Complex Cases - what mid-levels are not trained for

[zenman]

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Thank you for finally providing some cases that illustrate why Psychiatry residencies are useful, and how Psychiatric training is necessary beyond the skills that a Psychiatric Nurse Practitioner can provide (though their training is absolutely useful).

Are you, and others, wanting complex cases that involve both medical problems and psych or just psych (yea I know)?

 

[rmj254]

People think that if you learn about psych meds you can be a psychiatrist. This minimizes the 8 years of medical training we have invested in order to medically manage challenging patients every day. So to prove the point I'm opening up the discussion to complex cases we see, things that nobody in their right mind would have a nurse, assistant, or psychologist manage.

Are you, and others, wanting complex cases that involve both medical problems and psych or just psych (yea I know)?

I think the OP was just talking about cases that those with experience think go above the training of an NP and require the more extensive training of a Psychiatrist, whether med/Psych together or Psych by itself. I may be misinterpreting, though.

 

[vistaril]

40yo F with depression, acutely suicidal but high functioning and states she wouldn't do something to hurt herself, states that if you hospitalize her she'll end up losing her job and her whole life would really fall apart (and likely attempt suicide then).
.

Im not completely sure how a psychiatrist would neccessarily be uniquely qualified to handle that case over a psychologist or psych np.

 

[vistaril]

I think the OP was just talking about cases that those with experience think go above the training of an NP and require the more extensive training of a Psychiatrist, whether med/Psych together or Psych by itself. I may be misinterpreting, though.

it's an important distinction because in the real world nps and pas on internal medicine/hospitalist services serve as consultants *to* psychiatrists for routine medical problems on inpatient units.

 

[priorities2]

The first example with the other medical complications - AIDS etc - does seem best served by a doc. But the second one seems like it would just be best served by someone with lots of experience, be it PMHNP or psychiatrist or LCSW/psychologist who can consult a prescriber.

 

[billypilgrim37]

The first example with the other medical complications - AIDS etc - does seem best served by a doc. But the second one seems like it would just be best served by someone with lots of experience, be it PMHNP or psychiatrist or LCSW/psychologist who can consult a prescriber.

Residency training is about much more than learning how to prescribe. Psychiatrists deal with acute suicidality in their training under supervision over and over again. These other folks do not.

 

[AcronymAllergy]

Residency training is about much more than learning how to prescribe. Psychiatrists deal with acute suicidality in their training under supervision over and over again. These other folks do not.

Psychologists might, if that's an area on which they choose to focus. Outside of that, though, it's seen in the more "typical" context of being the outpatient provider who sends the individual to the ER.

 

[billypilgrim37]

Psychologists might, if that's an area on which they choose to focus. Outside of that, though, it's seen in the more "typical" context of being the outpatient provider who sends the individual to the ER.

But fairly rarely. These scenarios can come up once a week or so in residency training depending on the rotation. This kind of assessment is precisely an example of something a psychiatry residency prepares you for that other trainings will prepare you much less for. Much less. Simple matter of volume and clinical setting.

 

[kumar28]

You pop up in lots of threads posting this. You've called him/her a douchebag, said she/he has Asperger's, is a troll, and have yelled out for a moderator like an annoying diner at a restaurant yelling for a server repeatedly. As far as I can tell, most of your posts are about Vistaril, and they manage to say nothing. You could ignore him/her, but you might lose out on something to post about. I find his/her insights valuable and the mindless reactivity toward them tends to worsen my opinion of the other posters in this forum.

Wow..birchswing..thanks for following my posts

So in all seriousness I've been on this forum for over 10 years. throughout that time it has been a pleasure to receive useful insightful posts from attendings who have been in the field for many years and this has helped me as well as others im sure tremendously. thats why Im on this forum..so I can learn more about the field. So when I hear the useless dribble that comes from vistaril..who claims to be a 4th year resident who knows EVERYTHING about the field at this point in his career..its very frustrating. Not only that but the manner of which vistaril discusses these things clearly leaves the impression to me (and most others on this forum) that the guy is a troll who has a hatred for psychiatry..his views are negative, pessimistic, antagonistic and rude to other posters. Every now and then he'll try and fool you with a positive post..or something that makes you think..wow..ok ..he might know what he is talking about. But then he follows it up with garbage..not just negative views of the field but crap that doesn't make any sense whatsoever. If you followed him..you would know that there is something really wrong with this kid

there used to be alot of insightful attendings on this forum...alot of them have disappeared. Dont know where they went but I do know that they were extremely helpful. Now when a guy like vistaril joins a forum like this and posts over 1500 posts in less than a year that makes me think that his hijacking this forum led to people getting fed up with his crap and leaving. So those people that were most useful to me and others are no longer are on this forum. Now it may be because of people like vistaril..or maybe not..but if I were a betting man I would say it has alot to do with the latter. Which brings me to my next point...is he really helping you out in any way?? If you're taking advice from this guy then good luck on all your future endeavors

But this guy needs to be dealt with..hes clearly a troll or somone with an alterior motive than just providing advice. He's antagonistic and in all seriousness..a douchebag!

 

[rmj254]

it's an important distinction because in the real world nps and pas on internal medicine/hospitalist services serve as consultants *to* psychiatrists for routine medical problems on inpatient units.

Cool. Are there any cases that you consider Psychiatric residency training the minimum amount of training to handle (i.e. a Psych NP doesn't have enough training to do)? Have your four years of residency given you any such cases? Would you mind sharing them, if so?

 

[vistaril]

Cool. Are there any cases that you consider Psychiatric residency training the minimum amount of training to handle (i.e. a Psych NP doesn't have enough training to do)? Have your four years of residency given you any such cases? Would you mind sharing them, if so?

sure...there are certain cases where it is more likely a psychiatrist would do a good job than a psych np. I don't think this neccessarily means most psychiatrists would do a good job or that no psych nps could handle it. Something like true MDD with psychotic features(where most psych nps probably dont get enough volume) would probably be a good example.

 

[zenman]

Anyone have any good cases with PTSD, ADHD, and Insomnia, especially treating ADHD/PTSD syptoms that overlap. Treat concurrently, focus on one more than the other, etc..

 

[notdeadyet]

Anyone have any good cases with PTSD, ADHD, and Insomnia, especially treating ADHD/PTSD syptoms that overlap. Treat concurrently, focus on one more than the other, etc..

PTSD and Insomnia are treated concurrently. Untreated PTSD worsens sleep and untreated insomnia aggravates PTSD symptoms. Some treatments are effective at assisting both. Prazosin, of course. And the CBT for Insomnia protocol has good effect on PTSD symptoms after the initial painful first couple of weeks. I can't imagine a recommendation to not address both PTSD and insomnia at once.

The ADHD is a different kettle of fish. Is this maintenance of an existing condition already treated, is it a new onset, or is it undermanaged? Depending on the flavor of PTSD, I'd tread pretty carefully with stimulants and would try to see if their use is a factor in the insomnia.

The VA has traditionally taken a treat-the-PTSD-first approach a lot of the time, but new programs are proving this isn't the best route. Some of the more research-oriented VAs have clinics, groups and programs for comorbid mood/PTSD or substance/PTSD in which both are tackled at once and the data is stronger than trying to treat PTSD with an uncontrolled alcoholic and the like.

 

[zenman]

PTSD and Insomnia are treated concurrently. Untreated PTSD worsens sleep and untreated insomnia aggravates PTSD symptoms. Some treatments are effective at assisting both. Prazosin, of course. And the CBT for Insomnia protocol has good effect on PTSD symptoms after the initial painful first couple of weeks. I can't imagine a recommendation to not address both PTSD and insomnia at once.

The ADHD is a different kettle of fish. Is this maintenance of an existing condition already treated, is it a new onset, or is it undermanaged? Depending on the flavor of PTSD, I'd tread pretty carefully with stimulants and would try to see if their use is a factor in the insomnia.

The VA has traditionally taken a treat-the-PTSD-first approach a lot of the time, but new programs are proving this isn't the best route. Some of the more research-oriented VAs have clinics, groups and programs for comorbid mood/PTSD or substance/PTSD in which both are tackled at once and the data is stronger than trying to treat PTSD with an uncontrolled alcoholic and the like.

I was thinking about ADHD from childhood. Granted these people might be more inclined towards PTSD due to symptoms or from parents with the same condition. Mostly I was thinking of soldiers with ADHD from childhood who now have experienced a rough deployment resulting in PTSD.

 

[nitemagi]

PTSD and Insomnia are treated concurrently. Untreated PTSD worsens sleep and untreated insomnia aggravates PTSD symptoms. Some treatments are effective at assisting both. Prazosin, of course. And the CBT for Insomnia protocol has good effect on PTSD symptoms after the initial painful first couple of weeks. I can't imagine a recommendation to not address both PTSD and insomnia at once.

The ADHD is a different kettle of fish. Is this maintenance of an existing condition already treated, is it a new onset, or is it undermanaged? Depending on the flavor of PTSD, I'd tread pretty carefully with stimulants and would try to see if their use is a factor in the insomnia.

The VA has traditionally taken a treat-the-PTSD-first approach a lot of the time, but new programs are proving this isn't the best route. Some of the more research-oriented VAs have clinics, groups and programs for comorbid mood/PTSD or substance/PTSD in which both are tackled at once and the data is stronger than trying to treat PTSD with an uncontrolled alcoholic and the like.

I agree with the treat the PTSD first approach for adults AND children. ADHD isn't always ADHD, IMO. The hypervigilance and distractibility and even restlessness of real PTSD can look like ADHD and chasing that isn't useful, IMO, and just create iatrogenic issues (stimulant worsened anxiety, for example).

 

[zenman]

I agree with the treat the PTSD first approach for adults AND children. ADHD isn't always ADHD, IMO. The hypervigilance and distractibility and even restlessness of real PTSD can look like ADHD and chasing that isn't useful, IMO, and just create iatrogenic issues (stimulant worsened anxiety, for example).

ADHD and PTSD can both have, for example, inability to concentrate, mood swings, hyper-vigilance, irritability. Let's say someone has never been treated for ADHD and it is effecting their work performance, and now they have PTSD on top of ADHD, why not treat both at the same time?

 

[xlithiumx]

ADHD and PTSD can both have, for example, inability to concentrate, mood swings, hyper-vigilance, irritability. Let's say someone has never been treated for ADHD and it is effecting their work performance, and now they have PTSD on top of ADHD, why not treat both at the same time?

Because if you use a psychostimulant to treat the ADHD, you will likely worsen the PTSD. I suppose if you were going to use only A2 agonists for the ADHD, you might be okay, but those don't really work for the inattention symptoms anyway.

 

[notdeadyet]

ADHD and PTSD can both have, for example, inability to concentrate, mood swings, hyper-vigilance, irritability. Let's say someone has never been treated for ADHD and it is effecting their work performance, and now they have PTSD on top of ADHD, why not treat both at the same time?

If someone has never been treated for ADHD, I'd be very reluctant to introduce stimulants when there was a complicating PTSD picture. I'd treat the PTSD and monitor the ADHD symptoms over time to see which were resolved/improved.

 

[PsyDr]

"Residency training is about much more than learning how to prescribe. Psychiatrists deal with acute suicidality in their training under supervision over and over again. These other folks do not. "

In all fairness, psychologists can and do admit while assessing suicidal in their training. (state depending).

 

[zenman]

This explains my way of thinking about the two diagnosis, especially with my population:
http://www.add.org/?page=ADHDandPTSD

 

[notdeadyet]

This explains my way of thinking about the two diagnosis, especially with my population:
http://www.add.org/?page=ADHDandPTSD

He sounds like an interesting guy.

Despite what he hints at though, ADHD is likely actually less represented in the veteran than civilian population. While I'm sure you get a fair number of undiagnosed cases that make their way through, ADHD requiring medication or ADHD impacting recent academics is disqualifying and would prevent enlistment into the Army (I'm Reserve Corps army-side; I'm less familiar with Air Force or Navy, but their standards are likely to be similar). Not to say it doesn't happen, but statistically it's less likely than on civvie side.

It's NOT a disqualification once you're in, however, and the military diagnoses and treats a fair bit of ADHD.

So my treatment tree would likely be this:
- If they're already hold a documented diagnosis of ADHD and have a stable/established treatment regimen, I'd likely keep it.
- If tthey do not hold a diagnosis of ADHD and they made it through their childhood, high school, and military career without the use of stimulants for ADHD, I would leverage what techniques they used for this success while treating their PTSD and work on stabilizing that before I'd start a new medication with potential for abuse and potential for exacerbating the symptoms of PTSD I'm trying to treat.

Non-treatment of ADHD isn't ideal. But trying to come up with a new diagnosis of ADHD in a patient with current untreated PTSD is going to be iffy at best and the first step in coming up with an accurate ADHD diagnosis would be to separate out the PTSD symptoms, which would be done by symptom management. Introducing amphetamines and the like to an untreated PTSD case has risks that far outweigh benefits.

 

[vistaril]

While I'm sure you get a fair number of undiagnosed cases that make their way through, ADHD requiring medication or ADHD impacting recent academics is disqualifying and would prevent enlistment into the Army

How true is this? And how recent? Let's say some parent takes their active occasionally oppositional kid who is having trouble focusing in the first grade to the child psychiatrist, and they try some stimulant for a few years. The kid is now 18-21, is no longer on stimulants, and appears normal. Does that disqualify the kid from the armed services? If so, I would hope child psychiatrists are a little more conservative with putting such a high % of kids on stimulants.

then again, I'm not sure why the kid would list it(or even remember?) on his application to the army.

 

[zenman]

How true is this? And how recent? Let's say some parent takes their active occasionally oppositional kid who is having trouble focusing in the first grade to the child psychiatrist, and they try some stimulant for a few years. The kid is now 18-21, is no longer on stimulants, and appears normal. Does that disqualify the kid from the armed services? If so, I would hope child psychiatrists are a little more conservative with putting such a high % of kids on stimulants.

then again, I'm not sure why the kid would list it(or even remember?) on his application to the army.

I see quite a few (not just ADHD) who have told me their recruiters told them to stop meds before signing up. Then guess what happens....

 

[deleted307836]

I see quite a few (not just ADHD) who have told me their recruiters told them to stop meds before signing up. Then guess what happens....

Wow.

I've heard that recruiting practices can sometimes be rather shady but that's pretty surprising.

 

[notdeadyet]

How true is this? And how recent?

It's true. No clue how recent. It's been disqualifying since at least 2008 (that's as far back as my involvement goes). Likely much longer than that. The military in general has had a "no meds for 12 months" stipulation for even the psych diagnoses that are not immediately disqualifying.

Let's say some parent takes their active occasionally oppositional kid who is having trouble focusing in the first grade to the child psychiatrist, and they try some stimulant for a few years. The kid is now 18-21, is no longer on stimulants, and appears normal. Does that disqualify the kid from the armed services?

No, it wouldn't. As long as he's off meds and is able to function, he's fine.

then again, I'm not sure why the kid would list it(or even remember?) on his application to the army.

If it's a remote, short-term use of stimulants, he could easily enough forget, but that wouldn't be disqualifying anyway.

 

[notdeadyet]

I see quite a few (not just ADHD) who have told me their recruiters told them to stop meds before signing up. Then guess what happens....

Then they join and go to their provider lickety-split and get a diagnosis of ADHD and get put back on stimulants. Folks tend to do this rather than take it on the sly, since some ADHD treatments show up hot on a utox, which would be very bad juju.

That's why I think the scenario of ADHD not treated through childhood or military service that presents post-deployment in the setting of PTSD should be treated hyperconservatively.

CityLights- I was surprised by how many folks have had recruiters suggest they lie on their intake paperwork. I'm not as surprised anymore.