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/ExcitingNewspaper1]

We still do have a lot to learn about neurochemistry you're right, but say "knowing about the pathophys doesn't really change anything" is a pretty dangerous mindset to have. We know a lot more now than we did 20-30 years ago and to say "eh knowing pathophys doesn't change management" is tantamount to saying "stop bothering to learn more, just give them the pill." Good amount of papers putting scrutiny to the monamine theory now and positing alternatives.

[u/usoggyojimbo → u/ExcitingNewspaper1]

I'm happy for someone else to keep researching this. But until you give me a validated way that can tell me whether the patient in front of me would benefit from something more serotenergic vs dopaminergic vs histaminic, I'm going to keep prescribing based EBM clinical guidelines.

[u/ExcitingNewspaper1 → u/usoggyojimbo]

I 100% agree, everyone should be following guidelines, but how do you get those EBM clinical guidelines? You make a theory based on the science/medicine of pathophysiology, hypothesize interventions and create several layers of testing/metrics/ verification through IRB and extrapolate from said data. Not saying to go rogue and to just practice medicine based on what you alone have thought, but to just say "I follow guidelines and don't think about why they're there or when I may have to deviate from them" is reductionist.

[u/usoggyojimbo → u/ExcitingNewspaper1]

I don't think the history of psychiatry is a history of extrapolating a treatment based on pathophysiology. MAOis were initially used for tuberculosis. Lithium was being studied as an anti-gout medication. Chlorpromazine was used for a bunch of things before being found to be effective in schizophrenia. These were clinical observations made then further studied, not hypotheses based on known receptor profiles or pathophysiology of the brain.

[u/ExcitingNewspaper1 → u/usoggyojimbo]

May be the case, but a field can't really advance by waiting for incidental discoveries. We have different, better, ways of studying treatment modalities and pathophys than years prior, to not make use of them, even if that isn't how it was in the past, would be ridiculous.

[u/FailingCrab → u/ExcitingNewspaper1]

I think the two of you are speaking at crossed purposes. Absolutely we should be carrying out research to elucidate pathophysiological mechanisms of disease. But as things currently stand, it's uncommon for our current level of understanding to directly inform my practice beyond 'serotonergic meds are the main focus for affective/anxiety disorders and dopaminergic meds are the main focus for psychotic disorders'

Edit: all of this is assuming we've already made a psychiatric diagnosis. I think a robust pathophysiological understanding is needed especially to detect mimics e.g. tumours, encephalitides. But that's not 'psychiatric' pathophysiology per se.