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psychnpgirl

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I have a client prototypical of my clients in early meth remission. a lot of meth in my city and we work in collaboration with an addiction treatment program at an FQHC. This client is a 35 year old who was placed on Rexulti (not by me) in an acute psych setting just around the same time he got sober from meth 6 months ago. No other hx of mental health dx except probably depression, anxiety, with prominent irritability (but also meth). Had been using meth for decades. Brief periods of sobriety with no mania or psychosis apart from meth. Hx of psychosis involves "seeing shadows" (typical of meth users). No negative symptoms. No hx of aggression or violence. I took him off Rexulti around 3 mos sober and put him on Zoloft via a slow cross taper and told him to call with any uncomfortable changes in symptoms. Was this too risky of a move too early in knowing him- probably was 4th session? My main motivator was his treatment resistant EPS (didn't respond to amantadine or cogentin) which led me to think maybe we could get away without an antipsychotic. Now he's doing well but I'm in this malpractice prevention lecture and they're like- be super careful taking patients off antipsychotics! I probably should have been more careful getting past records or collateral before making this change? Thoughts?

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if you just think he had a meth-induced psychosis, and is no longer psychotic then it was fine to taper off the antipsychotic. you don't mention what kind of EPS he had (cogentin and amantadine would be used for very different things btw - cogentin is for parkinsonism, amantadine has been used largely unsuccessfully for TD).also dyskinesias are not uncoomon in chronic methaphetamine abusers. but yes you should have got his records prior to taking him off medications in order to clarify what the hell he was on it for in the first place
 
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Thanks. Benztropine and Amandtadine both have evidence for parkinsonian symptoms according to uptodate.
 
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I'm in this malpractice prevention lecture and they're like- be super careful taking patients off antipsychotics!
This sounds strange to me. Should you really be more careful with antipsychotics than other meds from a liability perspective?
 
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The NP-turned-lawyer cited a case in which a patient was taken off antipsychotics, attacked an ER staff person, and this staff person when sued the provider who removed the antipsychotic and won.
 
The NP-turned-lawyer cited a case in which a patient was taken off antipsychotics, attacked an ER staff person, and this staff person when sued the provider who removed the antipsychotic and won.
That doesn't really sound like an evidence-based concern if it's based on a single case. I still don't see why antipsychotics are special in this scenario.
 
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Do you need to taper the Rexulti? Can't you just discontinue it without a taper?
 
Have you considered discussing this case or requesting that your supervising physician evaluate him with you?
 
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Was this too risky of a move too early in knowing him- probably was 4th session? My main motivator was his treatment resistant EPS (didn't respond to amantadine or cogentin) which led me to think maybe we could get away without an antipsychotic. Now he's doing well but I'm in this malpractice prevention lecture and they're like- be super careful taking patients off antipsychotics! I probably should have been more careful getting past records or collateral before making this change? Thoughts?

What do you consider treatment resistant EPS, and why does that effect your decision to go without all drugs in the class?

The lecture from your brief summary sounds like a good lecture for first year med students. The take-away is that medicine is not simple. Everything we do should be done carefully, well-documented, and with sound reasoning. It is not specific in any way for neuroleptics.
 
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The NP-turned-lawyer cited a case in which a patient was taken off antipsychotics, attacked an ER staff person, and this staff person when sued the provider who removed the antipsychotic and won.

I have been to a lot of lectures on the opioid epidemic/opioid prescribing recently, and one of the points of these lectures is that a doctor can not simple routinely "continue" chronic opiates prescribed by another doctor. I see antipsychotics, and psychotropics in general, in a similar way. While there is not usually a need to make a hasty decision, a psychiatrist who is takes over a treatment of a patient on chronic antipsychotic therapy needs to carefully evaluate the therapy. Antipsychotics, like opiates, are dangerous but often necessary medications. Although the process can be done over several sessions, a psychiatrist needs to carefully evaluate whether antipsychotic treatment is medically indicated. A psychiatrist can not hide behind what the previous doctor did. I don't like the word "continue". The psychiatrist needs to decide whether he should "prescribe" an antipsychotic. Of course, if the psychiatrist does not think an antipsychotic is necessary, prolonged tapering rather than abrupt discontinuation, along with frequent re-evaluation, is in order.
 
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Totally not related, but, OP, out of curiosity what motivates you to use the word "client" instead of "patient"? Just a med student here, but used to be in consulting before medical school. I felt like we used "client" as a euphemism for "customer", which seems to have some interesting implications w/r/t expectations. quick google search found this:
Shades of grey: patient versus client

I wonder about the difference between lawyers and doctors. Perhaps it's that docs deal with the self, while lawyers are there to represent the person and advocate their interests.

Okay...back to studying....
 
Totally not related, but, OP, out of curiosity what motivates you to use the word "client" instead of "patient"? Just a med student here, but used to be in consulting before medical school. I felt like we used "client" as a euphemism for "customer", which seems to have some interesting implications w/r/t expectations. quick google search found this:
Shades of grey: patient versus client

I wonder about the difference between lawyers and doctors. Perhaps it's that docs deal with the self, while lawyers are there to represent the person and advocate their interests.

Okay...back to studying....

"Client" is standard terminology in the therapy world. Community mental health agencies are also fond of "consumer". If you don't especially buy into the medical model and do not like the passive connotations of patiens (Latin 'suffering') and would like terms that imply agency and some responsibility for recovery on the part of there person you are working with, it is a term that makes sense.
 
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I have been to a lot of lectures on the opioid epidemic/opioid prescribing recently, and one of the points of these lectures is that a doctor can not simple routinely "continue" chronic opiates prescribed by another doctor. I see antipsychotics, and psychotropics in general, in a similar way. While there is not usually a need to make a hasty decision, a psychiatrist who is takes over a treatment of a patient on chronic antipsychotic therapy needs to carefully evaluate the therapy. Antipsychotics, like opiates, are dangerous but often necessary medications. Although the process can be done over several sessions, a psychiatrist needs to carefully evaluate whether antipsychotic treatment is medically indicated. A psychiatrist can not hide behind what the previous doctor did. I don't like the word "continue". The psychiatrist needs to decide whether he should "prescribe" an antipsychotic. Of course, if the psychiatrist does not think an antipsychotic is necessary, prolonged tapering rather than abrupt discontinuation, along with frequent re-evaluation, is in order.
Very well said. Makes your job very difficult when you’re inheriting slews of mismanaged patients but that’s not an excuse not to practice good medicine. I needed that reminder thanks.
 
That doesn't really sound like an evidence-based concern if it's based on a single case. I still don't see why antipsychotics are special in this scenario.

does something have to be evidence-based to be a malpractice concern?

the term landmark case comes to mind, precedent cases are a way big deal in law

law does not function like medicine, hence the difficulties
 
does something have to be evidence-based to be a malpractice concern?
Yes. Saying, "I once got sued because of X, therefore you should worry more about X than Y," is not an appropriate way to teach psychiatric malpractice concerns. More than one psychiatrist/psychiatric APN have been sued before so we do have data on what sort of things are more likely to get you sued than others.
 
The NP-turned-lawyer cited a case in which a patient was taken off antipsychotics, attacked an ER staff person, and this staff person when sued the provider who removed the antipsychotic and won.

I’m going to assume that the discontinuation of the antipsychotics was not the primary reason for the legal action in this case. There was likely something more relevant going on.
 
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