Irrational Polypharmacy

[shan564]

Advertisement - Members don't see this ad

So the therapist who isn't a physician or NP tells a patient what medications they should be on and what side effects they do or don't have? Isn't that practicing outside the scope of their license? Seems almost reportable.

I'd be inclined to give the therapist the benefit of the doubt (assuming that it's actually a trained therapist, not a counselor with questionable qualifications). Seems more likely that the patient asked something like "I don't like this Lamictal, do you know of anything better?" and the therapist responds with something like "it's complicated - I know Celexa worked for me, but maybe you should talk to your psychiatrist"...

 

[Doctor Bagel]

I'd be inclined to give the therapist the benefit of the doubt (assuming that it's actually a trained therapist, not a counselor with questionable qualifications). Seems more likely that the patient asked something like "I don't like this Lamictal, do you know of anything better?" and the therapist responds with something like "it's complicated - I know Celexa worked for me, but maybe you should talk to your psychiatrist"...

That scenario is maybe a little more appalling -- my doc prescribed me X, you should try it. Yikes! Therapists disclosing their medication regimens to their patients can't be a good thing. Honestly, I don't think much would come of reporting this therapist, but it's certainly a violation of their role to be giving specific information about medications to their patients. It also creates a split in the treatment between the therapist and the psychiatrist, which is generally not a good thing.

 

[sunlioness]

I'd be inclined to give the therapist the benefit of the doubt (assuming that it's actually a trained therapist, not a counselor with questionable qualifications). Seems more likely that the patient asked something like "I don't like this Lamictal, do you know of anything better?" and the therapist responds with something like "it's complicated - I know Celexa worked for me, but maybe you should talk to your psychiatrist"...

There was no "you should talk to your psychiatrist" about it. And she knew he had one. She could read my notes on Epic. She probably didn't because they detailed failed SSRI trials with intolerable side effects and the rationale for trying a mood stabilizer. She asked the PCP who worked out of the same office site to make the change. Now he would not have had access to my notes as they're behind a wall, but the chart would have reflected a psychiatrist's involvement.

I should've talked to both of them about it and said, "hey not cool. You set this guy's treatment back by at least a month." But I didn't. Being fried and hating confrontation. 🙁

She was a masters level therapist LPC / LCPC level of training.


Sent from my iPhone using Tapatalk

 

[smalltownpsych]

The market is getting flooded with the LPC types and it's pretty scary how little they know about how to ethically and effectively practice. It is completely outside my scope of practice to recommend a specific medication. It is within my scope of practice to not increase opportunities for splitting. Here is how my conversation with a patient with erectile dysfunction and sexual desire issues went the other day. "Some antidepressants may impact sexual function. When you see your psychiatrist next week, make sure to talk to him about it. You might want to talk to him about smoking and blood pressure medications and the role that plays, as well. Meanwhile, let's talk more about your difficulty with expressing your feelings with your wife."

 

[shan564]

The market is getting flooded with the LPC types and it's pretty scary how little they know about how to ethically and effectively practice. It is completely outside my scope of practice to recommend a specific medication. It is within my scope of practice to not increase opportunities for splitting. Here is how my conversation with a patient with erectile dysfunction and sexual desire issues went the other day. "Some antidepressants may impact sexual function. When you see your psychiatrist next week, make sure to talk to him about it. You might want to talk to him about smoking and blood pressure medications and the role that plays, as well. Meanwhile, let's talk more about your difficulty with expressing your feelings with your wife."

Yeah, I really wish there were a more clear way to make sure that a therapist is appropriately qualified and skilled...

 

[Ceke2002]

Just out of curiosity, and basing this on the actual experience of a close friend who has a dual diagnosis of severe MDD and alcoholism, is there any rationale at all for having a patient on 7 different antidepressants, all at the maximum dosage?

edited to add: Oops, forgot to mention, this is going back years now, my friend is no longer seeing that particular Psychiatrist and is no longer on umpteen dozen different antidepressants. So not trying to slip in a request for medical advice or anything.

 

[MacDonaldTriad]

Sounds like someone kept throwing pills at the chief complaints while being afraid to mention the elephant in the room (ETOH).
[disclaimer, not medical advice, only extremely obvious]

 

[deleted343839]

It is completely outside my scope of practice to recommend a specific medication. It is within my scope of practice to not increase opportunities for splitting. Here is how my conversation with a patient with erectile dysfunction and sexual desire issues went the other day. "Some antidepressants may impact sexual function. When you see your psychiatrist next week, make sure to talk to him about it. You might want to talk to him about smoking and blood pressure medications and the role that plays, as well. Meanwhile, let's talk more about your difficulty with expressing your feelings with your wife."

This. Also, making patients aware of treatment alternatives is part of informed consent. If a patient meets criteria for Disorder X and I am aware of a practice guideline or a body of evidence to support medical management of Disorder X, then I need to share that information - in general terms. Making the patient aware of medical treatment options or alternatives is different than making specific treatment recommendations, and it's alarming how many therapists confuse the two. There are a few situations in which behavior therapy and medication management collide (e.g., benzo tapering for panic disorder after a positive response to CBT), but that is an indication for closer collaboration between clinicians rather than a "takeover."

 

[Ceke2002]

Sounds like someone kept throwing pills at the chief complaints while being afraid to mention the elephant in the room (ETOH).
[disclaimer, not medical advice, only extremely obvious]

Well considering my mate was turning up to sessions with his Psychiatrist drunk, and as far as I'm aware nothing was ever said or discussed about it, I'd say the elephant in the room was damn near squashing everyone and they still ignored it. Total exercise in frustration trying to talk to him back then and get him to at least see another Psychiatrist who might be able to treat his alcoholism along with the depression. He lost the job he had at the time for getting passed out drunk when he was supposed to be working, and his Psychiatrist added another AD to his med regime because he was feeling a bit down about it - never mind the fact that he was drunk on the job and maybe that should have been addressed, or at least spoken about.

He's doing a lot better now though at least, couple of stints in rehab, a new Psychiatrist who is actually providing proper therapy (the other one retired, thank f***!)), he's a lot more stable. Not cured, not 100% sober, but definitely improved from where he was. It still amazes me though that someone who has taken an oath to first do no harm can be so cavalier about throwing pill after pill at a problem, and yet allow their patient to continue to getting blind drunk on a daily basis, and still just tell them all they need to do is take their 7 different ADs and they'll be fine.

 

[AlfonsTheGuru]

I have said this a lot of times. I don't think I'm one of the best doctors out there or should be one of the best. I do think, however, that I work hard, keep up with journals, try to at least do the standard of care if not better, and I end up being better than most I see.

And this frightens me.

What I do should be average, perhaps somewhat above average. People should be able to go to a doctor and be confident that their doctor is at least doing the standard-not by community standards but by academic standards.

This is a reason why I tell residents to work in academia a few years (unless they're just too swamped with debt) cause IMHO you're still too green and at least you can be surrounded by what I hope would be a at least a few good doctors to innoculate you against the poor practice that's out there.

Call it narcissism, what have you, but when I see a psychiatrist giving a patient Seroquel because "she's blue and Seroquel's a warm medication" despite that the pt was doing fine on her previous medication regimen Abilify, and ends up gaining 50 lbs from the Seroquel and becoming diabetic but that doc still adheres to the "she's blue" bull**** I'm going to think I'm better than that psychiatrist.

And I wish I wasn't making that story up. Triple facepalm. I felt bad for the patient. I told her to demand her doctor to switch meds. She was trapped in a forensic hospital and told me she was about 6 months from being released and didn't want to risk changing meds because it could keep her back for several more months.

I used to go home mad everyday from this type of dung. My wife told me that I either have to leave the job or figure out some way to not be mad about this. This is major reason why I left the state hospital/private practice and joined U of Cincinnati despite what was about a 75K paycut. There I was no longer the best in the hospital. I saw doctors that were better than me, just as good, maybe some worse but very few significantly worse. I'd go to department meetings, sit in a chair, and peer at literally over as dozen colleagues that were in the top 100 doctor category (the real one vs that BS one I mentioned above), or had several other prestigious real accomplishments that were great doctors but also good people. I was happier with that. It was a joy to see a guy know something I didn't and learn from that person and not have to deal with the "she's blue" bull**** anymore.

What were definitions of "warm" and "blue"? What is this supposed to mean by this psychiatrist's logic?