Let me just show you this....

[WisNeuro]

Perhaps some hydroxyzine 25mg TID is also missing.

Not enough of an anticholinergic burden, pair it with diphenhydramine for sleep.

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[Salpingo]

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

I'd be shocked if he was taking

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

I'm guessing he actually takes 3, maybe 4 of those medications listed (my money is on the Adderall, temazepam, and Imitrex).

 

[erg923]

Well, depending on the SC of this individual, you, as a taxpayer may actually be paying the copays on all of those meds

Wait for it...service connected for...wait for it...."chronic adjustment disorder"

 

[keifernny2]

Wait for it...service connected for...wait for it...."chronic adjustment disorder"

I'd order elavil & lamictal levels with a utox to find out what is actually present in his bodily fluids.

 

[deleted343839]

Wait for it...service connected for...wait for it...."chronic adjustment disorder"

What.

 

[erg923]

What.

Exactly

 

[nexus73]

Wait for it...service connected for...wait for it...."chronic adjustment disorder"

How can it be a service connected chronic adjustment disorder? Once you're discharged the stressor causing the adjustment disorder would stop.

 

[WisNeuro]

I wouldn't try to use logic in figuring out the SC process. It will only lead to frustration and consternation. Just like trying to figure out how someone is 100% SC for "Traumatic brain disease" in the absence of any actual brain injury with LOC.

 

[st2205]

How can it be a service connected chronic adjustment disorder? Once you're discharged the stressor causing the adjustment disorder would stop.

There's no rhyme or reason to how service connection is given. People with legitimate PTSD and combat aren't given the diagnosis and aren't designated as combat veterans. Other people get 100% service connection for PTSD for getting in a fender-bender 20 years ago while stationed in Germany. The actual diagnosis is worthless and correlates in no way with clinical symptoms. 50% service connection for neurosis? Also baffled how things are service connected, meaning caused by the military, such as hypertension, sleep apnea, etc.

 

[erg923]

How can it be a service connected chronic adjustment disorder? Once you're discharged the stressor causing the adjustment disorder would stop.

In those cases the stressor is often the discharge and transition to civilian rather than being in service. I also think they sometimes conceptualize TBI as "chronic stressor"

The VA service connected vets for "organic brain syndrome too..."

 

[Therapist4Chnge]

The system seems even more broken than when I left 6+ yrs ago. Wow.

The "assumed" Criterion A for PTSD bugged me, but now I see that is small potatos when "chronic adjustment" qualifies for SC.

 

[st2205]

The system seems even more broken than when I left 6+ yrs ago. Wow.

The "assumed" Criterion A for PTSD bugged me, but now I see that is small potatos when "chronic adjustment" qualifies for SC.

To be fair, those with chronic adjustment disorder, in my experience, are the ones more likely to actually have PTSD than those with the PTSD service connection.

 

[randomdoc1]

I'd have to say some of my most rewarding cases were clearing up bad bad polypharmacy. I had a patient who was on multiple stimulants and benzos who had a whole slew of disorders in his documented psychiatric history. He tried to trick my staff into bumping his clonazepam to 7mg daily (he told them I meant to give a verbal order but forgot) on top of everything else he had. I got rid of all his benzos and stimulants because there was nothing convincing in the history I got directly from him of an indication (despite a previous provider stating he had anxiety spectrum disorders, bipolar disorder, ADHD, etc., etc., etc.). His mood stabilized (perfectly euthymic), concentration and sleep improved drastically.

 

[splik]

How can it be a service connected chronic adjustment disorder? Once you're discharged the stressor causing the adjustment disorder would stop.

adjustment disorder can continue if the consequences of that stressor are still presence. the most common reason for chronic adjustment disorder is an ongoing medical illness (and yes TBI would count though it would be particularly ridiculous if mTBI counted), however if someone experienced an accident/trauma during service with enduring consequences and did not meet criteria for PTSD they could be dx with chronic adjustment disorder. veterans can get secondary service connection if the non-service connected condition (which might be chronic adjustment disorder) was caused by a service connected condition (for example becoming an amputee)

 

[WingedOx]

The quoted guidelines, if you follow them, actually state that 3 contacts need to be made, and nowhere is it stated that it needs to be all within 24 hours.

At my site, a successfully placed voicemail message counts as sufficient followup after a no-show. Also counts for seven day followup if the patient no-shows after an admission. Thank god. No one from the regional or federal offices have made a stink about that yet.

It doesn't matter. Whatever you do will be followed by a crisis that has more to do with the idea of medications being reduced/stopped than the medications actually being reduced/stopped. The ideal would be if you can get them off for a sustained enough time for them to see that they feel just as ****ty off the medications as they did when they were on them.

You know damn well you can't do that without the patient insisting that he felt soooo much better back when he was on the whole pharmacy.

 

[WisNeuro]

At my site, a successfully placed voicemail message counts as sufficient followup after a no-show. Also counts for seven day followup if the patient no-shows after an admission. Thank god. No one from the regional or federal offices have made a stink about that yet.

Ours is similar. Phone call/vm left the day off counts as 1. Auto generated letter counts as 2. Just need a 3rd call at some point after that and we're done.

 

[st2205]

You know damn well you can't do that without the patient insisting that he felt soooo much better back when he was on the whole pharmacy.

"Well, your PHQ9 hasn't gotten any worse."

 

[WingedOx]

The veterans under 30 years old and the veterans with substance abuse no show the most, as you might expect.

The OEF/IEFers are almost always my most difficult to manage. If you told me to pick a patient between one who was 55 and a chronic cluster B substance use disorder disaster, and another who was 26, knowing nothing else about them, I'd go with the former. Not kidding.

Managing expectations in these kids who know absolutely nothing about mental health besides the fact "a crazy guy killed Chris Kyle" and the fact that too many of them are coming home to the same awful economic and social realities they went into the military to escape, is f-cking impossible.

 

[WingedOx]

Ours is similar. Phone call/vm left the day off counts as 1. Auto generated letter counts as 2. Just need a 3rd call at some point after that and we're done.

I'm not sure if we're really following the rule or not to be honest. I don't see us making an effort to follow it unless forced to. It's simply not realistic unless we have the secretarial backup to make it happen... which we don't.

 

[erg923]

I'm not sure if we're really following the rule or not to be honest. I don't see us making an effort to follow it unless forced to. It's simply not realistic unless we have the secretarial backup to make it happen... which we don't.

I would say i do 90% of the time. The other 10%...well...you didnt show. If your dont have enough motivation to come to an appt or bother to cancel, either: Its not that important to you OR you aren't motivated enough to benefit from meaningful/active treatment. I guess both are opposite sides of the same coin.

I happen to be in position that has downtime (as in hours some days), usually. And lowish productivity target accordingly. I can never understand how our NP or psychiatrist does this between their 15 patient/day "med checks"..not to mention all the other documentation, labs, and other things they are constantly having to do/check on.

 

[nexus73]

I would say i do 90% of the time. The other 10%...well...you didnt show. If your dont have enough motivation to come to an appt or bother to cancel, either: Its not that important to you OR you aren't motivated enough to benefit from meaningful/active treatment. I guess both are opposite sides of the same coin.

I happen to be in position that has downtime (as in hours some days), usually. And lowish productivity target accordingly. I can never understand how our NP or psychiatrist does this between their 15 patient/day "med checks"..not to mention all the other documentation, labs, and other things they are constantly having to do/check on.

Why do the doctors have to make the phone calls for no shows? I know it's complicated, but surely someone with a masters degree could be trained to dial a phone number and reschedule the patient. Maybe even someone with a bachelors degree could figure it out if there were some instructions with pictures.

 

[AcronymAllergy]

Why do the doctors have to make the phone calls for no shows? I know it's complicated, but surely someone with a masters degree could be trained to dial a phone number and reschedule the patient. Maybe even someone with a bachelors degree could figure it out if there were some instructions with pictures.

The MAS staff (i.e., clerks) are generally supervised by folks outside the department; what they're tasked to do can vary significantly from facility to facility.

However, I don't make my own phone calls for no shows; we've got a scheduler who handles that. She makes two telephone contact attempts, sends a letter as the third contact attempt, and if she doesn't hear back within two weeks, the consult is d/c'd.

The exception is if the patient is considered high risk (either flagged as such, or deemed such by the clinician after a chart review). In that case, the provider needs to make 3 contact attempts within 24 hours, and if unable to contact, has to decide if a wellfare check is warranted.

Edit: And yes, of the majority of cases I've seen where TBI is conceived as a chronic stressor, it's mTBI. The self-reported rates of which are (unsurprisingly) high.

 

[nancysinatra]

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

Why no klonopin?

 

[nancysinatra]

No, so many of you have got it all wrong! We have yet to try an MAOI! Don't forget to add an MAOI!

People who prescribe regimens like the one above are usually too chicken to try MAOIs.

 

[wholeheartedly]

I'm curious how many different prescribers were on that list.

Friend of my mom's had her son and his fiance living with her. Fiance was on a lengthy list of psych meds and didn't do much all day. My mom asked me how any psychiatrist would put someone on all those meds. I said it can happen, but I was willing to bet their were multiple docs involved. Sure enough, she checked the bottles and each one had a different prescriber...

 

[erg923]

I'm curious how many different prescribers were on that list.

Friend of my mom's had her son and his fiance living with her. Fiance was on a lengthy list of psych meds and didn't do much all day. My mom asked me how any psychiatrist would put someone on all those meds. I said it can happen, but I was willing to bet their were multiple docs involved. Sure enough, she checked the bottles and each one had a different prescriber...

One doc.

 

[nancysinatra]

One doc.

Was it a PCP? A psychiatrist wouldn't normally prescribe imitrex, since it's for headaches, and the lamictal and elavil are probably for headaches too. This looks like the work of an NP to me anyway.

 

[666357]

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

It's "compensation neurosis"
It pays to be sick at the VA...