PMHNP student - Meds vs Therapy

[indomie23, BSN, RN]

I am a PMHNP-student, and just began clinical preceptorship in a outpatient clinic, mainly seeing high-functioning adult patients dealing with MDD, GAD, schizo, Bipolar..I am starting to notice the disparity of the prescribing of meds vs. the recommendation/provision of therapy to high-functioning patients, and it kinda bothers me, as I know therapy in conjunction with meds is vital. But maybe this could be specific to the practice of the PMHNP who is doing outpatient. And it may also be because that I have just started courses in psychopharm and psych/mental health patho, and so maybe I will have a better sense of things once I complete these courses. Any advice for this mentality that I am having?

misc. question

-What is the differences with outpatient adult psych, and C/L, neuropsychiatry, or child psych? I am interested in these areas too.

Thank you!

[verene, MSN]

There are a much higher number of mental health professionals who can offer therapy services (often at much lower cost than PMHNPs), as such many (though certainly not all) PMHNPs tend to be medication management heavy in clinical practice, as this is both where agencies/organizations are going to want them to practice, as well as where the bulk of most PMHNPs training is. (Our training in therapy is VERY light compared to counselors, social workers, and psychologists). 

For those in private practice it may very - some enjoy medication management and may work in conjunction with local therapists -- my child psych preceptor worked this way - there are a number of child therapists in our area, but very, very few prescribers, so by keeping her practice medication management heavy she was able to see more patients for medications and work to meet the grossly unmet need for medication services in our community.  (Though she did keep a handful of therapy clients at a time).  Others may set up their private practice such that they can prioritize offering therapy services either alone or along side medication management.

I work inpatient/forensics and do a little bit of therapy, but a lot more medication management, behavioral management, assessment of legal competency, and a fair amount of case coordination as my patients often have needs in mental health system (inpatient), mental health (outpatient), medical/dental/vision needs, substance use treatment needs, and ALL are involved in the legal system - so I am often working with court system(s) and DOJ office in regards to patients' legal status and needs.  I simply don't have the bandwidth most of the time for regular therapy sessions (even if a patient could benefit), and many of my patients are not yet at a point in their psychiatric stability where they would benefit form therapy. So most of what I do is around psychoeducation, insight building, and skills building to lay the groundwork for therapy down the road, and I will commonly make recommendations for therapy services - including specific modalities which would likely be of benefit to the patient - as part of the care coordination with correctional and outpatient mental health services.

"What is the difference?" is a really broad question - what specifically are you hoping to learn about those specialities/practice areas?

[DizzyJ DHSc PA-C]

When I worked outpatient psych I did med management only.  The other PA and NP did the same.  We had therapists (LMFT, LCSW, and LPC) and recommended to all patients to see one of them.  

[indomie23, BSN, RN]

On 10/7/2020 at 6:42 PM, verene said:

There are a much higher number of mental health professionals who can offer therapy services (often at much lower cost than PMHNPs), as such many (though certainly not all) PMHNPs tend to be medication management heavy in clinical practice, as this is both where agencies/organizations are going to want them to practice, as well as where the bulk of most PMHNPs training is. (Our training in therapy is VERY light compared to counselors, social workers, and psychologists). 

For those in private practice it may very - some enjoy medication management and may work in conjunction with local therapists -- my child psych preceptor worked this way - there are a number of child therapists in our area, but very, very few prescribers, so by keeping her practice medication management heavy she was able to see more patients for medications and work to meet the grossly unmet need for medication services in our community.  (Though she did keep a handful of therapy clients at a time).  Others may set up their private practice such that they can prioritize offering therapy services either alone or along side medication management.

I work inpatient/forensics and do a little bit of therapy, but a lot more medication management, behavioral management, assessment of legal competency, and a fair amount of case coordination as my patients often have needs in mental health system (inpatient), mental health (outpatient), medical/dental/vision needs, substance use treatment needs, and ALL are involved in the legal system - so I am often working with court system(s) and DOJ office in regards to patients' legal status and needs.  I simply don't have the bandwidth most of the time for regular therapy sessions (even if a patient could benefit), and many of my patients are not yet at a point in their psychiatric stability where they would benefit form therapy. So most of what I do is around psychoeducation, insight building, and skills building to lay the groundwork for therapy down the road, and I will commonly make recommendations for therapy services - including specific modalities which would likely be of benefit to the patient - as part of the care coordination with correctional and outpatient mental health services.

"What is the difference?" is a really broad question - what specifically are you hoping to learn about those specialities/practice areas?

Thanks for your thorough response! Regarding outpatient practice, I am seeing my preceptor prescribe 2-3 medicines on a new eval, and may or may not recommend therapy. If I were a PMHNP I would suggest therapy to virtually all my patients, as well as diet changes, physical exercise, seeking social/community support if possible. I’ve always had this thought that I want to venture into having a role as a social worker/humanitarian (My top love language is Acts of Service & ENFJ personality), but I would like autonomy/flexibility of work schedule and the financial benefit of being a PMHNP. 

With forensics, rather than prescribing meds, you are deeming individuals mental competency? It sounds rather interesting.

[verene, MSN]

On 10/14/2020 at 7:16 AM, indomie23 said:

Thanks for your thorough response! Regarding outpatient practice, I am seeing my preceptor prescribe 2-3 medicines on a new eval, and may or may not recommend therapy. If I were a PMHNP I would suggest therapy to virtually all my patients, as well as diet changes, physical exercise, seeking social/community support if possible. I’ve always had this thought that I want to venture into having a role as a social worker/humanitarian (My top love language is Acts of Service & ENFJ personality), but I would like autonomy/flexibility of work schedule and the financial benefit of being a PMHNP. 

With forensics, rather than prescribing meds, you are deeming individuals mental competency? It sounds rather interesting.

I do think it is very possible to make those recommendations for diet, exercise, lifestyle change etc -- My preceptors in outpatient practice did this routinely, and while there isn't as much of this in inpatient (for many reasons), there are patients with whom I still have some of these conversations. Depending on the practice setting you are in therapy may be a requirement to even seeing a PMHNP (a few of the local community mental health centers operate this way - therapist does initial screen starts with therapy,  and may make recommendation that patient be seen by PMHNP for assessment of potential pharmacological treatment as well.) 

In forensic inpatient setting - I do prescribe medication. Many times patients come in very, very acutely ill and until their psychiatric symptoms are stabilizing on medication, other interventions are impossible.

Medications are certainly not the only tool in the tool box though, we do a LOT of work to understand what is driving patient behaviors and have a plethora of non-pharmacological tools at our disposal - everything from occupational therapy to individualized incentive plans to group and individual therapy and a really strong art therapy and music therapy program.  While the vast majority of my patients are on medications - not all of them are.  I will say that there is usually substantially LESS polypharmacy in my setting in outpatient  and the goal is always to have the patient on the minimal amount of effective medication if at all possible.  That being said - in this practice area we can also have the weird refractory/treatment resistant cases and the weird "zebra" pathologies- meaning you can also see some really strange medication combinations and some heroic dosing of medications that no sane outpatient provider would likely undertake.

Fortunately or unfortunately the goal of our treatment planning must always come back to - is the patient able to be restored to legal competency?  I do not make the determination if they are competent - this is done by an independent forensic evaluator (Psychologists and Psychiatrists are the only individuals who can be licensed to this in my state), who then makes a recommendation to the court as to competency. This decision *can* be contested and a court doesn't have to accept this recommendation (though they usually do).   Thus, we really work to make sure our patients are psychiatrically stable and have the necessary knowledge to achieve competency OR may make the recommendation to the evaluator and court (in rare cases this doesn't happen that often) that a patient is unlikely to ever be restored to competency. 

Other populations under the forensics umbrella includes individuals who've been adjudicated for a crime and in which the determination has been made that a mental illness played a role in the commission of the crime - you Not Guilty by reason of insanity / Guilty Except for insanity population (terminology varies by state) in which case patients may be more psychological stable, but there is a lot of work done to help them maintain that stability, process the emotions are crimes (suicide risk can be really, really high with this population), and develop the skills necessary to eventually reintegrate into society, as well as review risk assessment and make recommendations to the state Security board as to the patient's readiness to discharge into a less secure setting. The last category of forensics patient we treat in my setting is the "Danger to Society" population which is essentially a sub-type of civil commitment in which case the State has deemed that it is in the interest of the public for the patient to remain hospitalized due to the level of danger to society they represent. We have relatively few of these, but they can be some of the most challenging patients to work with (and some of the most rewarding when progress is actually made!) 

Another area which can be considered "forensics" is working in the correctional system and providing mental health care in a jail or prison population setting. Sometimes this can look like short-term stabilization, and sometimes longer term management including therapy - depending on the setting and population. 

One of the things you will find as you explore this field is the sheer variety of practice settings, populations, and sub-specialties.  Which means there is a lot of freedom to find the place and population which fits your interests and your practice goals.