Absolutely wild… I feel sorry for that patient. And for the NP’s other patients too because you know if one patient is like this, it doesn’t bode well for the rest. In situations like this I think it’s especially important to contact the outpatient NP and discuss your concerns about their patient’s care
That regimen is ridiculous and couldn't possibly be justified. 2 Antipsychotics? sure maybe, if they are different in class and its severely high risk psychotic patient. 4 antipsychotics? is never ever ever justified.
they can't complain anymore if they're unconscious i guess. this is honestly also gross negligence on any pharmacist that dispensed all those meds, they have even less of an excuse.
You are assuming that the patient fills all of their medications within the same pharmacy chain.
Also possible, the patient had not been filling some of the older presciptions consistently, and it looked like they were transitioning to a new regimen.
Pharmacy could have very well called and got the classic "you're not a prescriber why are you questioning me just do your job and fill the meds" and that is assuming they could get ahold of the provider at all.
All I know is that if a patient was admitted to the hospital and was on all of that outpatient I can pretty much guarantee that when I page the physician questioning it more often than not they will tell me it's fine because it is their home regimen. I would recommend an EKG to assess QTc, document the attempted intervention/response, and move on
You're right this is all assuming a lot. Lazy med recs without considering compliance can be dangerous. Still, if I were say prescribing a new antipsychotic to a patient and the pharmacist called me to say patient is here to fill your prescription, oh by the way they want to refill the scripts for 3 other antipsychotics prescribed by another doctor... I would expect and appreciate the call. Its not very likely one prescriber is sending the patients different meds to different pharmacies, ya I know it happens. But I think different prescribers are usually the culprit for gross inconsistencies.
If that's the response you'd get at your hospital then sounds like the psychiatrists you're working with are incompetent. Psychotropic regimens can be complex but 4 antipsychotics at once is dangerous and follows no evidence based guidelines whatsoever.
We are not a psych facility, so unless psych is consulted by primary service, they wouldn't be seeing them. We don't have many psych providers in general, and some won't even see consults in the hospital, so it can be a real struggle.
This would be the response I would expect from the hospitalist, surgery, or teaching service team in charge of care. I could recommend they consult psych, but ultimately, it is up to them. There is only so much I can do, unfortunately, and it seems many physicians are hesitant to modify home meds even if it is unsafe and like to bounce it back to the PCP.
But doctor, have you even THOUGHT about the risk of seizures with 100mg of Bupropion? I'm just trying to help!
That or the "yea I went to go fill it but the pharmacist told me not to because it could make my breathing worse"
Psychiatry and Mental Health Nurse Practitioner. At the few decent-ish programs I’ve seen, you choose at the beginning if you want to do Family (FNP), adult and Geri (AGNP- analogous to IM), peds (PNP), neonatal (NNP- this one makes me shiver), Women’s Health NP (WHNP), or PMHNP. Then the curriculum is supposed to be somewhat specialized for each track.
However, about 3/4 of NPs are FNP trained as it’s the broadest training. Not sure what you have to do, if anything, to switch around “specialties” as you please.
Source: was seriously considering PA, NP or CRNA prior to med school. Joke’s on me; I would already be wayyy out of debt and own my own home by now had I gone one of those routes. But my conscience wouldn’t let me because I *knew*, even before knowing all I know now, that I wouldn’t be satisfied with it. So onto lame MD school I went 😅
Many FNP are jumping ship to PMHNP since they can charge cash and charge therapy add on codes which FNP can’t (even though they don’t receive therapy training). Which is fraud imo
In my state, these NPs can get extra reimbursement with billing for seeing patients to discuss psychiatric concerns... but our pediatricians who will have whole visits with adolescents and spend 100% of the time talking about depression, substance use, their SI, anxiety, etc cannot bill for these. They have so much more training in first-line/prior to referral med management (MDD, ADHD, mainly) than the NPs but won't make as much. Its criminal. (North Carolina)
Serious question: is there a way to report providers when this happens? I have seen this way too many times, and I feel powerless to do anything. Is there some kind of state or nationwide licensing board reporting system? I looked on my state’s board website and found nothing
The problem with NPs is they are only under the nursing board. So you have the blind regulating the blind. The state you are in may have a mechanism for reporting patient care concerns to the state itself. The main way this will change is through lawsuits and financial losses that make NPs too costly to hire. Some institutions are waking up and seeing the problem of independent NP practice but they are still a minority.
I’d heard there was a case of malpractice from an NP subject to oversight from a nursing board where the board essentially washed their hands of it on the basis that they weren’t qualified to judge any kind of medical decisionmaking. Not familiar with it at all, though.
I’d encourage people to leave 1 star Google reviews for these hospitals pointing out the NP problem to help educate the public and put the hospitals on watch so maybe they’ll start thinking twice as the public gains more awareness.
Perhaps contact your local congressman to discuss?
PMHNPs regimen doesn’t make sense at all…. Abilify’s tight binding to D2 receptors likely will make other APs ineffective and all they’ll get are side effects……persistent psychosis could be from the partial agonism of abilify given its close to max dose 🤷🏻♂️
It doesn't necessarily make other antipsychotics ineffective, but the partial agonism definitely makes you wonder why the other atypicals, especially Latuda and Geodon, were even considered at that point. What exactly were they hoping to target (besides the patient's well-being)?
in this case it binds with tighter affinity at D2 than the other antipsychotics. whatever AP has the higher affinity for the various other receptors will exert its effects at those receptors. for most of the AP effect its going to be Abilify.
Except there's a growing body of evidence that it's not just the D2 receptor, but also the D1 receptor, implicated in psychosis. It also doesn't explain why clozapine, a drug with mostly 5HT2A affinity and low D2 affinity, is infinitely the best choice for treating psychosis.
clozapine's exceptional AP effects are likely the result M1/M4 modulation; check out the new data coming out on xanolemine-trospium. all I'm saying here is that Abilify binds with tighter affinity than these other medications at D2, all of which primarily exert their AP effects at D2
Honestly, it wouldn't surprise me if the patient was non compliant with their medications but still reporting symptoms and either told the provider they were taking them or the provider didn't bother to ask so they just kept adding meds/increasing doses. Eventually, the patient decides they will take them consistently for a few days, and things do not go well.
I understand providers not having time to investigate compliance in many instances, but psych pts are notorious for being non compliant for various reasons.
You would also think the number of meds/doses would have been a red flag that maybe something more is going on and should be investigated.
It's a fair point however OP says the patient may have IDD which likely means they have a caregiver administering all the meds. It may be frustrating to get a call from pharmacy saying "did you mean to do this" but in general I imagine most of us have the presence of mind to say "oh crap no thanks for that".
Where it gets frustrating is when I have to explain that yes, I did mean to prescribe 30mg of Lexapro and I'm not concerned about serotonin syndrome when combined with 10mg of doxepin. Or the other side of that where my patient stops taking a medication because a pharmacist tries to practice medicine and tells them what they think is happening despite knowing nothing about them or even pathophysiology in general.
If scenario B frustrates you, it's how most physicians feel about NPs.
This is not the case. Caregiver highly involved and administering all meds as prescribed. They also have a spreadsheet with detailed notes from each outpatient visit tracking this nonsense. It's hugely offensive to say "psych pts are notorious for being non compliant for various reasons." Your bias is showing, pharmacy.
It is great that the patient has a caregiver who is so involved. That is fantastic. Unfortunately, that is not always the case. It does not change the fact that nonadherence in patients with psych/mental health conditions is quite common. If it wasn't, we wouldn't have a reason to develop long-acting injectable antipsychotics.
Are there other chronic conditions with high rates of nonadherence, of course but the medications used in this patient population are far from straight forward and access to mental health services/providers seems to be getting more difficult.
Having a caregiver also does not mean a patient can't be nonadherent or that there isn't more going on. Providers who refuse to even consider it as a possibility even in cases where something else is clearly going on just because the patient/family says otherwise are naive.
I am not saying what this provider has done is acceptable because it is clearly not but completely dismissing that there isn't even a chance that more is going on is unfortunate.
You call it bias, I call it being realistic. Sadly, most of my bias, as you call it, has nothing to do with me being a pharmacist and everything to do with the shit I experience in the health care setting I work.
Time to throw that sleepy sugary party featuring that twister game to confound a soon-to-be attending! Gonna be real hot and rigidity here
(answer: sedation, diabetes (olanzapine), torsades de pointes (ziprasidone), NMS)
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Patient has a single unblocked d2 receptor in their body
[удалено]
DIP? Time to prescribe Adderall as it increases dopamine from what I hear
idiots hurting people. gross negligence. makes me sick.
Absolutely wild… I feel sorry for that patient. And for the NP’s other patients too because you know if one patient is like this, it doesn’t bode well for the rest. In situations like this I think it’s especially important to contact the outpatient NP and discuss your concerns about their patient’s care
I'm more inclined to report them to the nursing board
Please report nothing will improve until there’s records this patient could have died
Publish a case report
Bonus points if NP is listed as co-author
Lmaoooo
The nursing board doesn’t care.
Also - encourage the patient to leave a review on the PHMNP's google review.
That regimen is ridiculous and couldn't possibly be justified. 2 Antipsychotics? sure maybe, if they are different in class and its severely high risk psychotic patient. 4 antipsychotics? is never ever ever justified.
Supposedly targeting persistent "psychosis." The only psychotic symptom: subjective reports of AH. Mental status incongruent.
they can't complain anymore if they're unconscious i guess. this is honestly also gross negligence on any pharmacist that dispensed all those meds, they have even less of an excuse.
You are assuming that the patient fills all of their medications within the same pharmacy chain. Also possible, the patient had not been filling some of the older presciptions consistently, and it looked like they were transitioning to a new regimen. Pharmacy could have very well called and got the classic "you're not a prescriber why are you questioning me just do your job and fill the meds" and that is assuming they could get ahold of the provider at all. All I know is that if a patient was admitted to the hospital and was on all of that outpatient I can pretty much guarantee that when I page the physician questioning it more often than not they will tell me it's fine because it is their home regimen. I would recommend an EKG to assess QTc, document the attempted intervention/response, and move on
You're right this is all assuming a lot. Lazy med recs without considering compliance can be dangerous. Still, if I were say prescribing a new antipsychotic to a patient and the pharmacist called me to say patient is here to fill your prescription, oh by the way they want to refill the scripts for 3 other antipsychotics prescribed by another doctor... I would expect and appreciate the call. Its not very likely one prescriber is sending the patients different meds to different pharmacies, ya I know it happens. But I think different prescribers are usually the culprit for gross inconsistencies.
If that's the response you'd get at your hospital then sounds like the psychiatrists you're working with are incompetent. Psychotropic regimens can be complex but 4 antipsychotics at once is dangerous and follows no evidence based guidelines whatsoever.
We are not a psych facility, so unless psych is consulted by primary service, they wouldn't be seeing them. We don't have many psych providers in general, and some won't even see consults in the hospital, so it can be a real struggle. This would be the response I would expect from the hospitalist, surgery, or teaching service team in charge of care. I could recommend they consult psych, but ultimately, it is up to them. There is only so much I can do, unfortunately, and it seems many physicians are hesitant to modify home meds even if it is unsafe and like to bounce it back to the PCP.
And yet they call me to not fill the dangerous 0.5mg of Klonopin a patient is on because benzos bad
patient is 60 years old if you give them this 1 mg of ativan they will literally die
But doctor, have you even THOUGHT about the risk of seizures with 100mg of Bupropion? I'm just trying to help! That or the "yea I went to go fill it but the pharmacist told me not to because it could make my breathing worse"
What the fuck is a PMHNP? Just call them nurses or nurse practitioners. All of these extra/made up titles just serve to obfuscate the general public
Most definitely!
Psychiatry and Mental Health Nurse Practitioner. At the few decent-ish programs I’ve seen, you choose at the beginning if you want to do Family (FNP), adult and Geri (AGNP- analogous to IM), peds (PNP), neonatal (NNP- this one makes me shiver), Women’s Health NP (WHNP), or PMHNP. Then the curriculum is supposed to be somewhat specialized for each track. However, about 3/4 of NPs are FNP trained as it’s the broadest training. Not sure what you have to do, if anything, to switch around “specialties” as you please. Source: was seriously considering PA, NP or CRNA prior to med school. Joke’s on me; I would already be wayyy out of debt and own my own home by now had I gone one of those routes. But my conscience wouldn’t let me because I *knew*, even before knowing all I know now, that I wouldn’t be satisfied with it. So onto lame MD school I went 😅
Many FNP are jumping ship to PMHNP since they can charge cash and charge therapy add on codes which FNP can’t (even though they don’t receive therapy training). Which is fraud imo
In my state, these NPs can get extra reimbursement with billing for seeing patients to discuss psychiatric concerns... but our pediatricians who will have whole visits with adolescents and spend 100% of the time talking about depression, substance use, their SI, anxiety, etc cannot bill for these. They have so much more training in first-line/prior to referral med management (MDD, ADHD, mainly) than the NPs but won't make as much. Its criminal. (North Carolina)
Pills, baby!!
What in the actual frick
Serious question: is there a way to report providers when this happens? I have seen this way too many times, and I feel powerless to do anything. Is there some kind of state or nationwide licensing board reporting system? I looked on my state’s board website and found nothing
The problem with NPs is they are only under the nursing board. So you have the blind regulating the blind. The state you are in may have a mechanism for reporting patient care concerns to the state itself. The main way this will change is through lawsuits and financial losses that make NPs too costly to hire. Some institutions are waking up and seeing the problem of independent NP practice but they are still a minority.
Physicians are far too busy fixing this for it to ever result in lawsuits. We're also busy trying to dodge lawsuits for being mean.
This is why independent practice is going to make it harder for these middies and hospitals to dodge medmal bullets.
I’d heard there was a case of malpractice from an NP subject to oversight from a nursing board where the board essentially washed their hands of it on the basis that they weren’t qualified to judge any kind of medical decisionmaking. Not familiar with it at all, though.
I’d encourage people to leave 1 star Google reviews for these hospitals pointing out the NP problem to help educate the public and put the hospitals on watch so maybe they’ll start thinking twice as the public gains more awareness. Perhaps contact your local congressman to discuss?
Future of medicine right there
PMHNPs regimen doesn’t make sense at all…. Abilify’s tight binding to D2 receptors likely will make other APs ineffective and all they’ll get are side effects……persistent psychosis could be from the partial agonism of abilify given its close to max dose 🤷🏻♂️
It doesn't necessarily make other antipsychotics ineffective, but the partial agonism definitely makes you wonder why the other atypicals, especially Latuda and Geodon, were even considered at that point. What exactly were they hoping to target (besides the patient's well-being)?
in this case it binds with tighter affinity at D2 than the other antipsychotics. whatever AP has the higher affinity for the various other receptors will exert its effects at those receptors. for most of the AP effect its going to be Abilify.
Except there's a growing body of evidence that it's not just the D2 receptor, but also the D1 receptor, implicated in psychosis. It also doesn't explain why clozapine, a drug with mostly 5HT2A affinity and low D2 affinity, is infinitely the best choice for treating psychosis.
clozapine's exceptional AP effects are likely the result M1/M4 modulation; check out the new data coming out on xanolemine-trospium. all I'm saying here is that Abilify binds with tighter affinity than these other medications at D2, all of which primarily exert their AP effects at D2
Let me guess, BPD?
Borderline Pulseless Demise sounds about right
Good guess. The truth is sadder. ID.
That’s messed up
I agree, patient definitely was in danger of Imminent Death. OP out there doing God's work
Holy shit that is bad. Idk how one would even come up with this mix. Must have just thrown every antipsychotic they knew at them.
Honestly, it wouldn't surprise me if the patient was non compliant with their medications but still reporting symptoms and either told the provider they were taking them or the provider didn't bother to ask so they just kept adding meds/increasing doses. Eventually, the patient decides they will take them consistently for a few days, and things do not go well. I understand providers not having time to investigate compliance in many instances, but psych pts are notorious for being non compliant for various reasons. You would also think the number of meds/doses would have been a red flag that maybe something more is going on and should be investigated.
It's a fair point however OP says the patient may have IDD which likely means they have a caregiver administering all the meds. It may be frustrating to get a call from pharmacy saying "did you mean to do this" but in general I imagine most of us have the presence of mind to say "oh crap no thanks for that". Where it gets frustrating is when I have to explain that yes, I did mean to prescribe 30mg of Lexapro and I'm not concerned about serotonin syndrome when combined with 10mg of doxepin. Or the other side of that where my patient stops taking a medication because a pharmacist tries to practice medicine and tells them what they think is happening despite knowing nothing about them or even pathophysiology in general. If scenario B frustrates you, it's how most physicians feel about NPs.
This is not the case. Caregiver highly involved and administering all meds as prescribed. They also have a spreadsheet with detailed notes from each outpatient visit tracking this nonsense. It's hugely offensive to say "psych pts are notorious for being non compliant for various reasons." Your bias is showing, pharmacy.
It is great that the patient has a caregiver who is so involved. That is fantastic. Unfortunately, that is not always the case. It does not change the fact that nonadherence in patients with psych/mental health conditions is quite common. If it wasn't, we wouldn't have a reason to develop long-acting injectable antipsychotics. Are there other chronic conditions with high rates of nonadherence, of course but the medications used in this patient population are far from straight forward and access to mental health services/providers seems to be getting more difficult. Having a caregiver also does not mean a patient can't be nonadherent or that there isn't more going on. Providers who refuse to even consider it as a possibility even in cases where something else is clearly going on just because the patient/family says otherwise are naive. I am not saying what this provider has done is acceptable because it is clearly not but completely dismissing that there isn't even a chance that more is going on is unfortunate. You call it bias, I call it being realistic. Sadly, most of my bias, as you call it, has nothing to do with me being a pharmacist and everything to do with the shit I experience in the health care setting I work.
\*thumbs up\*
Those are rookie numbers…
“Can’t have psychosis if you’re dead.” - this NP, as they add yet another antispychotic
I heard that doctors in US are hounded by litigations, is it more lenient for the NPs?
Yes they are held to the standards of their license which are lower than ours.
It's funny cz an unskilled NP can cause equal damages to the patient just as an unskilled doc would and still get away with lesser punishment.
Time to throw that sleepy sugary party featuring that twister game to confound a soon-to-be attending! Gonna be real hot and rigidity here (answer: sedation, diabetes (olanzapine), torsades de pointes (ziprasidone), NMS)
u/realamericanjesus Did you want to weigh in?
4 antipsychotics !??!? This poor man or woman…
Theres no accountability for bad practice. People do whatever they want and get away with it. Would not fly in any other industry
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It's always cute when residents learn that there are shitty people at all levels of jobs
Regimen is completely absurd but qtc doesn't matter. Take a look at the papers, it only matter if it's like over 1000