Psych Meds

Psychcns · Jul 22, 2012

@newnp2012....I think it is awful you are trying to treat psych pts without support or likely the time. A full clinical evaluation takes 1-1.5 hours. Med follow-up visits are 20-30 minutes. And psych pts should usually be in therapy-- meds are not usually enough.. Zenman's summary (above post) is pretty much the things you have to consider with each patient.

I belong to a psychopharmacology list serv. members who prescribe psych meds present cases or ask questions and people respond. PM me if you want to know how to join. I get the Carlat Psychiatry report every month which helps me keep up...

As far as favorite meds for sleep, I use trazadone ( you have to explain about priapism) and ambian..i tell people that they can usually manage with 1/2 of 10 mg. and I go over sleep hygiene...for depression I start with the star-D protocol. I use the mood disorder questionnaire to screen for bipolar..it is best to get comfortable with 1-2 meds from each group to start...ie celexa and Prozac for SSRI's. Prozac can make people jittery so start low...you really need the time to do a full eval..

Maybe your practice could get some tele-psychiatry. This is a lot to incorporate into primary care. Best to you..

Long Term Care Columnist / Guide · Jul 22, 2012

As an RN who works with elderly psych patients, (and am a psych patient myself), it's been my experience that PCPs are way out of their league when it comes to prescribing for anything more complicated than depression. And some of them aren't even very knowledgeable about that. That's how my own case of bipolar disorder was misdiagnosed as MDD for over a decade......not that my internist is incompetent, but it's a hard diagnosis to make when you don't have the knowledge of what to look for (and the patient doesn't come to see you when s/he is feeling well, which is typical of BPers).

Right now I have a 56-year-old ALF resident with schizophrenia, borderline personality and factitious disorder who's being treated for these complex conditions by a very well-intentioned internist who doesn't know jack about prescribing psych meds. When he was in the hospital following a NSTEMI, he was evaluated by a psychiatrist who DID know what was what, and Rx'd him both Depakote and Zyprexa.

These meds made him a changed man; he was almost symptom-free for a year. Unfortunately, a neurologist he saw in March scared the hell out of him by declaring Zyprexa to be an evil drug that would cause him to develop a Parkinson's-like condition, then turned him back over to his internist to be weaned off and another antipsychotic prescribed "if needed".

Naturally, his PCP trying to prescribe the correct anti-psychotic is like a toddler trying to cross a freeway, so now his symptoms are returning with a vengeance. I've intervened and advocated as much as I know how (I've even consulted my own psychiatrist about this man because he doesn't have one), but of course I'm not a doctor nor do I know what meds are best for his particular conditions, so he's basically out of luck.

That's why we need more psych NPs and family doctors with specialized training in mental health issues. I live in a two-county area which has four psychiatrists for some 120,000 people; good insurance is the only reason I'm able to access the high-quality mental health services I have. Most people aren't as fortunate, so there is a HUGE need for these professionals since there is so much mental illness out there, and so few medical students choosing psychiatry. I can't even imagine trying to negotiate our nation's dysfunctional mental-health "system" when ill. It's sad that anyone has to.

Trauma Columnist · Jul 22, 2012

To the OP, we are being supportive. Believe me, as an APN who works nephrology, and who had NO renal experience, you can get into a lot of trouble without a serious back up system. So, for those of us that said maybe this unsupportive environment isn't the best place for you, that IS being supportive. APNs get sued too you know and with frightening frequency. Monitoring psych meds is not for the unprepared.

newnp2012 · Jul 24, 2012

thank you all for your feedback and traumaRUs I completely understand what you are saying. I am doing the best I can and I just want to do what is best for my patients. I guess I have been a bit over sensitive - I guess with the transition and frustration of feeling like I'm not doing good enough has played into my response. Please understand and again... Thank you all for your SUPPORT and hopefully not thinking I am the one who needs the psych meds hahahahahah

Trauma Columnist · Jul 24, 2012

No problem at all. When I was new, I worried about everything, now after 6 years, I only worry half that amt - lol. Take care.

Tinabeanrn · Jul 24, 2012

Hi newnp2012. I read the thread and I just wanted to chyme in and say I understand how you feel. When I think of all the responsibility it takes to be a NP...my heart flutters sometimes. Its like being a jack of all trades in a way. When we learned about psych meds in NP school, all of us were uncomfortable with the idea of prescribing these meds and we all felt we needed more education and training prior to doing so. It is a specialty area and there is a huge lack of psychiatric providers in my area as well. I was lucky enough to do a clinical at a homeless shelter with a psychiatrist that worked there. So I did learn a little bit more in that area. I wish you the best of luck. And don't be discouraged. It will all work out :)