Adult NP practicing in BH/psych?

Jules A, MSN · Feb 9, 2017

Contact your state's board of nursing, and get it in writing. This will vary and in addition to short changing your patients in many states you will put your license in jeopardy for practicing outside your scope if operating solely in psych without the required certification.

Psychcns · Feb 11, 2017

Same with malpractice insurance company.

elkpark · Feb 12, 2017

I always find it helpful to reframe this type of question: If you were presenting to a healthcare facility seeking psychiatric care, would you be expecting to be seen by someone specifically educated and credentialed in mental health, or would you be okay with someone trained in internal medicine who is "interested in" mental health?

Sailrmar9 · Feb 15, 2017

Thank you for your help. I obviously don't want to put my license in jeopardy. I understand the comment @elkpark has made. It is just interesting that adult NP's treat mental health disorders in primary care but cannot "specialize" without out the additional certification. However, if I wanted to go work in the urology department this would not be an issue and it would not "require" me to have any additional certification.

Jules A, MSN · Feb 15, 2017

Thank you for your help. I obviously don't want to put my license in jeopardy. I understand the comment @elkpark has made. It is just interesting that adult NP's treat mental health disorders in primary care but cannot "specialize" without out the additional certification. However, if I wanted to go work in the urology department this would not be an issue and it would not "require" me to have any additional certification.

I think much of it has to do with the fact that there is a Psych specialty track so therefore those who don't have it and are attempting work solely in psych have not received what is the established education minimum requirements.

Hopefully the adult NPs you speak of treating psych are in fact only doing the very basics for depression etc. because imo if an appropriate trial of 2 SSRIs doesn't cut it the patient needs to be referred to a mental health provider. You wouldn't believe the screwed up regimens I'm asked to take over most all of course including a PCP created benzodiazepine dependence.

Trauma Columnist · Feb 15, 2017

I work with chronically ill pts and although I've been at this almost 11 years, I am still nervous about psych stuff (as well I should be)!

However, while I will prescribe a renally-dosed anti-depressant, I refer to counseling also.

And...in my area the wait for even a tele-psych visit is 1 year if you are on medicaid!!!!

So...I can see where the PCP might be the prescriber for psych meds

Jules A, MSN · Feb 15, 2017

However, while I will prescribe a renally-dosed anti-depressant, I refer to counseling also.
And...in my area the wait for even a tele-psych visit is 1 year if you are on medicaid!!!!
So...I can see where the PCP might be the prescriber for psych meds

The therapy component is huge kudos. If there was access to decent therapists a majority of my patients would have very little need for me other than a brief stabilization period as therapy starts working.

I think where the major problem lies is in the lack of making the referral initially. Most of the patients I get turfed off from PCP because they now need a specialist would have already gotten a psych eval if the PCP hasn't waited until it was a train wreck to refer. Definitely put them on the waiting list. At my OP practice I have no problem doing a few med management consults and getting them back to their PCP for ongoing management but don't I appreciate getting a hot mess that I'm supposed to sort out in 30 minutes or less again especially with benzo dependence.

elkpark · Feb 15, 2017

It is just interesting that adult NP's treat mental health disorders in primary care but cannot "specialize" without out the additional certification. However, if I wanted to go work in the urology department this would not be an issue and it would not "require" me to have any additional certification.

Maybe I'm an outlier on this, but, if I were seeking out specifically urology care, as opposed to (or beyond) just seeing my PCP for my concerns, I would expect to be seen by someone specifically trained and credentialed in that specialty, not someone who was generally trained and had chosen to work in a specific specialty without further formal education and specialization.

I've been kvetching for decades now that if we, the psychiatric community, were out there treating people's heart disease and COPD and diabetes and gout, the rest of the medical community would be after us in an angry mob with torches and pitchforks -- but, somehow, eeeeeevvvvverybody with a license feels s/he is competent to treat psychiatric disorders. It's a specialty for a reason, folks.

elkpark · Feb 15, 2017

I think where the major problem lies is in the lack of making the referral initially. Most of the patients I get turfed off from PCP because they now need a specialist would have already gotten a psych eval if the PCP hasn't waited until it was a train wreck to refer. Definitely put them on the waiting list. At my OP practice I have no problem doing a few med management consults and getting them back to their PCP for ongoing management but don't I appreciate getting a hot mess that I'm supposed to sort out in 30 minutes or less again especially with benzo dependence.

We see this all the time in the psych consultation/liaison service on which I work. People get admitted to the hospital for something medical, and we get consulted while they're there because the PCP has been treating the individual for months (or years) for a serious psychiatric problem, has not referred her/him to any form of psychiatric treatment, has made a complete mess of the entire situation, which is now a major trainwreck, and, now, while the individual is in the hospital for some acute medical problem, wants us to fix that, please. (Or, as happens sometimes, actually admits them to the hospital on some flimsy pretext primarily so they can be seen by psychiatry. Y'know, so we can fix the mess the PCP has made.) You wouldn't believe (or maybe you would :)) the crazy psych med regimens we see, and tons of benzo dependence. (Having a bad day? Here, let me give you a scrip for six months' worth of Xanax. Enjoy!!) :rolleyes:

allnurses Guide · Feb 15, 2017

I no longer work as a PCP, but have never felt comfortable treating more than simple depression/anxiety. There's no way I have the training or expertise to deal with more serious psychiatric disorders, and I understand that I could do more harm than good despite my best intentions. It's criminal that there is not better access to mental health providers. PCPs are often caught in a bind of trying to help a patient while waiting to get them in to see a psych provider and therapist. I see a few of these patients in Urgent Care, but fortunately we have the ability to get them in to see psych in a relatively short time period. So, as psych providers, what is your advice to other providers who have a patient in need of mental health services, but can't get in to see one for months?

Jules A, MSN · Feb 15, 2017

So, as psych providers, what is your advice to other providers who have a patient in need of mental health services, but can't get in to see one for months?

Excellent question and this would be a great thread. There are several things I would suggest and I also attempt to work this in reverse for my mental health patients who do not have a pcp.

1. Make friends with local psych peeps both prescribers and therapists. I am always adding clinic hours to fit in a VIP whether that be a colleague, colleague's friend/family member or a patient of a colleague who is struggling. For those I'm especially close with and respect I'll do curbside consults gratis. What I can say is even with smart PCPs for some reason psych diagnoses and meds must not be instinctual because most often they have a less than stellar plan in mind.

2. Park your ego at the door. Its wonderful to be needed however attempting to be everything to everyone can result in poor care and actual harm to both your patient and your license. This is particularly important for patients who have psychosis, true BiPad, personality disorders or SUD. I'd avoid trying to go this alone. If you are trying to prescribe for psych conditions immediately also make referrals even if you hear the time frame is a year out at least they are on the list. Ask to have the patient put on a cancellation list. We call people on our list often and in the cases of the chronically ill who aren't working many times they can come in for an appointment with only a few hours notice.

3. Remember most refractory mental health issues, sans psychosis, are as much psychosocial as chemical. People who have a long list of medication failures, although very often not true medication failures, are not who I'd test the waters with. Again always recommend therapy.

4. With ADHD, Anxiety or Depression if your first two attempts at medication aren't helpful refer it out. I recently had a patient on Wellbutrin, Zoloft, Abilify and Xanax from PCP. The patient was hospitalized on my unit after a significant suicide attempt. At what point didn't the PCP realize they were in over their head? When adding the second antidepressant? Or the antipsychotic perhaps? Just because you see a med on TV as an adjunct to whatever doesn't mean its appropriate. FWIW this was not even a complicated case. It was mostly untreated psychosocial stressors and ridiculous polypharm.

5. If a patient is pushing you for a medication, usually benzos or stimulants, as the only thing that works and insinuating they will be a risk of harm if you don't order these medications this is a huge red flag. I would not touch this with a ten foot pole. Do not let their agitation, threats, shaking, screaming or tears make you as anxious as they seem and sway you to prescribe something you know is in appropriate.

6. If they are on a medication that causes dependence from another provider you are under no obligation to continue it or attempt a taper. Billing for a patient evaluation does not obligate you to prescribe anything and there is always the ED if at acute risk or send them back to the person who started that mess, document thoroughly.

7. As above please, please think of what you are doing before you cause someone to become dependent on benzodiazepines. They very often do more harm than good.

8. Children almost NEVER have psychosis or Bipolar. If they are having perceptual disturbances on a stimulant they are probably delirious. If you think you are seeing psychosis or mania in a child refer out, don't pass go, don't collect $200.