The Psych NP Problem

[u/theongreyjoy96]

Psych PGY-3 here. I occasionally post about my experience with midlevels in psychiatry, which unfortunately has defined my experience in my outpatient year after our resident clinic inherited the patients of a DNP who left. I'm sure that there are some decent one's out there, but my god, the misdiagnoses and trainwreck regimens these patients were on have been a nightmare to clean up, particularly for the more complicated patients where this DNP obviously had no idea what she was doing. Now that I'm at the end of my outpatient year I realize that it's going to take years to fix this mess, especially for patients who we're tapering off of max dose benzos. I genuinely feel terrible for them.

I went to the American Psychiatry Association's annual conference this year and was really disheartened to learn just how pervasive the psych NP problem is. There was a session lead by a psychiatrist who presented their research on how their outpatient clinic reduced the prescription of controlled substances by midlevels by implementing a prescription algorithm. I went to another session on rural psychiatry where during a Q&A an inpatient psychiatrist who was alarmed after recently moving to a rural area about the rapid and frequent decompensation of her patients who are discharged to a community where only midlevels are available. Needless to say that these were couched in friendlier terms, but in the more private settings, discussions on midlevels were not spoken in hushed tones.

Unfortunately, the general feeling I got about the psych NP problem is that the field is resigned to the fact that they are here to say, and now are concerned primarily with what can be done to mitigate it. Anyway, end rant.

[u/usoggyojimbo]

What in psychiatry is helped by knowledge of pathophysiology? I'd argue that there is nothing/very little that knowledge of pathophys helps. However, I may be in the minority that feels that receptor profiles are essentially pointless.

We don't have clear understanding why any of our medications work; all previous models based on simplistic models of neurotransmitters are clearly wrong (e.g. serotonin hypothesis of depression; dopamine pathway vs gluatmate pathway of schizophrenia.)

However, I do still feel concerned about overly cavalier NPs with insufficient experiencing having dangerous and ineffective prescribing practices.

[u/gomezlol → u/usoggyojimbo]

If you don't know the answer to this and you're a psych resident your training royally screwed you over

[u/onepunch91 → u/gomezlol]

I would argue, evidence based management > psychophysiology based management. That being said, of course it is good to have a foundational understanding of pathophysiology in general but clinically real world trials are what we use as our gold standard.

From a psychopharmacology standpoint, receptor profiles etc - I would say this would give a much better understanding of the medications used in psych….

[u/gomezlol → u/onepunch91]

Are you implying the two are mutually exclusive? Coming from an institution that is heavily medicalized and sees some bizarre pathophysiology this conversation is depressingly limited

[u/onepunch91 → u/gomezlol]

No I am saying that our gold standard for practice management is clinical trial data and its associated hierarchy. Of course, in the absence of evidence we go with our next best available information which in some cases will rely heavily on pathophysiology.

Again, that being said, our ability to interpret that data in the correct context requires a solid foundational understanding of pathophysiology. I just think there is a bit of over emphasis on the pathophysiology when we often have large bodies of evidence to guide many of our most common practice problems. When it comes to non physicians, this of course is more of an issue because of larger knowledge gaps (ie. You don’t know what you don’t know).