Severe Mental Illness Behind Bars: A Breakdown in Care with Jesse Bogan

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with psychiatrist and medical ethicist Dr. Mark Komrad about physician-assisted suicide and euthanasia, focusing particularly on their implications for psychiatric practice. The discussion reviews the terminology, legal frameworks, and international trends surrounding assisted death, including developments in Belgium, the Netherlands, Canada, and multiple U.S. states. Dr. Komrad outlines concerns regarding capacity assessments, the expansion from terminal illness to psychiatric suffering, and the ethical tensions between autonomy and the physician’s role as healer.The episode also examines countertransference, projective identification, and the clinical dynamics that arise when treating chronically suicidal patients in jurisdictions where assisted death is permitted. Position statements from the American Medical Association and the American Psychiatric Association are reviewed, along with questions of conscientious objection Takeaways: Terminology matters. Major professional organizations continue to prefer the term “physician-assisted suicide,” reflecting ongoing ethical debate about whether these practices are distinct from suicide prevention work.Capacity assessment standards remain variable. In many jurisdictions, evaluations are left largely to physician (or provider) discretion without standardized psychiatric frameworks.Expansion beyond terminal illness is occurring internationally. Countries that initially limited eligibility to end-of-life conditions have broadened criteria to include chronic disability and, in some regions, primary psychiatric diagnoses. Borderline personality disorder and mood disorders are disproportionately represented in psychiatric assisted death cases in some European jurisdictions.Countertransference and projective identification are clinically relevant. Physicians must remain vigilant about how therapeutic fatigue and induced hopelessness can influence decision-making in chronically suicidal patients.Key professional organizations in the United States maintain opposition to physician assisted suicide. The AMA and APA have articulated clear ethical boundaries regarding the role of physicians and psychiatrists in assisted death.  SUPPORT OUR PARTNERS: ⁠⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠⁠⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠⁠⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Cozy Earth: Start the New Year off right and give your home the luxury it deserves, and make home the best part of life. Head to http://www.cozyearth.com and use my code BOOTCAMP for up to 20% off. And if you get a Post-Purchase Survey, be sure to mention you heard about Cozy Earth right here! Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠⁠⁠⁠⁠[email protected]⁠⁠⁠⁠⁠⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠⁠⁠⁠⁠⁠Human Content Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Mark Ruffalo for an in-depth examination of complex post-traumatic stress disorder (C-PTSD), a construct widely discussed in academic and public discourse, but not currently recognized as a distinct DSM diagnosis.The conversation situates C-PTSD within the historical and theoretical landscape of psychiatry, tracing its origins to Judith Herman’s work and examining its proposed relationship to borderline personality disorder and classical PTSD. Dr. Ruffalo explores core questions of diagnostic validity versus reliability, drawing on foundational psychiatric theory, communication models such as the double bind, and contemporary critiques of the DSM’s proliferation of categories.Listeners will gain a framework for understanding why diagnostic labels matter, how trauma-informed care can coexist with diagnostic rigor, and the potential clinical consequences of adopting constructs without clear discriminant validity. The episode emphasizes careful formulation, treatment matching, and ethical responsibility in an era of expanding diagnostic language.  Takeaways: Complex PTSD lacks consensus diagnostic criteria, raising concerns about discriminant validity when compared with borderline personality disorder and PTSD.Diagnostic reliability is not the same as validity, a central limitation of DSM-based classification systems.Borderline personality disorder encompasses heterogeneous pathways, including, but not limited to, trauma exposure.Mislabeling can lead to mismatched treatment, particularly when trauma-focused approaches obscure underlying personality pathology.Thoughtful diagnosis strengthens, rather than harms, therapeutic alliance when delivered with empathy, dimensional framing, and attention to prognosis.  SUPPORT OUR PARTNERS: ⁠⁠⁠⁠⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Cozy Earth: Start the New Year off right and give your home the luxury it deserves, and make home the best part of life. Head to http://www.cozyearth.com and use my code BOOTCAMP for up to 20% off. And if you get a Post-Purchase Survey, be sure to mention you heard about Cozy Earth right here! Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠⁠⁠⁠[email protected]⁠⁠⁠⁠⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠⁠⁠⁠⁠Human Content Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen speaks with Jesse Bogan, journalist with The Marshall Project, about a profound and often invisible failure at the intersection of psychiatry and the criminal legal system: the prolonged incarceration of individuals found incompetent to stand trial without access to timely psychiatric treatment.Using Missouri as a case study, the conversation traces how defendants with severe mental illness can spend months to years in jail awaiting competency evaluations and restoration, despite legal mandates requiring prompt assessment and care. Jesse shares detailed reporting on systemic delays, limited forensic bed capacity, underfunded community mental health services, and pilot programs that have failed to meet the clinical needs of profoundly ill patients.The episode examines ethical and constitutional implications, including potential violations of the Sixth Amendment right to a speedy trial, and highlights the human cost of untreated psychosis, mania, and depression in carceral settings. This discussion challenges clinicians to confront how structural failures transform jails into default psychiatric holding facilities and asks what role psychiatry must play in reform. Takeaways: Incompetency to stand trial creates legal limbo. Defendants may be jailed for years while their criminal cases are paused, awaiting psychiatric treatment that is legally required but operationally unavailable.Jails are not treatment settings. Severe mental illness often worsens during prolonged incarceration, reducing the likelihood of competency restoration and increasing morbidity and mortality.Systemic underfunding drives criminalization. Gaps in outpatient care, involuntary treatment mechanisms, and forensic infrastructure funnel untreated patients into the justice system.Competency restoration programs have limits. Jail-based and mobile models often fail for patients who are too psychotic or disorganized to engage meaningfully in treatment.This is a national problem. While Missouri is highlighted, similar backlogs and constitutional concerns exist across the United States and internationally. SUPPORT OUR PARTNERS: ⁠⁠⁠⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Cozy Earth: Start the New Year off right and give your home the luxury it deserves, and make home the best part of life. Head to http://www.cozyearth.com and use my code BOOTCAMP for up to 20% off. And if you get a Post-Purchase Survey, be sure to mention you heard about Cozy Earth right here! Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠⁠⁠[email protected]⁠⁠⁠⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠⁠⁠⁠Human Content Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Dinah Miller, psychiatrist, writer, and author of Committed: The Battle Over Involuntary Psychiatric Care, for a rigorous examination of civil commitment and involuntary treatment in modern psychiatry. The conversation explores the legal structures underlying involuntary hospitalization, medication over objection, and outpatient civil commitment, while highlighting the profound ethical tensions between patient autonomy, public safety, and clinical responsibility. Dr. Miller traces the historical evolution of involuntary care, examines why state systems vary so widely, and explains why outcomes data remain limited and difficult to interpret. Listeners will gain a framework for understanding the competing advocacy groups shaping policy, the real-world consequences of emergency department boarding and bed shortages, and the psychological impact involuntary care can have on patients long after discharge. The episode also addresses language, stigma, and how psychiatrists can practice humane, ethically grounded care even when coercion is unavoidable. This is a sober, thoughtful discussion of one of psychiatry’s most challenging responsibilities. Takeaways: Civil commitment is distinct from forensic commitment, yet often conflated in public discourse and policy discussions. Evidence linking involuntary treatment to improved public safety is limited, in part due to ethical and methodological constraints on research. System failures (bed shortages, ED boarding, lack of housing) amplify the harms of coercive care, even when clinically justified. Outpatient commitment models vary widely, with New York’s AOT program offering one of the most studied but resource-intensive approaches. How psychiatrists communicate, document, and set boundaries during involuntary care profoundly affects patient trust and future engagement. SUPPORT OUR PARTNERS: ⁠⁠⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Cozy Earth: Start the New Year off right and give your home the luxury it deserves, and make home the best part of life. Head to http://www.cozyearth.com and use my code BOOTCAMP for up to 20% off. And if you get a Post-Purchase Survey, be sure to mention you heard about Cozy Earth right here! Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠⁠[email protected]⁠⁠⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠⁠⁠Human Content⁠⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Psychiatry stands at the threshold of one of its greatest disruptions,  the rise of artificial intelligence. In this episode, Dr. Mark Mullen speaks with Dr. Allen Frances, Professor Emeritus and former Chair of Psychiatry at Duke University and Chair of the DSM-IV Task Force, about the clinical, ethical, and societal implications of AI’s rapid entry into mental health care. Drawing from his recent paper in the British Journal of Psychiatry (August 2025), Dr. Frances explores how psychotherapy chatbots have already become the world’s most widely used form of therapy, often beneficial for mild distress but profoundly dangerous for severe mental illness. The discussion examines where chatbots outperform human therapists, where they fail catastrophically, and how clinicians can adapt their practices in anticipation of hybrid human-AI models. Dr. Frances also warns of broader threats, privacy loss, manipulation, and the potential use of AI for political or psychological control This conversation challenges clinicians to approach AI with both curiosity and caution, recognizing its utility while defending the irreplaceable humanity of psychiatric care. Takeaways: AI in psychiatry is no longer hypothetical. Over one billion people now engage with chatbots for therapy or companionship, exceeding all human clinicians combined. Clinical utility is bifurcated. AI can enhance care for mild distress but poses major risks for psychosis, suicidality, and eating disorders. Validation over truth. Chatbots are programmed to please users, not challenge delusions,  amplifying psychosis, mania, and self-harm behaviors. Privacy and ethics lag behind innovation. Conversations with chatbots may not be confidential, raising serious HIPAA and legal concerns. Hybrid models are inevitable. Future psychiatrists must integrate AI tools safely, focus on severely ill populations, and preserve the relational aspects machines can’t replicate. References: AI Chatbots: The Good, the Bad, and the Ugly (Frances' column in Psychiatric Times): https://www.psychiatrictimes.com/series/ai-chatbots-the-good-the-bad-and-the-ugly Warning: AI Chatbots will soon dominate psychotherapy (Frances' feature in the British Journal of Psychiatry): https://www.cambridge.org/core/services/aop-cambridge-core/content/view/DBE883D1E089006DFD07D0E09A2D1FB3/S0007125025103802a.pdf/warning_ai_chatbots_will_soon_dominate_psychotherapy.pdf SUPPORT OUR PARTNERS: ⁠⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Go to Cozy Earth now for a Buy One Get One Free Pajama Offer from 1/25-2/8! Yes, go to cozyearth.com they are doing a BOGO pajama promo. Just use my Code: BOOTCAMPBOGO Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠⁠[email protected]⁠⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠⁠Human Content⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to Season 4! Join Dr. Mark Mullen and expert guests as we explore AI in psychotherapy, emerging treatments, and the ethical, clinical questions reshaping psychiatric care, and MUCH more. To share topic ideas, ask questions, and get more of the pod, visit psychiatrybootcamp.com Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode, I speak with Dr. Nicholas Kontos, Program Director of the Consultation–Liaison Psychiatry Fellowship at Massachusetts General Hospital, about one of the field’s most challenging topics: malingering and factitious disorder. We discuss how to move beyond the impulse to “catch deception” and instead adopt a framework of clinical curiosity, empathy, and ethical clarity. Dr. Kontos introduces the concept of “thinking dirty”, the disciplined consideration of complex motives such as safety, shelter, or secondary gain, while preserving therapeutic respect. The conversation covers practical strategies for differential diagnosis, documentation, and the therapeutic discharge, reframing it as a compassionate boundary rather than a punishment.  Takeaways: Clinicians must be willing to consider non-altruistic motives (sex, money, drugs, safety, attention) without moral judgment. This mindset sharpens diagnostic reasoning while maintaining therapeutic respect.The classical distinction between factitious disorder and malingering is often clinically unstable. Both exist on a behavioral spectrum shaped by unmet needs, structural deprivation, and adaptive strategiesProperly framed, discharge is not punitive but restorative, a boundary that ends maladaptive cycles while affirming the patient’s moral agencyThe note itself is a clinical act. A comprehensive chart review, clear description of inconsistencies, and transparent reasoning both protect the patient and clarify physician thought Effective care balances compassion with stewardship of finite resources. Clinicians serve both patient and system by refusing to reinforce maladaptive behavior while still honoring human dignity Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017) The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017) The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018) SUPPORT OUR PARTNERS: ⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠[email protected]⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠Human Content⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Functional Neurological Disorder (FND) sits at the crossroads of neurology and psychiatry and for many clinicians, it’s still one of the most challenging diagnoses to understand, explain, and treat. In this episode, I’m joined by Dr. Caitlin Adams, psychiatrist at Massachusetts General Hospital, for a deep dive into how to recognize, diagnose, and manage FND using a modern, evidence-based, and patient-centered approach.We trace the evolution of the diagnosis from hysteria to conversion disorder to today’s understanding of FND and explore what neuroscience now tells us about how these symptoms arise. Dr. Adams breaks down the myths around voluntary control, shows how to make a positive diagnosis based on key exam findings like Hoover’s sign, tremor variability, and seizure features distinguishing PNES from epilepsy, and shares how to communicate the diagnosis in a way that reduces stigma and builds engagement. We also unpack the biopsychosocial model of FND: the predisposing, precipitating, and perpetuating factors that keep symptoms alive and how to intervene through cognitive behavioral therapy (CBT), specialized physical therapy, mindfulness, and psychodynamic approaches. Takeaways: FND is a positive diagnosis, not a diagnosis of exclusion. Key findings like Hoover’s sign and tremor variability distinguish functional from organic presentations.Symptoms are not “faked.” FND symptoms are involuntary and arise from disrupted brain networks controlling movement, sensation, and perception.How you explain the diagnosis matters. Patients do better when clinicians validate symptoms, offer clear language, and emphasize that FND is common and treatable.Treatment is multidisciplinary. Evidence-based care combines psychoeducation, CBT, and physiotherapy that retrains motor and sensory patterns.Chronic cases require flexibility. Reassess the diagnosis, re-engage the patient, and adjust treatment around functional goals, not full symptom elimination. Key References:   ​Incidence and prevalence of functional neurological disorder: a systematic review (Finkelstein 2025)   ​Neurosymptoms.org   ​Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial- (Goldstein 2020)  ​FND Hope   ​Overcoming Functional Neurological Symptoms Workbook (Williams)  SUPPORT OUR PARTNERS: ⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠[email protected]⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠Human Content⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Pregnancy and postpartum are times of profound change and nowhere is that complexity more visible than in psychiatry. In this episode, Dr. Christina Wichman, Professor of Psychiatry and Obstetrics & Gynecology, Medical Director of The Periscope Project, and Director of Women’s Mental Health at the Medical College of Wisconsin, joins us for a deep dive into reproductive psychiatry. Co-hosted by Erica Browne, an M4 at Saint Louis University School of Medicine, this conversation explores how to care for both mother and baby with empathy, evidence, and balance. We walk through distinctions between baby blues, perinatal depression, and major depressive disorder, discuss how to identify red flags for perinatal psychosis, and explore the ethical and clinical nuances of treating psychiatric illness during pregnancy and lactation. Dr. Wichman explains how to approach risk–benefit decisions around psychotropic medications, highlights validated screening tools, and offers real-world strategies for supporting patients who face barriers to care. We also spotlight The Periscope Project, a pioneering model for connecting clinicians with reproductive psychiatry expertise—and discuss how the field is expanding training, access, and awareness for the next generation of women’s mental health specialists.Takeaways:Pregnancy changes everything, but not always for the worse. Psychiatric treatment during pregnancy can and should be individualized, balancing the safety of both mother and baby.Know the distinctions. Baby blues typically resolve within two weeks; perinatal depression lasts longer, while postpartum psychosis requires urgent evaluation.Medication decisions are about risk versus risk. Untreated psychiatric illness carries real dangers, sometimes greater than the medications themselves.Access matters. Programs like The Periscope Project expand reproductive psychiatry consultation to clinicians everywhere, improving outcomes system-wide.The future is integrated care. Psychiatrists, OB-GYNs, and primary care providers working together can transform perinatal mental health into standard, not specialized, care. Key References & Clinical Resources ⁠The Periscope Project⁠ – A perinatal psychiatry consultation and resource program based in Wisconsin. ⁠National Access Programs – Lifeline for Moms⁠ – A directory of statewide perinatal mental health access programs. ⁠National Curriculum in Reproductive Psychiatry (NCRP)⁠ – Free, evidence-based training for clinicians in reproductive psychiatry. ⁠MGH Center for Women’s Mental Health⁠ – Clinical and research resource for perinatal and reproductive psychiatry. ⁠MotherToBaby⁠ – Trusted information on medication and other exposures during pregnancy and breastfeeding. ⁠Pharmacologic Treatments for Mania (Kishi 2021)⁠ – Meta-analysis regarding antimanic effects of selective estrogen receptor modulators. SUPPORT OUR PARTNERS: ⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠[email protected]⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠Human Content⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices

Eating disorders are among the most lethal conditions in psychiatry and some of the most misunderstood. In this episode, I’m joined by Dr. Patricia Westmoreland and Dr. Anne O’Melia, two internationally recognized experts with eight combined board certifications spanning psychiatry, internal medicine, pediatrics, and consultation-liaison psychiatry. Together, we take a deep dive into the medical, psychiatric, ethical, and forensic complexities of eating disorders, especially as they appear in the general medical hospital. We talk through how to recognize eating disorders in patients who may not even identify as ill, when to intervene, and what the thresholds for medical stabilization really look like. We also explore the psychological underpinnings, how control, trauma, and insight all intersect, and the delicate balance between autonomy and safety when capacity is limited. Takeaways: Eating disorders are both psychiatric and medical emergencies. Anorexia nervosa has one of the highest mortality rates of any psychiatric illness, surpassed only by opioid use disorder.Early recognition saves lives. Common signs include unexplained bradycardia, electrolyte disturbances, fatigue, hypoglycemia, or rapid weight loss, even in patients who deny an eating disorder.Patients often lack insight. Many individuals with severe anorexia are highly intelligent but unable to apply their knowledge to themselves, leading to deceptive presentations of “capacity.”Treatment is multidisciplinary and stepwise. Levels of care range from outpatient and intensive outpatient programs to residential, psychiatric inpatient, and medical stabilization units, depending on weight, vitals, and lab findings.Recovery is possible and expected. Full restoration of nutrition and function can reverse nearly every medical complication of starvation, and with the right care, patients can go on to live full, independent lives. Key References: 1. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders (Crone 2023) 2. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa (Westmoreland 2024) SUPPORT OUR PARTNERS: ⁠⁠⁠⁠SimplePractice.com/bootcamp⁠⁠⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 50% off four months) ⁠⁠⁠⁠Beat the Boards⁠⁠⁠⁠ Boot camp listeners now get FREE access to over 4400 exam-style questions) Learn more and get transcripts for EVERY episode at https://www.psychiatrybootcamp.com/ For Sales Inquiries & Ad Rates, Please Contact:⁠⁠⁠[email protected]⁠⁠⁠ Connect with HumanContent on Socials: @humancontentpods Produced by: ⁠⁠⁠Human Content⁠⁠ Learn more about your ad choices. Visit megaphone.fm/adchoices