carlosc1dbz

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I know many people with chronic pain suffer from depression. So i was wondering if psychiatrist maybe give pain medication to people in order to relieve them of their depressive, maybe suicidal thoughts, or do they just refer them to a pain specialist?
 

rgerwin

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I imagine it would depend also on the source of the pain. Diabetic neuropathy is often treated with psych drugs anyway, for example.
 

michaelrack

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I imagine it would depend also on the source of the pain. Diabetic neuropathy is often treated with psych drugs anyway, for example.

Just because something is treated by a "psych drug" doesn't mean that a psychiatrist is going to treat it.
 

whopper

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Insurance will usually not cover a psychiatrist who treats outside the scope of psychiatry. Legally, a medical license allows you to practice anything within the field of medicine, though insurance-wise you may not be covered.

As for pain, you need to be careful. While we usually don't treat pain, we often get people who been made dependent or addicted to their pain-medications by their non-psychiatric physicians.

So we should still be on top of pain-meds in an academic and clinical sense, even if we do not prescribe them. Our own field, academically, goes into much greater depth in the pharmacology of opioids vs other fields.

As for pain and depression, the two can exacerbate the other. Several psychotropic meds have been found to reduce chronic pain. E.g. almost any of the medications that block the reuptake of norepinephrine (SNRIs such as venlafaxine or duloxetine), bupropion, amitryptaline, etc. Gapapentin can also decrease pain.

So if our patient does suffer from chronic pain and they have a psychiatric disorder, this can influence our judgment as to what medication we choose to treat them. In patients with chronic pain who are depressed, I do consider giving them an SNRI over an SSRI.

Getting back to patients who've been made dependent or addicted to pain-meds by their PCPs or other physicians, if you have a patient on an opioid, you may sometimes see signs of dependence. In that case you should contact the physician giving it out.

I have a handful of patients on opioids and benzodiazapines from other doctors, and I highly question the rationale behind it. One of those patients, after an argument took a few extra xanax and crashed her car into someone else's. It was not a suicide attempt, she was driving under the influence, that she told me she done before--only after the incident happened. Only then did the PCP stop the xanax even though I wrote that doctor 3x telling the doctor that there was a questionable need for it because I got the patient's panic attacks under control, and she told me she used it inappropriately several times.

I documented everything that happened, and explained to her the risks and benefits of xanax, (and she told me her PCP never discussed these with her). I told her from my standpoint, I didn't see a need for it, but the PCP might have some rationale I didn't know about that may justify it's use (but the patient nor I didn't know about it, and heck, what exactly is the justification for xanax when the patient no longer has symptoms of anxiety and no sleep problems?) and that I would attempt to contact that PCP. 3 attempts-no response from that PCP.

So when the crash happened, I double checked my notes, and I had no fear of the case being brought to court. I was actually pseudo-welcoming it, because I wanted to see what that PCP would say on the stand. (Never happened).
 
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benjee

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Insurance will usually not cover a psychiatrist who treats outside the scope of psychiatry. Legally, a medical license allows you to practice anything within the field of medicine, though insurance-wise you may not be covered.

As for pain, you need to be careful. While we usually don't treat pain, we often get people who been made dependent or addicted to their pain-medications by their non-psychiatric physicians.

So we should still be on top of pain-meds in an academic and clinical sense, even if we do not prescribe them. Our own field, academically, goes into much greater depth in the pharmacology of opioids vs other fields.

As for pain and depression, the two can exacerbate the other. Several psychotropic meds have been found to reduce chronic pain. E.g. almost any of the medications that block the reuptake of norepinephrine (SNRIs such as venlafaxine or duloxetine), bupropion, amitryptaline, etc. Gapapentin can also decrease pain.

So if our patient does suffer from chronic pain and they have a psychiatric disorder, this can influence our judgment as to what medication we choose to treat them. In patients with chronic pain who are depressed, I do consider giving them an SNRI over an SSRI.

Getting back to patients who've been made dependent or addicted to pain-meds by their PCPs or other physicians, if you have a patient on an opioid, you may sometimes see signs of dependence. In that case you should contact the physician giving it out.

I have a handful of patients on opioids and benzodiazapines from other doctors, and I highly question the rationale behind it. One of those patients, after an argument took a few extra xanax and crashed her car into someone else's. It was not a suicide attempt, she was driving under the influence, that she told me she done before--only after the incident happened. Only then did the PCP stop the xanax even though I wrote that doctor 3x telling the doctor that there was a questionable need for it because I got the patient's panic attacks under control, and she told me she used it inappropriately several times.

I documented everything that happened, and explained to her the risks and benefits of xanax, (and she told me her PCP never discussed these with her). I told her from my standpoint, I didn't see a need for it, but the PCP might have some rationale I didn't know about that may justify it's use (but the patient nor I didn't know about it, and heck, what exactly is the justification for xanax when the patient no longer has symptoms of anxiety and no sleep problems?) and that I would attempt to contact that PCP. 3 attempts-no response from that PCP.

So when the crash happened, I double checked my notes, and I had no fear of the case being brought to court. I was actually pseudo-welcoming it, because I wanted to see what that PCP would say on the stand. (Never happened).
Hi whopper,
you just tell us a very good and common example on certain clienteles whom we face everyday. first, he/she didn't follow you instructions , second , he/she may have PD d/o?? borderline?? Her pcp may have told her the reasons or she forgot?? third, her pcp never responses your request which I encounter similar situation often times. anyway, the worst part is the client does not follow instructions leading to serious consequences. Not sure besides documentation, what else can we do to prevent injury?? any suggestions??
 

whopper

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first, he/she didn't follow you instructions , second , he/she may have PD d/o?? borderline?? Her pcp may have told her the reasons or she forgot?? third, her pcp never responses your request which I encounter similar situation often times. anyway, the worst part is the client does not follow instructions leading to serious consequences. Not sure besides documentation, what else can we do to prevent injury?? any suggestions??
1) The patient followed my instructions, but the PCP never contacted me back. Remember, I wasn't the one prescribing the benzos, it was the PCP, and the PCP contiuned to do so even after I told the PCP it wasn't needed. I faxed letters to the doctor's office, wrote a letter that I asked the patient to bring to the PCP (she said she was going to see the PCP a few days later), and called the PCP's office and left my cell phone number.

2) Her PCP may have told her reasons and the patient may have forgotten. Whether or not this is true, it has been my experience that a significant number of doctors do not explain the process to their patients. How do I know this? Well patient's claims may be exaggerated, but during consult service, most of requests for capacity were from patients who refused a procedure. When I asked the patient if the doctor explained the risks and benefits of the procedure, the patient claimed no, and when I explained it to them, they were open to the procedure. The doctor didn't document that he/she explained the procedure. This highly suggested there was no discussion.

This is very uncomfortable because we shouldn't be explaining the risks/benefits of the procedures to the patients if it's outside our field, and it's in essence dumped on us. Several doctors are of the impression that they don't have to talk to their patients, and that's psychiatry's job. No, everyone has to talk to their patients when explaining the risks and benefits of a procedure.

I would end such consults telling the patient that they need to discuss the risks and benefits with the doctor that ordered the consult and that while I did have some discussion with them, I was not treating them in that regard, nor knew all of the rationale behind the treating doctor's decision.

While a resident, I had about one patient a week who was dependent on a benzo or opioid and their PCP (per the patient) never once told the patient the risk of addiction and dependence with those medications. Further, the doctor gave it out for years with no apparent strategy that these medications cause tolerance, then that doctor upped the dosage gradually over time.

he/she may have PD d/o?? borderline??
This patient certainly had some cluster B issues. Let's just say, ahem, well it's kinda like the Jerry Springer show. She's involved in a relationship with a man who has long term relationships with other women. Each of the women hate each other, and hate that he sees the other women, but they will not break up with him. Very cluster B, and IMHO it's the basis of her panic attacks. They did not happen before she saw this man, however she does not meet enough criteria for an actual personality disorder other than perhaps NOS.

Not sure besides documentation, what else can we do to prevent injury?? any suggestions??
Document. If you write a letter to the other doctor, and they do not follow your wishes, there's only so much you can do.

You need to be careful because sometimes the doctor may have some rationale that actually makes sense, it's just that you dont' have the doctor's note in front of you and the patient might not remember.
 

benjee

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1) The patient followed my instructions, but the PCP never contacted me back. Remember, I wasn't the one prescribing the benzos, it was the PCP, and the PCP contiuned to do so even after I told the PCP it wasn't needed. I faxed letters to the doctor's office, wrote a letter that I asked the patient to bring to the PCP (she said she was going to see the PCP a few days later), and called the PCP's office and left my cell phone number.

2) Her PCP may have told her reasons and the patient may have forgotten. Whether or not this is true, it has been my experience that a significant number of doctors do not explain the process to their patients. How do I know this? Well patient's claims may be exaggerated, but during consult service, most of requests for capacity were from patients who refused a procedure. When I asked the patient if the doctor explained the risks and benefits of the procedure, the patient claimed no, and when I explained it to them, they were open to the procedure. The doctor didn't document that he/she explained the procedure. This highly suggested there was no discussion.

This is very uncomfortable because we shouldn't be explaining the risks/benefits of the procedures to the patients if it's outside our field, and it's in essence dumped on us. Several doctors are of the impression that they don't have to talk to their patients, and that's psychiatry's job. No, everyone has to talk to their patients when explaining the risks and benefits of a procedure.

I would end such consults telling the patient that they need to discuss the risks and benefits with the doctor that ordered the consult and that while I did have some discussion with them, I was not treating them in that regard, nor knew all of the rationale behind the treating doctor's decision.

While a resident, I had about one patient a week who was dependent on a benzo or opioid and their PCP (per the patient) never once told the patient the risk of addiction and dependence with those medications. Further, the doctor gave it out for years with no apparent strategy that these medications cause tolerance, then that doctor upped the dosage gradually over time.


This patient certainly had some cluster B issues. Let's just say, ahem, well it's kinda like the Jerry Springer show. She's involved in a relationship with a man who has long term relationships with other women. Each of the women hate each other, and hate that he sees the other women, but they will not break up with him. Very cluster B, and IMHO it's the basis of her panic attacks. They did not happen before she saw this man, however she does not meet enough criteria for an actual personality disorder other than perhaps NOS.



Document. If you write a letter to the other doctor, and they do not follow your wishes, there's only so much you can do.

You need to be careful because sometimes the doctor may have some rationale that actually makes sense, it's just that you dont' have the doctor's note in front of you and the patient might not remember.
Oh, mind, hope we are not talking about the same pt( just kidding). One of my pts with cluster B , very borderline , impulsive ,has similar pics , involving with a married man, has a suicidal attempt by OD, was in ICU, came out, still seeing the man, refuse to be complaint with treatment ,meds or therapy or DBT. Bascially, she is a time bomb.
About the benzo prescribed by pcp, i would not prescribe any benzo to the client , will tell her to get it from her pcp since she got it in the past.
agree that some pcps just do not response to other specialists.it's not uncommon.
 
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As for pain and depression, the two can exacerbate the other. Several psychotropic meds have been found to reduce chronic pain. E.g. almost any of the medications that block the reuptake of norepinephrine (SNRIs such as venlafaxine or duloxetine), bupropion, amitryptaline, etc. Gapapentin can also decrease pain.

I am not so sure about one exacerbating the other. It's likely that it's not A that exacerbates B or vice versa, but X is causing A and B.

here is a quote with suggested MoA of SNRI in chronic pain:
http://www.psychiatrist.com/pcc/pccpdf/v05s07/v05s0704.pdf

It has been suggested that serotonergic
and noradrenergic projections from the brainstem
are involved in the spinal pathways that modulate painful
physical symptoms and that dysfunction of these pathways
due to depression may lead to increased perceptions of
these symptoms.

In addition, it has been suggested that
depression and pain are mediated through a common pathway
and that the balance of 5-HT and NE influences the
perception of painful symptoms.

===end quote===

Hence, if we assume deficiency of both neurotransmitters with depression and chronic pain as presenting symptoms, then an SNRI would increase both, 5HT and NE, and possibly alleviate the symptoms.
 

masterofmonkeys

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I've felt for a long time that psych needs to take a more primary role in the management of pain. Considering a pain fellowship myself (we'll see how i feel in 5 years lol).

When I read that pain had become the '5th vital sign' I vomited all over my computer. It was not a cheap repair. Unlike BP or temp, reported level of pain is intimately tied to psychological state in a multitude of ways.

Pain is both a sensation and an experience. As yet, there are no good ways to measure the strength of the peripheral nervous response, the intensity with which the thalamus conveys it to our attention, or the degree to which the frontal lobes do their bit in mitigating subjective feelings of pain. And a simple number on a scale of 1-10 and LIQOR AAA don't do a great job of capturing the magnitude and impact of pain.

The subjective nature of pain is largely lost in our modern medical take on it. Which is unfortunate, as I'd argue that how we experience pain has a lot more to do with morbidity and quality of life than the actual pain itself.

Pain, at its root, evolved as a signal to stop doing things; it is by its nature a paralytic, of life, of movement, of will. It was a signal not to get bit by that gaudily colorful beetle, to ease up on that pulled muscle, to not stretch your skin and tear that scab loose. The response to this stimulus was to avoid pain. To change behavior in such a way as to minimize damage and improve healing. And in doing so, to remove the stimulus that causes us pain. But what happens if the stimulus itself cannot be revoked? Chronic pain was not an issue in our evolutionary history, because anything injury bad enough to hurt chronically, was an injury you probably weren't going to survive chronically.

Fast forward to today, where it is possible to survive what would have been conditionally life threatening injuries thousands of years ago. We are not equipped to deal with chronic pain, because there was never any selection benefit in doing so. And so a stimulus that, acutely, is adaptive, becomes maladaptive in the long-term. Moreover, the natural response to that stimulus, to feel that paralytic and nerve-sapping tint of pain, becomes maladaptive in the long-term. It thus becomes imperative that our response to that stimulus change.

Not doing so will lead to the pain controlling our lives. Which is the situation I see in all too many 'chronic pain' patients. They still seek an end to the pain. Their lives are paralyzed by it, their lives revolve around it. How can I make the hurting go away? And so they gradually withdraw from the things that used to give them pleasure, and then the things they simply needed to do. And sadly, turn into shells of their former selves.

I feel like the most important part of learning to live well with chronic pain is learning how to deal with that stimulus in a positive and adaptive way. And I don't think that's being well addressed by the medical community at large.
 

whopper

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Insurance will usually not cover a psychiatrist who treats outside the scope of psychiatry. Legally, a medical license allows you to practice anything within the field of medicine, though insurance-wise you may not be covered.
Need to add that even if you by some chance are covered by insurance, for malpractice purposes, you are expected to treat the condition as well as someone who provides the service on on a standard basis.

So, for example, if you intubated someone, you better intubate as well as an anesthesiologist.
 

nancysinatra

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I've felt for a long time that psych needs to take a more primary role in the management of pain. Considering a pain fellowship myself (we'll see how i feel in 5 years lol).

When I read that pain had become the '5th vital sign' I vomited all over my computer. It was not a cheap repair. Unlike BP or temp, reported level of pain is intimately tied to psychological state in a multitude of ways.

Pain is both a sensation and an experience. As yet, there are no good ways to measure the strength of the peripheral nervous response, the intensity with which the thalamus conveys it to our attention, or the degree to which the frontal lobes do their bit in mitigating subjective feelings of pain. And a simple number on a scale of 1-10 and LIQOR AAA don't do a great job of capturing the magnitude and impact of pain.
Probably that pain as a "5th vital sign" has nothing to do with the chronic pain patients you're talking about. (Although I think it sounds stupid too, because patients are not reliable pain raters). I imagine it's more useful for measuring acute abdominal pain, chest pain, labor pain, post op pain, terminal cancer pain, etc. I would guess that someone added it because it gets overlooked in the ER a lot.

Not all pain is musculoskeletal, neuropathic, chronic pain. Sometimes it just needs to be treated. Including with some types of chronic pain. Gout, arthritis... those aren't psychiatric issues. We had a patient on medicine not long ago, a heart transplant recipient, who had bad gout. He couldn't take his colchicine because together with his sirolimus it was ruining his kidneys. So the attending prescribed codeine, which worked! Wow! How horrible!

I am sometimes shocked by the lack of empathy I've seen within psych for patients reporting pain (not referring to your post, MOM). We admitted a patient to our psych floor s/p gunshot wound, without transfer instructions from ortho, post op day 2 or 3 max. My attending insisted on tylenol only. The patient was moaning all day long in pain. Then the wound started having problems so we had to call ortho. They were very surprised that their instructions, which included orders for morphine, hadn't been included, and also, that we were only giving the patient Tylenol. Even then my attending wanted to only go with Tylenol 3. Now if it was your family member, would you want a psychiatrist or an orthopedic surgeon dictating the post-op pain management on post op day 2 or 3, and who do you think would be more empathic about that pain? Over my time in psychiatry I'm getting the impression that attitudes toward pain in our patients are influenced by our experiences with opioids and benzo abuse, and experiences with somatasizing patients.

And don't get me wrong--I deal with "my back hurts please give me vicodin" all day long too.
 

masterofmonkeys

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Probably that pain as a "5th vital sign" has nothing to do with the chronic pain patients you're talking about. (Although I think it sounds stupid too, because patients are not reliable pain raters). I imagine it's more useful for measuring acute abdominal pain, chest pain, labor pain, post op pain, terminal cancer pain, etc. I would guess that someone added it because it gets overlooked in the ER a lot.

Not all pain is musculoskeletal, neuropathic, chronic pain. Sometimes it just needs to be treated. Including with some types of chronic pain. Gout, arthritis... those aren't psychiatric issues. We had a patient on medicine not long ago, a heart transplant recipient, who had bad gout. He couldn't take his colchicine because together with his sirolimus it was ruining his kidneys. So the attending prescribed codeine, which worked! Wow! How horrible!

I am sometimes shocked by the lack of empathy I've seen within psych for patients reporting pain (not referring to your post, MOM). We admitted a patient to our psych floor s/p gunshot wound, without transfer instructions from ortho, post op day 2 or 3 max. My attending insisted on tylenol only. The patient was moaning all day long in pain. Then the wound started having problems so we had to call ortho. They were very surprised that their instructions, which included orders for morphine, hadn't been included, and also, that we were only giving the patient Tylenol. Even then my attending wanted to only go with Tylenol 3. Now if it was your family member, would you want a psychiatrist or an orthopedic surgeon dictating the post-op pain management on post op day 2 or 3, and who do you think would be more empathic about that pain? Over my time in psychiatry I'm getting the impression that attitudes toward pain in our patients are influenced by our experiences with opioids and benzo abuse, and experiences with somatasizing patients.

And don't get me wrong--I deal with "my back hurts please give me vicodin" all day long too.
I agree with what you're saying. I don't hesitate to use opiates in post-traumatic or post-op situations. But that's not where our epidemic of painkiller abuse and loss of quality of life comes from. My attitude wasn't formed in residency but rather in the last 12 years I've spent living with chronic pain.
 

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This is very uncomfortable because we shouldn't be explaining the risks/benefits of the procedures to the patients if it's outside our field, and it's in essence dumped on us. Several doctors are of the impression that they don't have to talk to their patients, and that's psychiatry's job. No, everyone has to talk to their patients when explaining the risks and benefits of a procedure.
I work in a large hospital and I am not a medical student, resident, or any category of physician and I have to deal with this. Pt's can become very frustrated/angry when they ask me questions (because the doctors won't talk to them) and I legally and ethically cannot answer them, even when I know the answer. I am not a physician, I cannot be the one to explain their medical treatment. Furthermore, at this stage in my education, I would not want that responsibility. So what do I do? As soon as the pt leaves my office, I get on the horn and leave whatever doctor is responsible for the treatment in question a message on voicemail as well as email and hope they talk to the pt. The scary part is, you know there are people out there in my line of work who don't have this ethical/legal grounding and they will go ahead and tell the pt whatever. Then you have a non-physician giving information/opinions that should be coming from a physician.
 

whopper

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Pt's can become very frustrated/angry when they ask me questions (because the doctors won't talk to them) and I legally and ethically cannot answer them, even when I know the answer.
I was in that boat as well as I explained above. What bugged me more was politically, the attendings didn't want to make a stink about it, and I was a resident. Residents should not complain to attendings outside the department. It needs to be handled by the attendings.

The attendings didn't seem to care IMHO because they weren't the people suffering the brunt of this problem. All they had to do was sign the consult. It really was the resident that was having to spend about an hour on the case, only to figure out the medical attending didn't explain anything to the patient.

So, in short, problem is occurring, and problem will continue to go on.

The only good thing about this was that in consult service, it was typical to have several free hours in a day, and this is a problem occuring in several hospitals. To some degree, it was good training to be exposed to this type of problem.

One of my law professors (remember, I'm a forensic fellow) is fully aware of this phenomenon and the legal standards that mandate a doctor give a patient a reasonable amount of information on anything done to the patient. He told me anytime he goes to the hospital, doctor's office, any medical environment, for the heck of it, he snoops around to see if doctors are giving their patients a reasonable amount of info.

He said pretty much every time he snooped around, no doctor was giving information. My wife the other day had pharyngitis, and her doctor walked in, gave her a medication, and then left. The doctor explained nothing other than to take the antibiotic, and gave my wife a script. That's it!

And that's really the way the majority of the doctors I've seen practice.
 

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Here's the deal... Pain is "or at least was" where the money was at, so every specialty including pathology and radiology was trying at some point to get a piece of the pie. As often happens, Psychiatry just sits back and watches not taking enough of an active role. Then, by default, as soon as doctors couldn't handle or solve a patients condition thereby becoming "a difficult patient," they get sent to see the psychiatrist. So we end up taking a double stuff in the back without the ky or a kiss.

Now, pain fellowships are comprised of four specialties which train in a multi-disciplinary way. Psychiatry is one of the specialties, and I encourage future residents to apply if they have an interest. The training for an ACGME accredited pain fellowship is EXACTLY the same as for the other three specialties and they are required to consider Psychiatry residents.

There will always be a bias against psychiatrists, so do not get discouraged in your applications. If you keep pushing and demonstrate your skill set, they will respect you as an equal colleague. Often times, I've seen psychiatrists get discouraged and drop out.

For those not doing a fellowship, I highly encourage you to at least do CME's in pain medicine and treat patients in your practice with underlying pain conditions. It makes no sense whatsoever to treat a patient for depression secondary to chronic pain if the pain is not being addressed.
 

masterofmonkeys

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Here's the deal... Pain is "or at least was" where the money was at, so every specialty including pathology and radiology was trying at some point to get a piece of the pie. As often happens, Psychiatry just sits back and watches not taking enough of an active role. Then, by default, as soon as doctors couldn't handle or solve a patients condition thereby becoming "a difficult patient," they get sent to see the psychiatrist. So we end up taking a double stuff in the back without the ky or a kiss.

Now, pain fellowships are comprised of four specialties which train in a multi-disciplinary way. Psychiatry is one of the specialties, and I encourage future residents to apply if they have an interest. The training for an ACGME accredited pain fellowship is EXACTLY the same as for the other three specialties and they are required to consider Psychiatry residents.

There will always be a bias against psychiatrists, so do not get discouraged in your applications. If you keep pushing and demonstrate your skill set, they will respect you as an equal colleague. Often times, I've seen psychiatrists get discouraged and drop out.

For those not doing a fellowship, I highly encourage you to at least do CME's in pain medicine and treat patients in your practice with underlying pain conditions. It makes no sense whatsoever to treat a patient for depression secondary to chronic pain if the pain is not being addressed.
:thumbup::thumbup::thumbup:

We need more psych people in pain. Have you done a pain fellowship and if so may I pump you for information?