Mid-school Crisis (PMHNP)

[indomie23, BSN, RN]

HeIlo! I am going through a mid-school crisis in my PMHNP program, and wanted your advice. I am in Psychopharm and Psych-patho, and I cannot shrug off the thought of mental illness and psychotropic medications not being concrete concepts for me. I am often reading in my textbooks that there is inconclusive evidence to a medication's proven efficacy on a disorder, and there is a large risk for misdiagnosing due to overlap of symptoms. I am torn whether these psychiatric disorders are part of the natural process of a person actually coping/developing, and if psychotropics cause more harm than good, and if there really is a true difference between placebo and medication. I understand the need for psychotropics in acute, severe situations to manage a patient, but I guess I am more skeptical about outpatient treatment in more stable patients.

I think I want to continue in this program, but it's difficult with these thoughts I have. Any advice? TIA!

[ToFNPandBeyond]

You bring up very valid concerns that many in the medical/nursing field shy away from talking about. 

You're correct, many of these psychotropic, and other pharmaceutical meds, have a whole host of side effects. And when you get into a situation of polypharmacy, which usually happens in the field of psychiatry, as well as family medicine, then you end up treating the side effects from the meds (WITH MORE MEDS LOL), in addition to, or sometimes in lieu of, the actual medical condition.

However, you'll likely experience this dilemma iN other fields as well. For example, in primary care where I use to work, I knew of many ppl who were quick to treat pre-diabetes or mild elevated lipids with meds instead of lifestyle changes and monitoring. Are they wrong to do so? It's debatable....

I work in psych, and I've adopted the approach of if it's essential (I.e. affecting quality of life, ability to do ADLs, or is severe) , I treat with meds. If not, I provide education, motivational interviewing, and other resources so that they can manage without meds, and I state my rationale. The beauty of being a provider is that you can choose how you want to practice. Not everyone will need meds. Now, from a billing standpoint, politics do come into play. You wouldn't be able to do this with every pt, but that's kind of the point...you won't need to, because in psych, you see the full spectrum of illness and severity. 

 

Hope this helps.

[verene, MSN]

^This, ToFNPandBeyond, stated much more succinctly than I managed - but I fully agree.

Indomie23 - I saw your PM and sent you a response. Hope it helps.

 

[CommunityRNBSN, BSN, RN]

I’m an RN, not advanced practice. But I really feel what you are talking about. I work in an FQHC, so our patients have all sorts of socioeconomic stressors and poor education, transient lifestyle, etc. I work in internal medicine, but many of them also see our behavioral health department.  Just due to the realities of our situation, they are often thrown pills on top of pills. As one example: I have SO MANY patients who tell me “Yeah I go to the ED a few times a month with panic attacks when my Xanax doesn’t work.”  We know that panic disorder is highly highly treatable with appropriate therapy— CBT or other psychotherapy, patient education, plus in some cases SSRIs or a short course of benzodiazepines. But it’s almost impossible for our patients to get the best treatment, so the prescribers throw Xanax at them, because it at least allows the patient to function, to some extent, and the patient believes they can’t survive without it.  But it doesn’t actually treat them, as evidenced by the fact that their symptoms are out of control.  It’s incredibly frustrating and I’m not sure what the solution is. 

[myoglobin, ASN, BSN, MSN]

I would suggest listening to podcasts such as The Carlat Report, Dr. David Puder, and The Psychopharmacology Institute.  All of these focus on evidence based psychopharmacology and therapy. For some conditions such as ADHD are medications are highly effective about 0.8 of a standard deviation better than placebo. I read somewhere that the average for all drugs including those for infection and hypertension that the average was only 0.3 standard deviations better than placebo. However, for other conditions such as anxiety our medications are less effective.  Still, it is a matter of integrating lifestyle changes, natural approaches and where appropriate the best evidence based  medicines. About 30% of my clients only need to see me once or twice and are able to achieve great improvement or remission from a combination of lifestyle changes, CAM approaches and other interventions without ever even taking a prescription medication.  Also, certain CAM approaches such as SAM(e), Omega three fatty acids, Saint John's Wort, standardized lavender extract, strength training, yoga and aerobic exercise have reasonable evidence in depression and anxiety with minimal side effects (certainly when compared to medications such as SSRI, SNRI's and Trycyclic antidepressants).  

[DrCOVID, DNP]

I am just finishing my DNP/PMHNP and getting ready to sit for boards. I felt the same way you did when I entered thinking I might have to drop it since I don't really believe much in medication... While you are correct, there is so much gray area in psych and many people will have more than one thing going on. There is a severe lack of information and evidence in a lot of the more obscure corners. But that is what keeps me interested. 

To the other providers in the thread... when you start mixing more than 2 medications together, you have no idea what you are doing biologically... there is little to no evidence or trials regarding this type of polypharmacy. That being said, you do treat everyone individually and sometimes do need to be more aggressive. 

At the end of the day, when you can really help someone get their life together with the right medication the job is totally worth it. Good luck.

[NuggetsHuman, BSN, RN]

On 11/13/2020 at 3:44 PM, CommunityRNBSN said:

I’m an RN, not advanced practice. But I really feel what you are talking about. I work in an FQHC, so our patients have all sorts of socioeconomic stressors and poor education, transient lifestyle, etc. I work in internal medicine, but many of them also see our behavioral health department.  Just due to the realities of our situation, they are often thrown pills on top of pills. As one example: I have SO MANY patients who tell me “Yeah I go to the ED a few times a month with panic attacks when my Xanax doesn’t work.”  We know that panic disorder is highly highly treatable with appropriate therapy— CBT or other psychotherapy, patient education, plus in some cases SSRIs or a short course of benzodiazepines. But it’s almost impossible for our patients to get the best treatment, so the prescribers throw Xanax at them, because it at least allows the patient to function, to some extent, and the patient believes they can’t survive without it.  But it doesn’t actually treat them, as evidenced by the fact that their symptoms are out of control.  It’s incredibly frustrating and I’m not sure what the solution is. 

I feel you so much on this, Community.

The barriers to accessing appropriate and quality mental health care for our FQHC patients are astounding and so many people don't actually understand what those barriers are, and why they're so insurmountable.

[PMHP61, BSN]

On 11/10/2020 at 10:49 PM, indomie23 said:

great insight and good questions ! I would complete the degree and if you want to add holistic interventions you can do so. 

 

[CommunityRNBSN, BSN, RN]

On 11/23/2020 at 12:22 AM, myoglobin said:

I would suggest listening to podcasts such as The Carlat Report, Dr. David Puder, and The Psychopharmacology Institute.  All of these focus on evidence based psychopharmacology and therapy. 
 

Thank you for this!!  I am an RN but will soon be entering a PMHNP program. I didn’t even know that psychiatry podcasts existed. As soon as I read this, I subscribed to the Carlat podcast, and it is fantastic. Great information in bits that I can digest while commuting etc. 

[nurse.christine]

I am so glad I came upon this post. I am in a PMHNP program and feel the same way. I feel strongly about natural and alternative medicine, and have been in an “existential crisis” as it were, regarding continuing. I t feels good to know others are out there who feel this way as well. 

[DrCOVID, DNP]

Again, please do not get dissuaded by program curriculum. It is well known that curricula are a lot of fluff and dumpster courses.

Your practice & efficacy as a provider has little to do with the courses you take, and much more about what you make of it and the effort you put into being an advanced practice nurse. Take school for what it is - mostly a for profit institution to give you a piece of paper saying "you passed basic *** requirements for XXX job." Even if you went to medical school - you would still LIKELY not "feel ready" until you did a few years of on the job residency. 

There is so much good work you can do and continue self improvement past school. It's hard to see while you are in school, but that is a few short years of your life, while learning advanced practice is much more of an art and requires mostly people skills.

The #1 thing that matters in psych & (medical practice probably) is - the therapeutic alliance. Not what degree you got, not what school you went to, not your IQ...

 

[PMHNP Student 2021]

This is definitely a very interesting topic.  I have thought about this extensively too.