Case presentation

[psychma]

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I have a client I have been seeing for 1 year. She was prescribed Wellbutrin by a psychiatric nurse practitioner for depression. After starting the Wellbutrin and increasing the dose, she experienced mania which resulted in a diagnosis of bipolar 1 disorder by the NP and treatment with lithium and 6 mg of risperdal. The client was then prescribed 4mg/day of klonopin and is taking 15?mg of ambien a night for sleep. She is also prescribed 30mg of Adderall. Additionally, the client was prescribed trazodone because the ambien is not keeping her asleep. Due to her depression deepening, she was prescribed a pretty good dose of pramipexole. At the current time, this client is taking 8 psychiatric medications. She is a shell of the person I first met. This client has begun writing impulsively and writes messages, letters, texts, and nonsensical documents day and night with significant consequences. Her partner says this behavior is completely out of character for her. The psych np has now piled on a list of diagnoses to justify her prescribing pattern. I’m really concerned as a clinician that this client is experiencing some iatrogenic effects of medications. Could she be experiencing punding (impulsive writing) from the pramipexole? Does this sound like appropriate prescribing? I don’t feel necessarily comfortable suggesting she find a new psychiatric provider because I’m not a medical provider. Before starting all of these medications, this person was lively, friendly, and doing well socially and occupationally (working as a 60+ year old). She was just experiencing some depressive symptoms. Is anyone willing to share their thoughts? This client is geriatric and does not have a history of mental health problems besides depression.

 

[Fan_of_Meehl]

I have a client I have been seeing for 1 year. She was prescribed Wellbutrin by a psychiatric nurse practitioner for depression. After starting the Wellbutrin and increasing the dose, she experienced mania which resulted in a diagnosis of bipolar 1 disorder by the NP and treatment with lithium and risperdal. The client was then prescribed 4mg/day of klonopin and is taking 15?mg of ambien a night for sleep. She is also prescribed 30mg of Adderall. Additionally, the client was prescribed trazodone because the ambien is not keeping her asleep. Due to her depression deepening, she was prescribed a pretty good dose of pramipexole. At the current time, this client is taking 8 psychiatric medications. She is a shell of the person I first met. This client has begun writing impulsively and writes messages, letters, texts, and nonsensical documents day and night with significant consequences. Her partner says this behavior is completely out of character for her. The psych np has now piled on a list of diagnoses to justify her prescribing pattern. I’m really concerned as a clinician that this client is experiencing some iatrogenic effects of medications. Could she be experiencing punding (impulsive writing) from the pramipexole? Does this sound like appropriate prescribing? I don’t feel necessarily comfortable suggesting she find a new psychiatric provider because I’m not a medical provider. Before starting all of these medications, this person was lively, friendly, and doing well socially and occupationally (working as a 60+ year old). She was just experiencing some depressive symptoms. Is anyone willing to share their thoughts? This client is geriatric and does not have a history of mental health problems besides depression.

Take any of what I am about to say with grains of salt (I am a psychologist and also not a prescriber)...I'm just compelled to write down some thoughts I'd have off the top of my head if I were in your shoes.

1. Is there ANY aspect of 'team care' relevant or operative in her case? E.g., any hospital team or interdisciplinary care team you could leverage to (a) get some consensus on the obvious fact that this is bad, man...like, REALLY bad and dangerous? and (b) appeal to the humanity, logic, sanity, licensure status of any other medical provider(s) on the care team (even if they are primary care, other occupations that more directly interface with 'medicine' proper) so that you're not doing all the heavy lifting alone in shining light on a potential problem with the prescribing practices for this person.
2. You mentioned her 'partner.' Would it not be appropriate to (even Socratically) engage the patient (to the ability her mental status currently allows) and/or her partner in conversations about the situation and see if they naturally express (I would imagine they would) concerns about the situation (in terms of number of meds, prescribing practices/regimen) and then they can utilize their role as the patient (and concerned family) to assertively express these concerns to their current psychoparm prescriber and/or request (or initiate) a change in provider for their psychotropic meds?
3. What sort of relationship do you have with current prescriber? Would they be open to discussing this case or perhaps seeking input (either from other practitioners in her institution (assuming we're not talking about a private practice scenario here)? You could at least document in an email or in contemporaneous notes of your own that you've raised concerns or had questions and tried to express them for productive discussion to maximize effective and safe care for the patient whom you are both treating.

Best of luck. My first thought was to simply type out 'Jesus Christ' in reply but I didn't think that would be very helpful.

 

[psychma]

Take any of what I am about to say with grains of salt (I am a psychologist and also not a prescriber)...I'm just compelled to write down some thoughts I'd have off the top of my head if I were in your shoes.

1. Is there ANY aspect of 'team care' relevant or operative in her case? E.g., any hospital team or interdisciplinary care team you could leverage to (a) get some consensus on the obvious fact that this is bad, man...like, REALLY bad and dangerous? and (b) appeal to the humanity, logic, sanity, licensure status of any other medical provider(s) on the care team (even if they are primary care, other occupations that more directly interface with 'medicine' proper) so that you're not doing all the heavy lifting alone in shining light on a potential problem with the prescribing practices for this person.
2. You mentioned her 'partner.' Would it not be appropriate to (even Socratically) engage the patient (to the ability her mental status currently allows) and/or her partner in conversations about the situation and see if they naturally express (I would imagine they would) concerns about the situation (in terms of number of meds, prescribing practices/regimen) and then they can utilize their role as the patient (and concerned family) to assertively express these concerns to their current psychoparm prescriber and/or request (or initiate) a change in provider for their psychotropic meds?
3. What sort of relationship do you have with current prescriber? Would they be open to discussing this case or perhaps seeking input (either from other practitioners in her institution (assuming we're not talking about a private practice scenario here)? You could at least document in an email or in contemporaneous notes of your own that you've raised concerns or had questions and tried to express them for productive discussion to maximize effective and safe care for the patient whom you are both treating.

Best of luck. My first thought was to simply type out 'Jesus Christ' in reply but I didn't think that would be very helpful.

Her partner is very concerned and the client is able to recognize that this is unlike her. She likes and trusts this provider. I do not think that her provider would respond well to me, but I am open to interacting with her primary care provider and am sure that I could get an ROI to do this. I am truly appalled by this. Thank you for validating my concerns.

 

[Bartelby]

Sounds like time for the patient to seek a second opinion from a psychiatrist, and turn over prescribing to them.

 

[psychma]

Sounds like time for the patient to seek a second opinion from a psychiatrist, and turn over prescribing to them.

I feel like this is polypharmacy and this is not my first client with this issue. I have seen it with physician psychiatrists as well. I think suggesting a second opinion is appropriate.

 

[mistafab]

This treatment is a mess. Get a second opinion. This seems like the classic 'rookie mistake' of starting meds but never stopping any - even if they aren't working.

 

[psychma]

I feel like polypharmacy is something that I see but am not able to address. In addition to that geriatric client, I have an 8 year old boy client currently taking risperdal, adderall, trazodone, Prozac, and guanfacine with at least a 30 pound weight gain on a small frame. Seems like it’s not right either, but honestly, I have no clue. I’m wading outside of my scope on that. That is physician prescribed. I also have a client taking Wellbutrin, Zoloft, and Effexor at the same time which seems weird to me. But I’ll creep back to my scope.

 

[Osminog]

This sounds like a polypharmacy disaster, with likely iatrogenic harm. The client should seek a second opinion from a board-certified psychiatrist, not just regarding medications but also regarding diagnoses (geriatric-onset bipolar disorder, ADHD, etc.).

Seems like it’s not right either, but honestly, I have no clue. I’m wading outside of my scope on that. That is physician prescribed.

Misdiagnosis and inappropriate polypharmacy are extremely common in psychiatry today, and many patients lack the health literacy, confidence, or social power to advocate for themselves. When something seems off in a client’s medication regimen, you shouldn't hesitate to speak up. It’s completely within your role to support the client in seeking clarification or getting a second opinion. Medications can be helpful, but when used inappropriately or without adequate monitoring, they can also contribute to unfathomable misery and dysfunction. Advocating for safe pharmacological care is part of protecting your client’s wellbeing.

 

[Wilf]

She needs to be treated by a psychiatrist, not a nurse. It continues to baffle me that despite the very obvious difference in the level of care, patients and their loved ones still allow nurse “practitioners” to “treat” them.

 

[nexomed]

The patient needs an MD or DO psychiatrist. There is unfortunately an increasing contingent advertising themselves as 'psychiatrists', and introducing themselves as 'doctor'. One issue underlying this is that nurses are not held accountable for mismanagement of patients in the same way that physicians are. An example is found in this case where a nurse practitioner had sex with their patient and continued to practice 'psychiatry' for at least a year following this. This podcast describes the case:

Podcast | Patients at Risk

www.patientsatrisk.com

Until nurses are held to the same standards as physicians, and are held to the same bar when patients are harmed, we will continue to see cases like you describe. And unfortunately, the patients most at risk are those that are most vulnerable in our society.

Would encourage referring patients to MD and DO psychiatrists only and avoid practices that employ a contingent of mid-level providers, in same way that I think psychiatrists are looking to refer to therapists with expertise in a sea of people setting up shop as therapists without training.

 

[Stagg737]

I agree with the psyhiatrists above, I would have her seek a second opinion from an actual psychiatrist with an MD or DO degree. They may be awful as well and just decide her Adderall/Xanax ratio is off and that will fix everything (sarcastic joke, to be clear), but hopefully they take the time to really figure out what's going on. With the vignette you've given, this absolutely sounds like a completely inappropriate med list.

I feel like this is polypharmacy and this is not my first client with this issue. I have seen it with physician psychiatrists as well. I think suggesting a second opinion is appropriate.

The above said, I've seen patients in the hospital on similar crazy med lists and after talking to their outpt psychiatrist there's actually really well-thought out reasoning for what seems like a wild med list. Sometimes a med list sounds bad to people with less experience but may not actually be inappropriate at all. For example a med list like:

I feel like polypharmacy is something that I see but am not able to address. In addition to that geriatric client, I have an 8 year old boy client currently taking risperdal, adderall, trazodone, Prozac, and guanfacine with at least a 30 pound weight gain on a small frame. Seems like it’s not right either, but honestly, I have no clue. I’m wading outside of my scope on that. That is physician prescribed. I also have a client taking Wellbutrin, Zoloft, and Effexor at the same time which seems weird to me. But I’ll creep back to my scope.

This sounds like a kid with ADHD who might also be on the autism spectrum or something similar who has severe anger outbusts regularly. The Adderall + guanfacine is pretty standard for ADHD in kids. Adding low dose risperidone, especially if PRN, could be very reasonable for behavioral outbursts, especially if they're severe like say flipping desks at school or grabbing teacher's/staffs breasts or butts repeatedly when they get upset (both of which my wife encountered while teaching an 8 year old). Prozac may have been used first to help with mood dysregulation or maybe depression/anxiety. Completely reasonable to start and keeping if having some benefit but needing further augmentation of risperidone. Trazodone for sleep in a kid isn't ideal, but isn't unreasonable. I think the CAPs here like @Merovinge and @clozareal would probably agree that while this is far from an ideal med list it could be completely appropriate for plenty of kids.

The Wellbutrin + Zoloft + Effexor is only weird because of the Zoloft and Effexor being used together, but I can also think of plenty of situations where that could be appropriate although not ideal. Neither of those med lists are nearly as egregious as the one in your OP which seems to be legitimately a dumpster fire for this poor woman.

The only other thing I'd question is her actual (or new) cognitive baseline. You mentioned she's over 60, so starting to get neurocog testing when she's at a true baseline isn't unreasonable to see if this whole misadventure has possibly unmasked some underlying early neurocognitive deficits. This shouldn't be done until her meds are straightened out though, as several of those meds can cause neurocognitive problems.

 

[Stagg737]

She needs to be treated by a psychiatrist, not a nurse. It continues to baffle me that despite the very obvious difference in the level of care, patients and their loved ones still allow nurse “practitioners” to “treat” them.

Most patients don't know that there is a difference between NPs and physicians. I cannot tell you how many of the patients I'm consulted on have a "psychiatrist" managing their meds only to find out they're an NP, and sometimes not even a psych NP or PMHNP or whatever alphabet soup they want to use. I've had more than a few get furious when they found out their "psychiatrist" wasn't a physician and felt betrayed, but how are they supposed to know when there are no consequences to throwing whatever label they want on themselves?

 

[psychma]

It’s a really delicate place to be as this client feels attached to her NP and the idea that the NP “listens” and that doctors don’t. I am truly concerned about harm and will be seeking out some collaboration on this in order to help this client see that a second opinion would be a good idea. I also agree with the idea of neuropsych testing.

 

[nexomed]

It’s a really delicate place to be as this client feels attached to her NP and the idea that the NP “listens” and that doctors don’t. I am truly concerned about harm and will be seeking out some collaboration on this in order to help this client see that a second opinion would be a good idea. I also agree with the idea of neuropsych testing.

It is an incredibly delicate position. I wonder if the patient could be curious around what it means for them to feel listened to.

I think there might be some patients who may equate feeling listened to when they are prescribed adderall, klonopin, and ambien together; and might perceive someone who is setting boundaries around prescribing to be perceived as withholding or dismissive -- or describe the doctor as one who does not listen. Wonder if this is a dynamic or conflict that was present in the patient's development...I think our current environment (where one can simply present to a practitioner and get started with a stimulant, benzo, ketamine, stellate ganglion block--for example--in response to the first sign of distress -- makes it extraordinarily challenging for complex patients who might actually do better when boundaries are set and a frame established within the environment where medications are being prescribed.

 

[psychma]

I agree with the psyhiatrists above, I would have her seek a second opinion from an actual psychiatrist with an MD or DO degree. They may be awful as well and just decide her Adderall/Xanax ratio is off and that will fix everything (sarcastic joke, to be clear), but hopefully they take the time to really figure out what's going on. With the vignette you've given, this absolutely sounds like a completely inappropriate med list.


The above said, I've seen patients in the hospital on similar crazy med lists and after talking to their outpt psychiatrist there's actually really well-thought out reasoning for what seems like a wild med list. Sometimes a med list sounds bad to people with less experience but may not actually be inappropriate at all. For example a med list like:


This sounds like a kid with ADHD who might also be on the autism spectrum or something similar who has severe anger outbusts regularly. The Adderall + guanfacine is pretty standard for ADHD in kids. Adding low dose risperidone, especially if PRN, could be very reasonable for behavioral outbursts, especially if they're severe like say flipping desks at school or grabbing teacher's/staffs breasts or butts repeatedly when they get upset (both of which my wife encountered while teaching an 8 year old). Prozac may have been used first to help with mood dysregulation or maybe depression/anxiety. Completely reasonable to start and keeping if having some benefit but needing further augmentation of risperidone. Trazodone for sleep in a kid isn't ideal, but isn't unreasonable. I think the CAPs here like @Merovinge and @clozareal would probably agree that while this is far from an ideal med list it could be completely appropriate for plenty of kids.

The Wellbutrin + Zoloft + Effexor is only weird because of the Zoloft and Effexor being used together, but I can also think of plenty of situations where that could be appropriate although not ideal. Neither of those med lists are nearly as egregious as the one in your OP which seems to be legitimately a dumpster fire for this poor woman.

The only other thing I'd question is her actual (or new) cognitive baseline. You mentioned she's over 60, so starting to get neurocog testing when she's at a true baseline isn't unreasonable to see if this whole misadventure has possibly unmasked some underlying early neurocognitive deficits. This shouldn't be done until her meds are straightened out though, as several of those meds can cause neurocognitive problems.

Thank you for this. May I ask how this type of rapid weight gain in a child is usually managed relative to the risk of diabetes, etc? Obviously I don’t intend to offer medical advice to the family. I’m just really curious as I have seen this child absolutely balloon out.

 

[psychma]

It is an incredibly delicate position. I wonder if the patient could be curious around what it means for them to feel listened to.

I think there might be some patients who may equate feeling listened to when they are prescribed adderall, klonopin, and ambien together; and might perceive someone who is setting boundaries around prescribing to be perceived as withholding or dismissive -- or describe the doctor as one who does not listen. Wonder if this is a dynamic or conflict that was present in the patient's development...I think our current environment (where one can simply present to a practitioner and get started with a stimulant, benzo, ketamine, stellate ganglion block--for example--in response to the first sign of distress -- makes it extraordinarily challenging for complex patients who might actually do better when boundaries are set and a frame established within the environment where medications are being prescribed.

I see a lot of clients who feel like they have a “relationship” with their provider and feel protective even when it appears things might not be okay. I’m sure everyone sees this though.