Wheelhouse question (psych)

[tr]

Looking for opinions on whether this is ok to do.

I'm psych with focus on reproductive.
Often see PMDD, usually advise either luteal-phase SSRI or OCP. If SSRI I prescribe, if OCP I tell them to go get it from gyn. Usually offer recs for type of pill (continuous or at least monophasic, Yaz if no clotting related contraindication).

I have patient who asked if I would write the OCP as she is between gyns right now. I said no but generally wondering if this would be an ok thing to do. Ok to start new OCP for PMDD without pelvic exam? Or better to continue to defer to gyn? Asking from both a medicolegal and medical safety perspective.

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[theshellyb]

This sounds like a totally reasonable thing for you to do. OCPs are the treatment for PMDD, which you are diagnosing. We start OCPs on patients ALL THE TIME without pelvic exams. They are not necessary for initiating birth control. The idea of holding OCP refills hostage for a patient to get them to come in for annual pelvics is outdated medicine - and ACOG Is pushing for over the counter birth control.

In short: Write those scripts!

 

[smq123]

I have patient who asked if I would write the OCP as she is between gyns right now. I said no but generally wondering if this would be an ok thing to do. Ok to start new OCP for PMDD without pelvic exam? Or better to continue to defer to gyn? Asking from both a medicolegal and medical safety perspective.

As theshellyb said, very little reason to not write for OCPs. As an FYI, some patients can actually get their OCPs over the internet - there are services like nurx.com, The Pill Club, and SimpleHealth.com will allow you to get birth control delivered to your house without a formal prescription from a clinic. According to one of my patients who uses one of these services, they sometimes even include free samples of food in their deliveries, so she's gotten free candy or free cookies just by getting her birth control filled.

 

[tr]

Thanks! This is helpful!

 

[Sushirolls]

Thanks! This is helpful!

I'm psych and won't.

This is an excellent reason why all people should have a PCP, and if they don't provide them with a local referral list you preference and encourage them to get one.

The problem with psych, and people, is the convenience factor, granted its a logical fallacy, but once you say yes, they'll just keep asking to get it from you because they have no need to go to the PCP or OB/GYN. I see it as a means to help people help themselves. And when needed even preference its good to have a PCP at a minimum - because if a tragedy befalls me - you have a legit reason to press your PCP to prescribe your psychotropics until you find another Psychiatrist.

 

[AMEHigh]

I'm psych and won't.

This is an excellent reason why all people should have a PCP, and if they don't provide them with a local referral list you preference and encourage them to get one.

The problem with psych, and people, is the convenience factor, granted its a logical fallacy, but once you say yes, they'll just keep asking to get it from you because they have no need to go to the PCP or OB/GYN. I see it as a means to help people help themselves. And when needed even preference its good to have a PCP at a minimum - because if a tragedy befalls me - you have a legit reason to press your PCP to prescribe your psychotropics until you find another Psychiatrist.

The main reason I disagree with this is because one treatment option for PMDD is OCPs. Therefore if you’re going to diagnose PMDD, then you should be comfortable with prescribing the treatment of OCPs. In general OCPs are very very safe and you don’t need to do an exam before starting. In other countries they’re over the counter. You need to know just a few contraindications for CHCs and there is the MEC app (or online) to double check.

In my opinion this isn’t the same as asking a psych to prescribe someone’s BP meds. This is a pretty straight forward treatment for PMDD that a psychiatrist should be able to manage with initial dosing.

 

[Candidate2017]

By their nature, anxious and depressed psych patients tend towards inaction and dependency. Psych patients have more frequent visits (and trust) with their psychiatrists than other doctors, and as mentioned above, it is too easy for them to come up with excuses why they haven't made an OB-GYN or PCP appointment and ask you for refills.

From a medicolegal perspective, once you write an outpatient script, you are on the hook for it and have to be prepared to manage it for at least the period defined by your state's abandonment laws. If you're a reproductive psychiatrist, then maybe you should be ok with that. Personally, I'm not and there's a reason why psychiatry has the lowest malpractice premiums.

And sure, I can start and manage thyroid/BP/DM meds but psych patients are time intensive. Should I use 10 minutes of their appointment time to tinker with non-psych meds and labs when PCP can do it? How many times have we had a patient talk about everything and on the 29th minute, BTW yeah last week I had a gun in my hand and thought of killing myself?

Also, psych patients, like everyone else, tend to compartmentalize their psychiatrists from other doctors and do not view their psychiatric visit as a medical appointment. Sitting on a couch and talking to someone who doesn't wear a white coat or stethoscope kind of does that. It's not uncommon for psych patients to leave out or deny chunks of relevant PMH (like clotting disorders in their family) because, in their mind, it has no relation to their psychiatric issue.

 

[AMEHigh]

I'm psych and won't.

This is an excellent reason why all people should have a PCP, and if they don't provide them with a local referral list you preference and encourage them to get one.

The problem with psych, and people, is the convenience factor, granted its a logical fallacy, but once you say yes, they'll just keep asking to get it from you because they have no need to go to the PCP or OB/GYN. I see it as a means to help people help themselves. And when needed even preference its good to have a PCP at a minimum - because if a tragedy befalls me - you have a legit reason to press your PCP to prescribe your psychotropics until you find another Psychiatrist.

Also, it's interesting to me that you expect a pcp to prescribe psychotropic meds that we might not be familiar with, but you don't feel comfortable/think a psychiatrist should start a very safe and straightforward medication like OCPs, for a disorder that a psychiatrist should easily be able to diagnose and treat.

 

[Sushirolls]

PCPs are primary. That means they can be aggressive with their patients and get them sign ROI's for their psychiatrist and have them fax over every single note just like a cardiologist, Rheum, GI, etc. They can also delineate that care is thru them and that all other specialists are consultants and only they write the Rxs for meds based upon the recommendations of their consultant specialists. This is in the right, and purview of a Primary Care Physician. Real world most don't do this.

Real world most PCPs prescribe more psychotropics than psychiatrists. I don't like that but that's the real world. PCPs do temporary bridging 'clean up' for patients all the time when specialists retire, lose their license, quit/change jobs, die in skiing accident, etc. They say, I'll hit refill, no dose changes, but you must get a new specialist by X weeks [X is defined by that PCP local area and years of knowledge of how long it takes to get in to see that type of specialist for that patient with insurance Y].

I differentiate and some seizure disorders from functional and can initiate antiepileptics, but I don't. I still tell people to get the work up by Neurology and the management there. Same for basic HTN, DM, HLD, etc. I can spot and diagnosis thyroid disorders, but I still punt to PCP or Endo to manage. I could manage the hormone changes for my transgender patients, but I don't, I point to Endo or their PCP. The list goes on for the things of overlap with Psychiatry, but I know my scope of practice and when to point people to the appropriate place for more refined management.

Using what is over the counter in other countries is a poor argument. Other countries also have benzos and opioids over the counter, too. Even if our Pharmacy regulations disappeared, I would still tell patients to discuss their options with their PCP or OB for OCPs.

 

[theshellyb]

The main reason I disagree with this is because one treatment option for PMDD is OCPs. Therefore if you’re going to diagnose PMDD, then you should be comfortable with prescribing the treatment of OCPs. In general OCPs are very very safe and you don’t need to do an exam before starting.

This. There are many medications that fall within the wheelhouse of multiple specialties for multiple uses. If a pulmonologist is diagnosing pulmonary hypertension, it would be insane for them to refer to a urologist for sildenafil. GIs use misoprostol for stomach ulcers and OBs use them for miscarriage management. If you are a psychiatrist diagnosing PMDD, you should be willing to write the prescription to treat PMDD - you're not prescribing it for contraception or endometriosis, you're prescribing it to treat the psychiatric indication you are diagnosing.

 

[AMEHigh]

PCPs are primary. That means they can be aggressive with their patients and get them sign ROI's for their psychiatrist and have them fax over every single note just like a cardiologist, Rheum, GI, etc. They can also delineate that care is thru them and that all other specialists are consultants and only they write the Rxs for meds based upon the recommendations of their consultant specialists. This is in the right, and purview of a Primary Care Physician. Real world most don't do this.

Real world most PCPs prescribe more psychotropics than psychiatrists. I don't like that but that's the real world. PCPs do temporary bridging 'clean up' for patients all the time when specialists retire, lose their license, quit/change jobs, die in skiing accident, etc. They say, I'll hit refill, no dose changes, but you must get a new specialist by X weeks [X is defined by that PCP local area and years of knowledge of how long it takes to get in to see that type of specialist for that patient with insurance Y].

I differentiate and some seizure disorders from functional and can initiate antiepileptics, but I don't. I still tell people to get the work up by Neurology and the management there. Same for basic HTN, DM, HLD, etc. I can spot and diagnosis thyroid disorders, but I still punt to PCP or Endo to manage. I could manage the hormone changes for my transgender patients, but I don't, I point to Endo or their PCP. The list goes on for the things of overlap with Psychiatry, but I know my scope of practice and when to point people to the appropriate place for more refined management.

Using what is over the counter in other countries is a poor argument. Other countries also have benzos and opioids over the counter, too. Even if our Pharmacy regulations disappeared, I would still tell patients to discuss their options with their PCP or OB for OCPs.

But none of those examples are what OP is asking about.
PMDD is something that psychiatrists diagnose. There are safe treatment options that include SSRIs and/or OCPs. I really do not understand why you wouldn't start a very straightforward treatment option for your patients?

So you would send the patient to their pcp or obgyn to write the rx, then have them follow up back with you to see how they're doing, then tell the pcp or obgyn when/if the rx should be stopped if the treatment isn't working?

The only reason I was pointing out that the meds are OTC in other countries (and hopefully in the US soon) is because it seemed like OP and the subsequent responses made it sound like OCPs are dangerous for some reason. Otherwise, I'm not understanding why a psychiatrist wouldn't rx them for a specific psych diagnosis that has that as a treatment option.
But maybe I'm misunderstanding. So what is the exact reason you or other psychiatrists won't write a treatment option that is indicated for a diagnosis you (in theory) see regularly?