequently, its language lacks the emotive flair we have come to relish in normal human interactions. In the interview, Altman discusses several solutions that will soon raise the quality of ChatGPT’s currently deficient emotional quotient to approximate its superior IQ. Altruistically, Altman has opened ChatGPT to all, so we can freely interact and utilize its potential to increase our productivity exponentially. As a result, ChatGPT interfaces with millions of humans through RLHF (reinforcement learning from human feedback), which makes each iteration more in tune with our sensibilities.² Another initiative Altman is undertaking is to depart his Silicon Valley bubble for a road trip to interact with “regular people” and gain a better sense of how to make ChatGPT more user-friendly.¹

What’s so saddening about Dr. Nasrallah’s homework assignment is that he is asking us to evaluate with our mature adult standards an article that was written at the emotional stage of a child in early high school. But our hubris and complacency are entirely unfounded because ChatGPT is learning much faster than we ever could, and it will quickly surpass us all as it continues to evolve.

It is also quite disconcerting to hear how Altman is naively relying upon governmental regulation and corporate responsibility to manage the potential misuse of future artificial general intelligence for social, economic, and political control and upheaval. We know well the harmful effects of the internet and social media, particularly on our youth, yet our laws still lag far behind the fact that these technological innovations are simultaneously enhancing our knowledge while destroying our souls. As custodians of our world, dedicated to promoting and preserving mental well-being, we cannot wait much longer to intervene in properly parenting AI along its wisest developmental trajectory before it is too late.

Maxwell Zachary Price, BA
Nutley, New Jersey

Richard Louis Price, MD
New York, New York

References

1. Sam Altman: OpenAI CEO on GPT-4, ChatGPT, and the Future of AI. Lex Fridman Podcast #367. March 25, 2023. Accessed April 5, 2023. https://www.youtube.com/watch?v=L_Guz73e6fw

2. Heikkilä M. How OpenAI is trying to make ChatGPT safer and less biased. MIT Technology Review. Published February 21, 2023. Accessed April 5, 2023. https://www.technologyreview.com/2023/02/21/1068893/how-openai-is-trying-to-make-chatgpt-safer-and-less-biased/

Disclosures

The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

In his recent editorial (“A ‘guest editorial’ … generated by ChatGPT?” Current Psychiatry, April 2023, p. 6-7, doi:10.12788/cp.0348), Dr. Nasrallah asked for feedback on the ChatGPT-generated editorial on myths surrounding psychiatry. I found the “product” equivalent to a diligent high schooler’s homework assignment. ChatGPT lacks the nuance of a historical perspective, one that has observed the ever-changing enthusiasms (from Freud’s “cure” for posttraumatic stress disorder through dopamine, then 5HT, now glutamate and psychedelics) because mental illness is so difficult to treat. For the guest editorial on myths, a little googling would have yielded the same content, if not a similar list of myths. Surely such an editorial would never be accepted in any psychiatry journal; maybe in Reader’s Digest!

Sara Hartley, MD
Berkeley, California

I just read the “guest editorial” generated by ChatGPT. Thank you for this article. Although this is truly an amazing advancement in artificial intelligence (AI), I feel this guest editorial was very basic. It did not read like scientific writing. It read more like it was written at an 11th- or 12th-grade level, though I am fully aware that the question was simple, and thus the answer was not very deep. I can’t deny that if I had been tested, chances are good I would have fallen among the 32% of my peers who would not have recognized it as AI. I appreciate that you (and your team) are working on a protocol regarding how to include content generated by or with the help of AI. God knows if (most likely, when) people with evil minds will use AI to spread false information that may dispute the accredited scientific data and research that guide the medical world and many other fields. I wonder if AI can serve as a search engine that is better or easier to use than PubMed (for example) and the other services we use for research and learning.

Alex Mustachi, PMHNP-BC
Suffern, New York

I wanted to let you know how much I enjoyed reading your recent editorial on AI and scientific writing. Sharing the 4 AI-generated “articles” with readers (“For artificial intelligence, the future is finally here,” Current Psychiatry, April 2023, p. 8-11,29, doi:10.12788/cp.0354) was a delightfully clever/engaging exercise. Other journals need to take a more proactive/targeted stand on this very important issue.

Martha Sajatovic, MD
Cleveland, Ohio

Continue to: The AI-generated samples...

The Al-generated samples were fascinating. As far as I superficially noted, the spelling, grammar, and punctuation were correct. That is better than one gets from most student compositions. However, the articles were completely lacking in depth or apparent insight. The article on anosognosia mentioned it can be present in up to 50% of cases of schizophrenia. In my experience, it is present in approximately 99.9% of cases. It clearly did not consider if anosognosia is also present in alcoholics, codependents, abusers, or people with bizarre political beliefs. But I guess the “intelligence” wasn’t asked that. The other samples also show shallow thinking and repetitive wording—pretty much like my high school junior compositions.

Maybe an appropriate use for AI is a task such as evaluating suicide notes. AI’s success causes one to feel nonplussed. Much more disconcerting was a recent news article that reported AI made up nonexistent references to a professor’s alleged sexual harassment, and then generated citations to its own made-up reference.¹ That is indeed frightening new territory. How does one fight against a machine to clear their own name?

Linda Miller, NP
Harrisonburg, Virginia

References

1. Verma P, Oremus W. ChatGPT invented a sexual harassment scandal and named a real law prof as the accused. The Washington Post. April 5, 2023. Accessed May 8, 2023. https://www.washingtonpost.com/technology/2023/04/05/chatgpt-lies/

Thank you, Dr. Nasrallah, for your latest thought-provoking articles on AI. Time and again you provide the profession with cutting-edge, relevant food for thought. Caveat emptor, indeed.

Lawrence E. Cormier, MD
Denver, Colorado

Continue to: We read with interest...

We read with interest Dr. Nasrallah’s editorial that invited readers to share their take on the quality of an AI-generated writing sample. I (MZP) was a computational neuroscience major at Columbia University and was accepted to medical school in 2022 at age 19. I identify with the character traits common among many young tech entrepreneurs driving the AI revolution—social awkwardness; discomfort with subjective emotions; restricted areas of interest; algorithmic thinking; strict, naive idealism; and an obsession with data. To gain a deeper understanding of Sam Altman, the CEO of OpenAI (the company that created ChatGPT), we analyzed a 2.5-hour interview that MIT research scientist Lex Fridman conducted with Altman.¹ As a result, we began to discern why AI-generated text feels so stiff and bland compared to the superior fluidity and expressiveness of human communication. As of now, the creation is a reflection of its creator.

Generally speaking, computer scientists are not warm and fuzzy types. Hence, ChatGPT strives to be neutral, accurate, and objective compared to more biased and fallible humans, and, consequently, its language lacks the emotive flair we have come to relish in normal human interactions. In the interview, Altman discusses several solutions that will soon raise the quality of ChatGPT’s currently deficient emotional quotient to approximate its superior IQ. Altruistically, Altman has opened ChatGPT to all, so we can freely interact and utilize its potential to increase our productivity exponentially. As a result, ChatGPT interfaces with millions of humans through RLHF (reinforcement learning from human feedback), which makes each iteration more in tune with our sensibilities.² Another initiative Altman is undertaking is to depart his Silicon Valley bubble for a road trip to interact with “regular people” and gain a better sense of how to make ChatGPT more user-friendly.¹

What’s so saddening about Dr. Nasrallah’s homework assignment is that he is asking us to evaluate with our mature adult standards an article that was written at the emotional stage of a child in early high school. But our hubris and complacency are entirely unfounded because ChatGPT is learning much faster than we ever could, and it will quickly surpass us all as it continues to evolve.

It is also quite disconcerting to hear how Altman is naively relying upon governmental regulation and corporate responsibility to manage the potential misuse of future artificial general intelligence for social, economic, and political control and upheaval. We know well the harmful effects of the internet and social media, particularly on our youth, yet our laws still lag far behind the fact that these technological innovations are simultaneously enhancing our knowledge while destroying our souls. As custodians of our world, dedicated to promoting and preserving mental well-being, we cannot wait much longer to intervene in properly parenting AI along its wisest developmental trajectory before it is too late.

Maxwell Zachary Price, BA
Nutley, New Jersey

Richard Louis Price, MD
New York, New York

References

1. Sam Altman: OpenAI CEO on GPT-4, ChatGPT, and the Future of AI. Lex Fridman Podcast #367. March 25, 2023. Accessed April 5, 2023. https://www.youtube.com/watch?v=L_Guz73e6fw

2. Heikkilä M. How OpenAI is trying to make ChatGPT safer and less biased. MIT Technology Review. Published February 21, 2023. Accessed April 5, 2023. https://www.technologyreview.com/2023/02/21/1068893/how-openai-is-trying-to-make-chatgpt-safer-and-less-biased/

Disclosures

The authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

Intranasal esketamine is an FDA-approved ketamine molecule indicated for use together with an oral antidepressant for treatment-resistant depression (TRD) in patients age ≥18 who have had an inadequate response to ≥2 antidepressants, and for depressive symptoms in adults with major depressive disorder with suicidal thoughts or actions.¹ Since March 2019, we’ve been treating patients with intranasal esketamine. Based on our experiences, here is a summary of what we have learned.

REMS is required. Due to the potential risks resulting from sedation and dissociation caused by esketamine and the risk of abuse and misuse, esketamine is available only through a Risk Evaluation and Mitigation Strategy (REMS) program. The program links your office Drug Enforcement Administration number to the address where this schedule III medication will be stored and given to the patient for self-administration. Requirements and other details about the REMS are available at www.spravatorems.com.

Treatment. Start with the online REMS patient enrollment/consent form. Contra­indications include having a history of aneurysmal vascular disease, intracerebral hemorrhage, or allergy to ketamine/esketamine. Adjunctive treatment with esketamine plus sertraline, escitalopram, venlafaxine, or duloxetine are comparably effective.¹ We have found that adding magnesium to block glutamate action at N-methyl-D-aspartate (NMDA) receptors, bupropion, and the oral NMDA receptor antagonist dextromethorphan may amplify and prolong esketamine’s therapeutic effects. Titrate to a maximum tolerated dose of 3 devices (84 mg total), 5 minutes apart. Administer esketamine twice weekly for 4 weeks, then weekly for the next 4 weeks (for TRD), and continue weekly or twice monthly.¹ Open-label clinical trial data over 4 years support continuing treatment for relapse prevention, and have not reported the long-term cognitive impairment or ulcerative/interstitial cystitis associated with frequent, chronic ketamine use.² TRD clinical trials have shown a response rate (>50% reduction in baseline Montgomery-Åsberg Depression Rating Scale score) of 70% by the end of Week 4, emerging at 4 hours, independent of dissociation.³

Iatrogenic effects rarely lead to dropout. The first session is critical to allay anticipatory anxiety. Sedation, blood pressure increase, and dissociation are common but transient adverse effects that typically peak at 40 minutes and resolve by 90 minutes. Record blood pressure on a REMS monitoring form before treatment, at 40 minutes, and at 2 hours. Avoid administering sedative or prohypertensive medications together with esketamine.¹ Dissociation is more common in patients with a history of trauma. Combine music, guided image­ry, or psychotherapy to harness this for therapeutic benefit. Sleepiness can last 4 hours; make sure the patient has arranged for a ride home, as they cannot drive until the next day. Verify normal blood pressure before starting treatment. Clonidine or labetalol for hypertension/severe dissociation and ondansetron or prochlorperazine for nausea are rarely needed. Advise patients to use the bathroom before treatment and keep a trash can nearby for vomiting. Other transient adverse effects found in TRD clinical trials that occurred >5% and twice that of placebo were dizziness, vertigo, numbness, and feeling drunk.¹

Reimbursement for treatment with esketamine is available through most insurances, including copay cards, rebates, deductible support, and free assistance programs. Coverage is either through pharmacy benefit, assignment of medical benefit (pharmacy handles the medical benefit), or medical benefit with remuneration above wholesale price.

Zeitgeist shift. Emergency departments are backlogged and patients languish waiting to feel the effects of oral antidepressants. Intranasal esketamine could help alleviate this situation by producing a more immediate response. We also have observed improvements in comorbid posttraumatic stress disorder and in cognitive deficits of dementia, possibly due to rapidly enhanced neuroplasticity, neurogenesis, and astrocyte functioning, which NMDA receptor antagonism, AMPA activation, and downstream mediators (eg, brain-derived neurotrophic factor) may promote.⁴

Intranasal esketamine is an FDA-approved ketamine molecule indicated for use together with an oral antidepressant for treatment-resistant depression (TRD) in patients age ≥18 who have had an inadequate response to ≥2 antidepressants, and for depressive symptoms in adults with major depressive disorder with suicidal thoughts or actions.¹ Since March 2019, we’ve been treating patients with intranasal esketamine. Based on our experiences, here is a summary of what we have learned.

REMS is required. Due to the potential risks resulting from sedation and dissociation caused by esketamine and the risk of abuse and misuse, esketamine is available only through a Risk Evaluation and Mitigation Strategy (REMS) program. The program links your office Drug Enforcement Administration number to the address where this schedule III medication will be stored and given to the patient for self-administration. Requirements and other details about the REMS are available at www.spravatorems.com.

Treatment. Start with the online REMS patient enrollment/consent form. Contra­indications include having a history of aneurysmal vascular disease, intracerebral hemorrhage, or allergy to ketamine/esketamine. Adjunctive treatment with esketamine plus sertraline, escitalopram, venlafaxine, or duloxetine are comparably effective.¹ We have found that adding magnesium to block glutamate action at N-methyl-D-aspartate (NMDA) receptors, bupropion, and the oral NMDA receptor antagonist dextromethorphan may amplify and prolong esketamine’s therapeutic effects. Titrate to a maximum tolerated dose of 3 devices (84 mg total), 5 minutes apart. Administer esketamine twice weekly for 4 weeks, then weekly for the next 4 weeks (for TRD), and continue weekly or twice monthly.¹ Open-label clinical trial data over 4 years support continuing treatment for relapse prevention, and have not reported the long-term cognitive impairment or ulcerative/interstitial cystitis associated with frequent, chronic ketamine use.² TRD clinical trials have shown a response rate (>50% reduction in baseline Montgomery-Åsberg Depression Rating Scale score) of 70% by the end of Week 4, emerging at 4 hours, independent of dissociation.³

Iatrogenic effects rarely lead to dropout. The first session is critical to allay anticipatory anxiety. Sedation, blood pressure increase, and dissociation are common but transient adverse effects that typically peak at 40 minutes and resolve by 90 minutes. Record blood pressure on a REMS monitoring form before treatment, at 40 minutes, and at 2 hours. Avoid administering sedative or prohypertensive medications together with esketamine.¹ Dissociation is more common in patients with a history of trauma. Combine music, guided image­ry, or psychotherapy to harness this for therapeutic benefit. Sleepiness can last 4 hours; make sure the patient has arranged for a ride home, as they cannot drive until the next day. Verify normal blood pressure before starting treatment. Clonidine or labetalol for hypertension/severe dissociation and ondansetron or prochlorperazine for nausea are rarely needed. Advise patients to use the bathroom before treatment and keep a trash can nearby for vomiting. Other transient adverse effects found in TRD clinical trials that occurred >5% and twice that of placebo were dizziness, vertigo, numbness, and feeling drunk.¹

Reimbursement for treatment with esketamine is available through most insurances, including copay cards, rebates, deductible support, and free assistance programs. Coverage is either through pharmacy benefit, assignment of medical benefit (pharmacy handles the medical benefit), or medical benefit with remuneration above wholesale price.

Zeitgeist shift. Emergency departments are backlogged and patients languish waiting to feel the effects of oral antidepressants. Intranasal esketamine could help alleviate this situation by producing a more immediate response. We also have observed improvements in comorbid posttraumatic stress disorder and in cognitive deficits of dementia, possibly due to rapidly enhanced neuroplasticity, neurogenesis, and astrocyte functioning, which NMDA receptor antagonism, AMPA activation, and downstream mediators (eg, brain-derived neurotrophic factor) may promote.⁴

Intranasal esketamine is an FDA-approved ketamine molecule indicated for use together with an oral antidepressant for treatment-resistant depression (TRD) in patients age ≥18 who have had an inadequate response to ≥2 antidepressants, and for depressive symptoms in adults with major depressive disorder with suicidal thoughts or actions.¹ Since March 2019, we’ve been treating patients with intranasal esketamine. Based on our experiences, here is a summary of what we have learned.

REMS is required. Due to the potential risks resulting from sedation and dissociation caused by esketamine and the risk of abuse and misuse, esketamine is available only through a Risk Evaluation and Mitigation Strategy (REMS) program. The program links your office Drug Enforcement Administration number to the address where this schedule III medication will be stored and given to the patient for self-administration. Requirements and other details about the REMS are available at www.spravatorems.com.

Treatment. Start with the online REMS patient enrollment/consent form. Contra­indications include having a history of aneurysmal vascular disease, intracerebral hemorrhage, or allergy to ketamine/esketamine. Adjunctive treatment with esketamine plus sertraline, escitalopram, venlafaxine, or duloxetine are comparably effective.¹ We have found that adding magnesium to block glutamate action at N-methyl-D-aspartate (NMDA) receptors, bupropion, and the oral NMDA receptor antagonist dextromethorphan may amplify and prolong esketamine’s therapeutic effects. Titrate to a maximum tolerated dose of 3 devices (84 mg total), 5 minutes apart. Administer esketamine twice weekly for 4 weeks, then weekly for the next 4 weeks (for TRD), and continue weekly or twice monthly.¹ Open-label clinical trial data over 4 years support continuing treatment for relapse prevention, and have not reported the long-term cognitive impairment or ulcerative/interstitial cystitis associated with frequent, chronic ketamine use.² TRD clinical trials have shown a response rate (>50% reduction in baseline Montgomery-Åsberg Depression Rating Scale score) of 70% by the end of Week 4, emerging at 4 hours, independent of dissociation.³

Iatrogenic effects rarely lead to dropout. The first session is critical to allay anticipatory anxiety. Sedation, blood pressure increase, and dissociation are common but transient adverse effects that typically peak at 40 minutes and resolve by 90 minutes. Record blood pressure on a REMS monitoring form before treatment, at 40 minutes, and at 2 hours. Avoid administering sedative or prohypertensive medications together with esketamine.¹ Dissociation is more common in patients with a history of trauma. Combine music, guided image­ry, or psychotherapy to harness this for therapeutic benefit. Sleepiness can last 4 hours; make sure the patient has arranged for a ride home, as they cannot drive until the next day. Verify normal blood pressure before starting treatment. Clonidine or labetalol for hypertension/severe dissociation and ondansetron or prochlorperazine for nausea are rarely needed. Advise patients to use the bathroom before treatment and keep a trash can nearby for vomiting. Other transient adverse effects found in TRD clinical trials that occurred >5% and twice that of placebo were dizziness, vertigo, numbness, and feeling drunk.¹

Reimbursement for treatment with esketamine is available through most insurances, including copay cards, rebates, deductible support, and free assistance programs. Coverage is either through pharmacy benefit, assignment of medical benefit (pharmacy handles the medical benefit), or medical benefit with remuneration above wholesale price.

Zeitgeist shift. Emergency departments are backlogged and patients languish waiting to feel the effects of oral antidepressants. Intranasal esketamine could help alleviate this situation by producing a more immediate response. We also have observed improvements in comorbid posttraumatic stress disorder and in cognitive deficits of dementia, possibly due to rapidly enhanced neuroplasticity, neurogenesis, and astrocyte functioning, which NMDA receptor antagonism, AMPA activation, and downstream mediators (eg, brain-derived neurotrophic factor) may promote.⁴

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) just completed my first semester of medical school. An important lesson imparted in my coursework so far has been to remain a staunch advocate for patients. Yet compared to the rigors of medical school, over the past year it has been far more difficult to help patients locate generic Adderall. Physicians were already overburdened with administrative responsibilities stretching into burnout territory well before the shortage, and now this! Unlike paper prescriptions of old, which patients could take to any pharmacy, e-prescribing apps require selection of a specific pharmacy, and controlled substances such as stimulants require 2-factor authentication. But if the designated pharmacy does not have the medication in stock, the entire process must be repeated with an alternative pharmacy, long after the visit has concluded.

To add insult to injury, the generic stimulant shortage has grown even worse. As of February 2023, generic Adderall remained hard to find and generic Concerta was also in short supply. How did this happen? In 1985, Bulow et al¹ coined the game theory concept of “strategic substitutes,” where (for example) as beef becomes less readily accessible, consumers may switch to eating chicken as their protein. Unable to locate generic Adderall, many patients have turned to generic Concerta as a substitute psychostimulant to continue management of their attention-deficit/hyperactivity disorder.

In addition to the increase in demand, compounding the shortage is that one of the manufacturers of generic Concerta has discontinued production.² Branded methylphenidates and amphetamines, which are much more expensive than their generic counterparts, have remained in ample supply, but many insurers require trials of generics before considering coverage for more expensive brands.

Our approach to this situation

Each morning we call our local and chain pharmacies to take a census of their supply of generic stimulants. Some pharmacies refuse to release this information. Despite these census reports, we have found cases where patients have been turned away from pharmacies when they are not “regular customers,” while patients whom the pharmacies know retain access as “members.” Hence, a patient is unlikely to obtain these medications if their regular pharmacy is out of stock.

We want to share a workaround that has been effective. After unsuccessfully searching for generic stimulants at the patient’s regular pharmacy, I (RLP) write “dispense as written” for the closest branded version and file a prior authorization with the patient’s insurance company, noting “patient unable to trial any generic amphetamines or methylphenidates due to current nationwide shortage.” Even with the most difficult insurers, the response has been “a temporary 3-month authorization has been granted,” which is at least a small victory for our desperate patients and busy prescribers who are both struggling to negotiate a fragmented health care system.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) just completed my first semester of medical school. An important lesson imparted in my coursework so far has been to remain a staunch advocate for patients. Yet compared to the rigors of medical school, over the past year it has been far more difficult to help patients locate generic Adderall. Physicians were already overburdened with administrative responsibilities stretching into burnout territory well before the shortage, and now this! Unlike paper prescriptions of old, which patients could take to any pharmacy, e-prescribing apps require selection of a specific pharmacy, and controlled substances such as stimulants require 2-factor authentication. But if the designated pharmacy does not have the medication in stock, the entire process must be repeated with an alternative pharmacy, long after the visit has concluded.

To add insult to injury, the generic stimulant shortage has grown even worse. As of February 2023, generic Adderall remained hard to find and generic Concerta was also in short supply. How did this happen? In 1985, Bulow et al¹ coined the game theory concept of “strategic substitutes,” where (for example) as beef becomes less readily accessible, consumers may switch to eating chicken as their protein. Unable to locate generic Adderall, many patients have turned to generic Concerta as a substitute psychostimulant to continue management of their attention-deficit/hyperactivity disorder.

In addition to the increase in demand, compounding the shortage is that one of the manufacturers of generic Concerta has discontinued production.² Branded methylphenidates and amphetamines, which are much more expensive than their generic counterparts, have remained in ample supply, but many insurers require trials of generics before considering coverage for more expensive brands.

Our approach to this situation

Each morning we call our local and chain pharmacies to take a census of their supply of generic stimulants. Some pharmacies refuse to release this information. Despite these census reports, we have found cases where patients have been turned away from pharmacies when they are not “regular customers,” while patients whom the pharmacies know retain access as “members.” Hence, a patient is unlikely to obtain these medications if their regular pharmacy is out of stock.

We want to share a workaround that has been effective. After unsuccessfully searching for generic stimulants at the patient’s regular pharmacy, I (RLP) write “dispense as written” for the closest branded version and file a prior authorization with the patient’s insurance company, noting “patient unable to trial any generic amphetamines or methylphenidates due to current nationwide shortage.” Even with the most difficult insurers, the response has been “a temporary 3-month authorization has been granted,” which is at least a small victory for our desperate patients and busy prescribers who are both struggling to negotiate a fragmented health care system.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) just completed my first semester of medical school. An important lesson imparted in my coursework so far has been to remain a staunch advocate for patients. Yet compared to the rigors of medical school, over the past year it has been far more difficult to help patients locate generic Adderall. Physicians were already overburdened with administrative responsibilities stretching into burnout territory well before the shortage, and now this! Unlike paper prescriptions of old, which patients could take to any pharmacy, e-prescribing apps require selection of a specific pharmacy, and controlled substances such as stimulants require 2-factor authentication. But if the designated pharmacy does not have the medication in stock, the entire process must be repeated with an alternative pharmacy, long after the visit has concluded.

To add insult to injury, the generic stimulant shortage has grown even worse. As of February 2023, generic Adderall remained hard to find and generic Concerta was also in short supply. How did this happen? In 1985, Bulow et al¹ coined the game theory concept of “strategic substitutes,” where (for example) as beef becomes less readily accessible, consumers may switch to eating chicken as their protein. Unable to locate generic Adderall, many patients have turned to generic Concerta as a substitute psychostimulant to continue management of their attention-deficit/hyperactivity disorder.

In addition to the increase in demand, compounding the shortage is that one of the manufacturers of generic Concerta has discontinued production.² Branded methylphenidates and amphetamines, which are much more expensive than their generic counterparts, have remained in ample supply, but many insurers require trials of generics before considering coverage for more expensive brands.

Our approach to this situation

Each morning we call our local and chain pharmacies to take a census of their supply of generic stimulants. Some pharmacies refuse to release this information. Despite these census reports, we have found cases where patients have been turned away from pharmacies when they are not “regular customers,” while patients whom the pharmacies know retain access as “members.” Hence, a patient is unlikely to obtain these medications if their regular pharmacy is out of stock.

We want to share a workaround that has been effective. After unsuccessfully searching for generic stimulants at the patient’s regular pharmacy, I (RLP) write “dispense as written” for the closest branded version and file a prior authorization with the patient’s insurance company, noting “patient unable to trial any generic amphetamines or methylphenidates due to current nationwide shortage.” Even with the most difficult insurers, the response has been “a temporary 3-month authorization has been granted,” which is at least a small victory for our desperate patients and busy prescribers who are both struggling to negotiate a fragmented health care system.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) recently started medical school, and one of the first things we learned in our Human Dimension class was to listen to our patients. While this may seem prosaic to seasoned practitioners, I quickly realized the important, real-world consequences of doing so.

Clinicians rightfully presume that when they send a prescription to a pharmacy, the patient will receive what they have ordered or the generic equivalent unless it is ordered “Dispense as written.” Unfortunately, a confluence of increased demand and supply chain disruptions has produced nationwide shortages of generic Adderall extended-release (XR) and Adderall, which are commonly prescribed to patients with attention-deficit/hyperactivity disorder (ADHD).¹ While pharmacies should notify patients when they do not have these medications in stock, we have encountered numerous cases where due to shortages, prescriptions for generic dextroamphetamine/amphetamine salts XR or immediate-release (IR) have been filled with the same milligrams of only dextroamphetamine XR or IR, respectively, without notifying the patient or the prescribing clinician. Pharmacies have included several national chains and local independent stores in the New York/New Jersey region.

Over the past several months, we have encountered patients who had been well stabilized on their ADHD medication regimen who began to report anxiety, jitteriness, agitation, fatigue, poor concentration, and/or hyperactivity, and who also reported that their pills “look different.” First, we considered their symptoms could be attributed to a switch between generic manufacturers. However, upon further inspection, we discovered that the medication name printed on the label was different from what had been prescribed. We confirmed this by checking the Prescription Monitoring Program database.

Pharmacists have recently won prescribing privileges for nirmatrelvir/ritonavir (Paxlovid) to treat COVID-19, but they certainly are not permitted to fill prescriptions for psychoactive controlled substances that have different pharmacologic profiles than the medication the clinician ordered. Adderall contains D-amphetamine and L-amphetamine in a ratio of 3:1, which makes it different in potency from dextroamphetamine alone and requires adjustment to the dosage and potentially to the frequency to achieve near equivalency.

Once we realized the issue and helped our patients locate a pharmacy that had generic Adderall XR and Adderall in stock so they could resume their previous regimen, their symptoms resolved.

It is important for all clinicians to add “medication substitution reaction” to their differential diagnosis of new-onset ADHD-related symptoms in previously stable patients.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) recently started medical school, and one of the first things we learned in our Human Dimension class was to listen to our patients. While this may seem prosaic to seasoned practitioners, I quickly realized the important, real-world consequences of doing so.

Clinicians rightfully presume that when they send a prescription to a pharmacy, the patient will receive what they have ordered or the generic equivalent unless it is ordered “Dispense as written.” Unfortunately, a confluence of increased demand and supply chain disruptions has produced nationwide shortages of generic Adderall extended-release (XR) and Adderall, which are commonly prescribed to patients with attention-deficit/hyperactivity disorder (ADHD).¹ While pharmacies should notify patients when they do not have these medications in stock, we have encountered numerous cases where due to shortages, prescriptions for generic dextroamphetamine/amphetamine salts XR or immediate-release (IR) have been filled with the same milligrams of only dextroamphetamine XR or IR, respectively, without notifying the patient or the prescribing clinician. Pharmacies have included several national chains and local independent stores in the New York/New Jersey region.

Over the past several months, we have encountered patients who had been well stabilized on their ADHD medication regimen who began to report anxiety, jitteriness, agitation, fatigue, poor concentration, and/or hyperactivity, and who also reported that their pills “look different.” First, we considered their symptoms could be attributed to a switch between generic manufacturers. However, upon further inspection, we discovered that the medication name printed on the label was different from what had been prescribed. We confirmed this by checking the Prescription Monitoring Program database.

Pharmacists have recently won prescribing privileges for nirmatrelvir/ritonavir (Paxlovid) to treat COVID-19, but they certainly are not permitted to fill prescriptions for psychoactive controlled substances that have different pharmacologic profiles than the medication the clinician ordered. Adderall contains D-amphetamine and L-amphetamine in a ratio of 3:1, which makes it different in potency from dextroamphetamine alone and requires adjustment to the dosage and potentially to the frequency to achieve near equivalency.

Once we realized the issue and helped our patients locate a pharmacy that had generic Adderall XR and Adderall in stock so they could resume their previous regimen, their symptoms resolved.

It is important for all clinicians to add “medication substitution reaction” to their differential diagnosis of new-onset ADHD-related symptoms in previously stable patients.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

I (MZP) recently started medical school, and one of the first things we learned in our Human Dimension class was to listen to our patients. While this may seem prosaic to seasoned practitioners, I quickly realized the important, real-world consequences of doing so.

Clinicians rightfully presume that when they send a prescription to a pharmacy, the patient will receive what they have ordered or the generic equivalent unless it is ordered “Dispense as written.” Unfortunately, a confluence of increased demand and supply chain disruptions has produced nationwide shortages of generic Adderall extended-release (XR) and Adderall, which are commonly prescribed to patients with attention-deficit/hyperactivity disorder (ADHD).¹ While pharmacies should notify patients when they do not have these medications in stock, we have encountered numerous cases where due to shortages, prescriptions for generic dextroamphetamine/amphetamine salts XR or immediate-release (IR) have been filled with the same milligrams of only dextroamphetamine XR or IR, respectively, without notifying the patient or the prescribing clinician. Pharmacies have included several national chains and local independent stores in the New York/New Jersey region.

Over the past several months, we have encountered patients who had been well stabilized on their ADHD medication regimen who began to report anxiety, jitteriness, agitation, fatigue, poor concentration, and/or hyperactivity, and who also reported that their pills “look different.” First, we considered their symptoms could be attributed to a switch between generic manufacturers. However, upon further inspection, we discovered that the medication name printed on the label was different from what had been prescribed. We confirmed this by checking the Prescription Monitoring Program database.

Pharmacists have recently won prescribing privileges for nirmatrelvir/ritonavir (Paxlovid) to treat COVID-19, but they certainly are not permitted to fill prescriptions for psychoactive controlled substances that have different pharmacologic profiles than the medication the clinician ordered. Adderall contains D-amphetamine and L-amphetamine in a ratio of 3:1, which makes it different in potency from dextroamphetamine alone and requires adjustment to the dosage and potentially to the frequency to achieve near equivalency.

Once we realized the issue and helped our patients locate a pharmacy that had generic Adderall XR and Adderall in stock so they could resume their previous regimen, their symptoms resolved.

It is important for all clinicians to add “medication substitution reaction” to their differential diagnosis of new-onset ADHD-related symptoms in previously stable patients.