frustrated

[randomdoc1]

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While that;s very possible, i think we all know patients also often hear what they want to hear too. I would have a "So, help me understand..."convo with that therapist to investigate this. To have a licensed therapist to believe that they cant do anything with insomnia means their training was garbage.

lol. That is actually similar to what I sort of said. I did confront her and said I have a hard time believing the therapist did not recommend any form of therapy for the insomnia. And if she didn't, I was rather concerned about the care she was getting.

 

[Attending1985]

I very much disagree with this. Care is better but because of effects that don't have to do with the treatment prescribed itself. I would agree that, much of the time, care with prescription of placebo would be better.

Yes but a therapist or caring family medicine doctor can provide those non-specific effects you don't need a psychiatrist or NP providing possibly addictive/damaging medications to achieve this

 

[thoffen]

Yes but a therapist or caring family medicine doctor can provide those non-specific effects you don't need a psychiatrist or NP providing possibly addictive/damaging medications to achieve this

Oh yes I agree that the treatment is often wrong and dangerous. But I also think that you often do need a psychiatrist or NP doing the treatment. As much as we would sometimes like to relegate a therapeutic relationship for a complicated patient to a therapist, it's often a fantasy, and often for reasons other than practical availability of qualified therapist. Some people need (at least in the beginning) a person that represents in training, age, appearance, degree, etc. some conflicted internal object in order to work on their problems through the treatment relationship. As psychiatry swings toward biology (very much more in professed understanding than any new or more effective treatment), very many people latch on to this model. A lot of these people won't seek or be able to develop a rich therapeutic attachment outside of someone who represents that model of treatment.

I want society to support a different and more flexible view of the mind, and I intensely dislike the way psychiatry has partnered in it, but I really don't get to choose what other people do.

 

[Attending1985]

Oh yes I agree that the treatment is often wrong and dangerous. But I also think that you often do need a psychiatrist or NP doing the treatment. As much as we would sometimes like to relegate a therapeutic relationship for a complicated patient to a therapist, it's often a fantasy, and often for reasons other than practical availability of qualified therapist. Some people need (at least in the beginning) a person that represents in training, age, appearance, degree, etc. some conflicted internal object in order to work on their problems through the treatment relationship. As psychiatry swings toward biology (very much more in professed understanding than any new or more effective treatment), very many people latch on to this model. A lot of these people won't seek or be able to develop a rich therapeutic attachment outside of someone who represents that model of treatment.

I want society to support a different and more flexible view of the mind, and I intensely dislike the way psychiatry has partnered in it, but I really don't get to choose what other people do.

Wish we could go back to the model of psychiatrist providing both medications and therapy. In my experience, those employed positions do not exist.

 

[erg923]

lol. That is actually similar to what I sort of said. I did confront her and said I have a hard time believing the therapist did not recommend any form of therapy for the insomnia. And if she didn't, I was rather concerned about the care she was getting.

Sounds about right. I will say that from my time in primary care psych (in which therapy is usually limited to 6-12 sessions), jumping into a protocol of CBT-I can be intimating for the patient (depending on where they are in the "stages of change" and their general motivation and availability for weekly therapy). I also found that real doses of the formal CBT-I protocol come with adherence problems that are probably only rivaled by PE and CPT. Given that chronic insomnia can be frustrating for the patient and therapist alike, none of what you wrote surprises me in the least.

 

[st2205]

Is there any data about different prescribing behaviors between different providers types? E.g., PCP vs psychiatry, vs NP and the like? I'd be interested in if it's more anecdotal or if there are association there. Because, I don't really see much of a difference when it comes to benzos, opiates, and stims in my settings. I'd be curious if there were any actual differences in this, or say geographically (we have opiate data, just haven't seen the other two in this area).

I had a chart from a presentation I did that broke down (per state) the % of the prescriber pool that were midlevels and the % of total prescriptions that were written by midlevels. They were a minority of all providers and in some states the majority of prescriptions. I’ll have to go pull this out and see the source. One big confounded is that only a few states were profiled.

(This was also all of medicine and not just psychiatry).

 

[WisNeuro]

I had a chart from a presentation I did that broke down (per state) the % of the prescriber pool that were midlevels and the % of total prescriptions that were written by midlevels. They were a minority of all providers and in some states the majority of prescriptions. I’ll have to go pull this out and see the source. One big confounded is that only a few states were profiled.

(This was also all of medicine and not just psychiatry).

I'd be interested in seeing this as well. Although, we'd need some other descriptives to make sense of the data. Otherwise you could just be measuring outliers, of which outliers in the larger group would be slightly washed out by the mere fact of a larger n, making the smaller group look more extreme when they could actually be fairly equivalent.

 

[st2205]

I'd be interested in seeing this as well. Although, we'd need some other descriptives to make sense of the data. Otherwise you could just be measuring outliers, of which outliers in the larger group would be slightly washed out by the mere fact of a larger n, making the smaller group look more extreme when they could actually be fairly equivalent.

Looking back over it, I misspoke about being >50% of prescriptions but rather that in some instances their prescription representation vs. actual representation amongst prescribers was 2x as high.

Here's the link, with some notables on pages 36 and 37.

http://www.imshealth.com/files/web/IMSH Institute/Reports/Medicines-Use-and-Spending-in-the-US-2015-to-2020/IMS_Institute_Medicines_Use_and_Spending_in_2015.pdf

It is what it is so please resist the temptation to assume I believe this captures every particular.

 

[WisNeuro]

I guess I was more looking for what actual drugs are being prescribed. That chart is for healthcare in general. I was curious if there was anything about what people were prescribing by type of provider.

 

[thoffen]

Wish we could go back to the model of psychiatrist providing both medications and therapy. In my experience, those employed positions do not exist.

I know people that do that but with a cash practice. I bet the therapy add on codes that people do for what otherwise was no different than a med visit for them are ruining the real use of these codes.

But combined treatment introduces other dynamics too. I don't prefer it, but it's not like split treatment isn't introducing a whole lot more. I wonder what happens more: "my therapist says you need to change my meds (or says I need to be on Xanax)", or "my doctor says you need to help me with my problems with my mom (or anything other than meds)".

 

[clausewitz2]

Oh yes I agree that the treatment is often wrong and dangerous. But I also think that you often do need a psychiatrist or NP doing the treatment. As much as we would sometimes like to relegate a therapeutic relationship for a complicated patient to a therapist, it's often a fantasy, and often for reasons other than practical availability of qualified therapist. Some people need (at least in the beginning) a person that represents in training, age, appearance, degree, etc. some conflicted internal object in order to work on their problems through the treatment relationship. As psychiatry swings toward biology (very much more in professed understanding than any new or more effective treatment), very many people latch on to this model. A lot of these people won't seek or be able to develop a rich therapeutic attachment outside of someone who represents that model of treatment.

I want society to support a different and more flexible view of the mind, and I intensely dislike the way psychiatry has partnered in it, but I really don't get to choose what other people do.

So much this. And as much as we love to complain about the psychotropic alchemists who want to have just the right tailored polypharmacy, it is easy to lose sight of the fact that this is sometimes what they are looking for, that therapeutic attachment.

If the price of developing that is fiddling with someone's Buspar constantly or a slightly wacky Wellbutrin dosing schedule, is that really a problem?

 

[FlowRate]

Is there any data about different prescribing behaviors between different providers types? E.g., PCP vs psychiatry, vs NP and the like? I'd be interested in if it's more anecdotal or if there are association there. Because, I don't really see much of a difference when it comes to benzos, opiates, and stims in my settings. I'd be curious if there were any actual differences in this, or say geographically (we have opiate data, just haven't seen the other two in this area).

The research that has been done has been 1. short duration 2. funded by nursing associations 3. aimed at noninferiority.

It's really easy to do research to support the position that you don't kill more people than other doctors. Or that doctors who work longer hours don't kill more people than doctors who have limited work hours. It's hard to kill people.

Edit: I missed the key "prescribing behavior" part of your post when I read it at first. I was speaking to general "outcomes" studies of NP vs. MD.

 

[Attending1985]

So much this. And as much as we love to complain about the psychotropic alchemists who want to have just the right tailored polypharmacy, it is easy to lose sight of the fact that this is sometimes what they are looking for, that therapeutic attachment.

If the price of developing that is fiddling with someone's Buspar constantly or a slightly wacky Wellbutrin dosing schedule, is that really a problem?

Fiddling with antidepressants no but many of our meds have serious toxicities. Like people with td who were on antipsychotics long term for something other than psychosis. Very sad.

 

[WisNeuro]

The research that has been done has been 1. short duration 2. funded by nursing associations 3. aimed at noninferiority.

It's really easy to do research to support the position that you don't kill more people than other doctors. Or that doctors who work longer hours don't kill more people than doctors who have limited work hours. It's hard to kill people.

Edit: I missed the key "prescribing behavior" part of your post when I read it at first. I was speaking to general "outcomes" studies of NP vs. MD.

Well, that is another side issue, tangentially related, that is important to address. There is indeed research from midlevels aimed at advocacy, and it definitely has the potential for bias. But, on the flip side, there is no real data to say that those studies' conclusions are not valid. We do a poor job of outcome research in general, but we also make a lot of assumptions on outcome with either missing, or insufficient data, rather relying on status quo to inform our opinion.