FNP's - how much psych do you do?

  1. I am a family NP in a pretty large community health clinic (10 MD's, 2 NP's). We're in a pretty rural area, at least four hours away from the nearest major metro area. I see between 18 and 28 patients a day, and I would say that at least 25% of my patients a day are actually in for mental health concerns. We have one psychiatrist in the area, who doesn't take the Medicaid most of my patients have, doesn't take the disability insurance, and will not see anyone who is self pay unless they come up with the initial visit up front (at least $300). The mental health clinic we did have, staffed with at least one psychiatrist and numerous psychologists, apparently imploded a few years back because of poor management.

    I spend more time with these patients than I should (try 15 minutes for a suicidal teen:angryfire), end up prescribing meds that I'm not really comfortable with, and now the one psychiatrist's office is sending their patients to me for primary care. I have talked to the other providers in my office about how much they're doing, and it seems that they tell these patients "sorry, that's not my specialty." Meanwhile, these people are suicidal, depressed, bipolar, even schizophrenic and not getting any help at all.

    What is your experience? Do you find that it's better to try (I stick with depakote, lithium, tegretol, and very little in the atypical antipsychotics) than to leave it alone? Or am I exacerbating the problem by trying at all? I have a lot of mental health background just from experience with family and friends (how do I learn not to attract those people :trout:!?!), but I am definitely not trained for this.

    I'd love any input. I have actually thought of trying a distance psych NP program (I'm a pretty new grad, though, so probably wouldn't do that for at least two or three more years).
  2. Visit catch33er profile page

    About catch33er

    Joined: Sep '02; Posts: 31; Likes: 1
    Nurse Practitioner - community health center
    Specialty: urgent care, GYN, primary care

    11 Comments

  3. by   ERNP
    In the ER, there is a fair amount of psych. But nothing like what you are describing. Mostly just setting up for outpatient, or getting the crisis response team involved after medical clearance for those requiring admission (voluntary or involuntary).

    I wouldn't feel prepared to do what you describe. Making occasional med adjustments based on levels, yes. Initiating and following the ongoing care of these problems is another story.

    My hat is off to you for trying, but my opinion is that some of what you are talking about is specialty care. I would be concerned about scope of practice issues in what can be a high risk group.

    Anyone else?
  4. by   sirI
    Quote from catch33er
    I am a family NP in a pretty large community health clinic (10 MD's, 2 NP's). We're in a pretty rural area, at least four hours away from the nearest major metro area. I see between 18 and 28 patients a day, and I would say that at least 25% of my patients a day are actually in for mental health concerns. We have one psychiatrist in the area, who doesn't take the Medicaid most of my patients have, doesn't take the disability insurance, and will not see anyone who is self pay unless they come up with the initial visit up front (at least $300). The mental health clinic we did have, staffed with at least one psychiatrist and numerous psychologists, apparently imploded a few years back because of poor management.

    I spend more time with these patients than I should (try 15 minutes for a suicidal teen:angryfire), end up prescribing meds that I'm not really comfortable with, and now the one psychiatrist's office is sending their patients to me for primary care. I have talked to the other providers in my office about how much they're doing, and it seems that they tell these patients "sorry, that's not my specialty." Meanwhile, these people are suicidal, depressed, bipolar, even schizophrenic and not getting any help at all.

    What is your experience? Do you find that it's better to try (I stick with depakote, lithium, tegretol, and very little in the atypical antipsychotics) than to leave it alone? Or am I exacerbating the problem by trying at all? I have a lot of mental health background just from experience with family and friends (how do I learn not to attract those people :trout:!?!), but I am definitely not trained for this.

    I'd love any input. I have actually thought of trying a distance psych NP program (I'm a pretty new grad, though, so probably wouldn't do that for at least two or three more years).
    Hello, catch33er,

    I will attempt to adress some of your concerns.


    prescribing meds that I'm not really comfortable with, and now the one psychiatrist's office is sending their patients to me for primary care
    You should not be prescribing any medication if you have no experience with the drug/s.

    The psychiatrist is expecting you to treat the patient on a primary care level or to screen, dx, tx on a mental health level? If the latter, you are out of your scope/expertise for you haven't the formal training as psych/mental health NP except for what you received in your FNP program (which does not qualify you to see these pts. exclusively without experience).

    What is your experience? Do you find that it's better to try (I stick with depakote, lithium, tegretol, and very little in the atypical antipsychotics) than to leave it alone? Or am I exacerbating the problem by trying at all?
    Definitely not better to try (as the inexperienced NP here). These patients need psych referral. The NP must know when to refer and it is obvious here these patients need referral to a qualified mental health HCP.


    I have a lot of mental health background just from experience with family and friends (how do I learn not to attract those people :trout:!?!), but I am definitely not trained for this.
    Personal experience does not qualify a provider. You need formal training and/or experience treating patients in the health care setting. By your own admittance, you are not trained.

    I'd love any input. I have actually thought of trying a distance psych NP program (I'm a pretty new grad, though, so probably wouldn't do that for at least two or three more years)
    Good idea for the future should you decide to pursue the mental health/psych NP role.

    Please note these are my observations gathered from your post in that you point out your hesitancy to provide care for these patients. IMHO.
  5. by   catch33er
    The problem is that there is no psychiatrist (or psych NP) to treat them. Do I just send them out the door? Most of the time I am not starting new medications, but adjusting doses. I do not want to do psych, but it always seems to find me...
  6. by   sirI
    No, you don't make the decision to turn them away. You need to go to the physicians in your group and refer/consult as needed. You may work with the physician to get these patients referred to the nearest psych facility for acute treatment.

    I work in a rural area as well. Nearest psych facility is 4 hours away. We have to admit for acute psych cases or transfer to acute facility. OR, set them up for psych referral, if stable enough on out patient basis. Have to jump through many hoops in order to serve the patient.

    Pose your concerns to your physician staff at your clinic. Don't take on the sole responsibility.
  7. by   Germanicus
    I used to do a fair amout of psych related treatment early on in my career. I refer them to psychiatrists now. I won't prescribe anything stronger than anti-depressants. I stopped prescribing benzos years ago and I don't try to manage psych drugs that need blood levels checked. It turns into a big headache. People with true mental illness need to be managed by a psychiatrist and manage is the key word here.
  8. by   brownrice
    "People with true mental illness need to be managed by a psychiatrist and manage is the key word here."


    Germanicus, regarding your statement above regarding psychiatrists:
    Please don't forget about Psych NP's!!!!!!!!!!!!! They can manage this patient load just as well, and are doing so as we speak. If you look at the number of psychiatrists available per density of population, it's abyssmal. Psych NP's have been and will continue to fill this gap. ESPECIALLY for the rural areas. The state university here has been given a large grant by the state/federal government to expand/give tuition grant assistance to psych NP students here. This NP specialty is doing a beautiful job supplying NP's to fill in where the Psychiatrist either doesn't exist, or doesn't have time to handle.

    Any psych NP's out there want to add a word or two?
  9. by   catch33er
    Thanks for your input/opinions. I am finding, in several different types of patients, that at first I took on too much and overstepped my scope of practice. I am really backing off now, and being better able to tell patients they need to see someone else.

    I'll do more investigation for resources, but have been told, again and again, that there's nothing around for these people. It's really sad to see how much this is ignored.

    This is what I come to this forum for. I really appreciate the information.
  10. by   sirI
    I'm curious about what your fellow clinic NPs' take on all of this, catch33er?? Maybe ya'll can get together and present to the physicians an alternative? Check out the nearest resources and see how you can assist these patients. You are right......it is sad if they are ignoring them and refuse to entertain alternatives.

    Yes, it is always nice to have a place where you can come and troubleshoot.

    allnurses is the place........anytime!!!
  11. by   brownrice
    Dear Catch33er:

    I empathize with your plight. I will be an FNP in a year, and could just as well be facing this issue. As you remember from the pm I sent, I'm about an hour away from you geographically. I emailed one of my favorite NP professors PhD/ARNP to pick her brain about your issue. She is very active politically in Washington state and knows legislation pertaining to nurses, healthcare, insurance, extremely well. She works in a small practice for underserved part-time, and teaches part-time. She is a very intelligent, nice person.

    This is her message:

    Unfortuantely, as limited as mental health care is for insured people it is almost non-existent for the uninsured unless there is a volunteer staffed clinic. I am not familiar with the resources in Walla Walla and suspect this NP knows better than I. One thing she may want to do is set up a mechanism for consulting on cases and do some CE on psych issues. Also, people who have severe mental health issues may be directed to apply for disability on the basis on their psych problems which then can gain them access to mental health services if they qualify for Medicaid or Medicare.

    If there is anything I can do to help her - even just talking through ideas
    about how to approach the problem - she should feel free to contact me.


    So, If you would like her email address, just pm me, and I'm happy to pass it on.
  12. by   RN/MSN/JD
    Quote from catch33er
    I am a family NP in a pretty large community health clinic (10 MD's, 2 NP's). We're in a pretty rural area, at least four hours away from the nearest major metro area. I see between 18 and 28 patients a day, and I would say that at least 25% of my patients a day are actually in for mental health concerns. We have one psychiatrist in the area, who doesn't take the Medicaid most of my patients have, doesn't take the disability insurance, and will not see anyone who is self pay unless they come up with the initial visit up front (at least $300). The mental health clinic we did have, staffed with at least one psychiatrist and numerous psychologists, apparently imploded a few years back because of poor management.

    I spend more time with these patients than I should (try 15 minutes for a suicidal teen:angryfire), end up prescribing meds that I'm not really comfortable with, and now the one psychiatrist's office is sending their patients to me for primary care. I have talked to the other providers in my office about how much they're doing, and it seems that they tell these patients "sorry, that's not my specialty." Meanwhile, these people are suicidal, depressed, bipolar, even schizophrenic and not getting any help at all.

    What is your experience? Do you find that it's better to try (I stick with depakote, lithium, tegretol, and very little in the atypical antipsychotics) than to leave it alone? Or am I exacerbating the problem by trying at all? I have a lot of mental health background just from experience with family and friends (how do I learn not to attract those people :trout:!?!), but I am definitely not trained for this.

    I'd love any input. I have actually thought of trying a distance psych NP program (I'm a pretty new grad, though, so probably wouldn't do that for at least two or three more years).
    I have taken both Advanced General Pharmacology AND Advanced Psychopharmacology. Testing in the 'general' course consisted of two questions about lithium.

    Since you asked, MY best recommendation is to get into an advanced psychopharm course ASAP. Sometimes, this is offered in the Psychology Department of major universities. It may not be accepted as credential for NP, but since you already ARE one, that doesn't really matter. What matters is that you don't really know what you are doing. Also, if you have not had any education about psychiatric diagnostics you are in double trouble.

    One company that offeres some good workshops in psych is Contemporary Forums. They have a web page and offere seminars on CD. This is NOT an advertisement. I have nothing to do with this company and have no financial interest in it.
  13. by   ERNP
    Quote from RN/MSN/JD

    One company that offeres some good workshops in psych is Contemporary Forums. They have a web page and offere seminars on CD. This is NOT an advertisement. I have nothing to do with this company and have no financial interest in it.
    LOL!! Spoken like a JD.

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