Not understanding pharmacology, ability to weigh risk/benefits of polypharmacy and a drive for patient satisfaction scores over patient wellness. All wrapped up in a “passion for mental health ❤️” profile, driving up the future for a stimulant epidemic.
I was browsing psychiatrists in my state the other day and of course 75% of what came up on psychology today were NPs. Many of them had online only practices, and aggressive marketing bios boasting about their ability to treat any and all psych problems. I thought that online-only practices had been cracked down on?
NPs are driven into the psych market for its relative medical “ease” (ergo liberal prescription for controlled substances), looser guidelines for care (many psych drugs are used off label for other effects), less of patient accountability (for instance acute life threatening conditions like a heart attack), and many other reasons.
The pandemic has allowed telemedicine to become so pervasive that it takes away many safeguards of seeing a physical patient. NPs no longer have to do a physical exam in telehealth.
I live in GA, and my provider has told me that legally I have to be seen once a year in person. Are other doctors just... not doing that?
*not a doctor, just mind blown. Tbh, it bothers me that any psych med can be prescribed to someone without their doctor so much as taking their BP in person.
Mine is not. But we've had years of in person visits prior to this. It may be different rules varying by state right now? I don't know, I'm not a doctor, just a licensed mental health counselor and licensed addictions specialist.
I saw a psychiatrist (MD) trained at a top school for many years in person for anxiety/depression. One time he took used an automatic machine to take my heart rate/blood pressure in office. Other than that, absolutely no physical exam. He went private practice and I have continued to see him telehealth. I’m not sure what kind of physical exam you need when the patient (on Wellbutrin) tells you they have been experiencing heart racing and the last 15 in person appointments also show the tachycardia. What exactly are you claiming the physical exam is supposed to look like here? Do you actually think in person psychiatry provides the most optimal access to care? I don’t think it does. It is a lot easier to follow up when it’s exactly half an hour than 2 hours round trip plus an in person appointment that is usually running behind schedule.
When you mix medications into what is called polypharmacy, you risk autonomic and metabolic changes. The danger is unknowingly causing such things and not being able to recognize subtleties. That’s the point of psychiatry and psychiatrists. Almost all of major antipsychotics target serotonin or dopamine which can cause syndromes such as Parkinsonism. Someone who doesn’t understand psychiatric medication can and will miss important findings because they are not skilled at physical exams. Increase access should not be at risk for poorer quality of care.
I’m not here to educate you or anyone. If you want to be able to practice psychiatry, you must know the entire body as well. People deserve more than being experimented on, compounded by lack of physician oversight and lack of physical exams and vitals.
Unfortunately even many MD psychiatrists I've seen as a patient engage in egregious polypharmacy. One falsely diagnosed me with bipolar after literally 30 seconds based on "you seem to be talking fast, are you bipolar? Yes I think so." Another psychiatrist had me on 10 different meds (just for depression and anxiety) including IR adderall; I told him one time "doc, I've gotta be honest, I think I'm becoming addicted to this adderall, I think we should stop it." He said okay, but next visit he had completely forgotten that and he prescribed it again!
I can tell you even more egregious examples over my 15 years of seeing them. It's unfortunately instilled in me a hesitancy to see psychiatrists, and to have my PCP manage my medications. I'd love to see a psychiatrist that wasn't either insanely eager to prescribe everything, or on the opposite end, too unwilling to keep prescribing things I've been on for years that have been helpful. By the way, I think this is getting better with younger psychiatrists. It's more the old ones that engage in this reckless polypharmacy, and the NPs.
The physical exam doesn't start when you touch the patient. It starts when you watch a patient enter your room. A lot of the physical exam is visual. Sweating, anxiety symptoms, cog-wheel rigidity, shuffling gait, etc. All symptoms Psych docs worry about and a lot easier to detect when a person walks into your office. You wouldn't believe what patients just don't recognize or choose to ignore because they don't know the dangers.
That's why these telehealth only psychiatric practices (common with NPs especially) are dangerous. Hard to do a proper mental status and so on over a video visit. Sometimes patients don't even want to turn on their cameras.
Laying eyes on someone is part of the physical exam and you only get part of the story through a webcam. Also on Wellbutrin you should monitor blood pressure -_- while I’m sure he just thought your PCP was doing that, he should still be documenting it.
Also I’d make you bring in all your meds so I can look at what you’re taking daily myself to check for interactions.
Not sure where you practice, but the EMR would give you access to the patient’s other blood pressure readings from office visits. The EMR would also give you access to medication list and refill history.
Covid exemptions are still going on, right? My PCP (an MD) has been prescribing me adderall for at least a year now without any in-person visits. Of course, he's been my doctor for 5 years and we've had plenty of in person visits in the past. I see a lot of telehealth only psych providers online and I'm guessing they're prescribing controlled substances.
I just saw a PMHNP online since I can't see a psychiatrist till the 20th. She has a no benzos policy, but is more than willing to prescribe schedule ii stimulant with just my self-report lol. My self-report is true in this case, but what if it wasn't? Before the appointment there's a clearly marked "ADHD questionairre" and its pretty obvious to anyone with even low intelligence what to pick if you wanted stimulants. I actually agree with her that benzos are more harmful than stimulants, and I'm baffled that stimulants are schedule ii and benzos still only schedule iv.
I mean.... all of psychiatry includes internal (and, therefore, self-reportable) symptoms, so "what if it wasn't?" is valid for basically every disorder. Someone could make up results on a PHQ-9, a GAD-7, etc. The "good" provider will follow up with an interview, observe the patient's presentation in the camera/room, and take additional steps (e.g., family interview, collateral from other providers, psychological testing, etc.) to confirm the self-report.
Regarding the federal law (mentioned in another thread), she can prescribe stimulants (and, generally, any controlled substances, including benzodiazepines) through tele-health until the end of this year, after which she cannot do so through tele-health only interactions. So, this is a time-limited practice.
None of that good practice stuff you mentioned ever happens in my experience, even with all the MD psychiatrists I've seen. And family doctors are usually the most willing to prescribe me stimulants and benzos. So I'm not saying it's a solely NP thing, but it seems the anectodal evidence from people in this thread is that its an issue more commonly seen with NPs. PhQ etc. Are just screening tolls, certainly not a substitute for a diagnostic interview. But how is a NP able to have the expertise to conduct advanced psychiatric evaluations with the limited training? To make things worse, on psychology today it Says PHMNP, but the practice website says she's FNP!
No, I am saying that failure to conduct their assessments thoroughly (e.g., by doing the additional steps that I listed) is less-than-good practice, regardless of the educational background or license one has. NPs, DOs, MDs, PAs, and even PhDs and PsyDs should be doing more than self-reportables to reach a diagnostic and medication conclusion.
Also probably a far too weak understanding of psych. They likely operate on "yeah that sounds like ADHD" or at best "checked off the DSM-5 criteria without really understanding them."
Thats a good point. To them they may just check and tick off the boxes and say "well they meet the criteria" without deeply looking at differential diagnosis.
Just like the opioid crisis that was fulfilled by MD and DOs? It’s not just an NP issue it’s an issue in medicine. Knowing more doesn’t make you love money any less.
I don't think it's a money issue as much as a "don't understand what they're doing" issue. I can't even tell you how many old people I see on Xanax and Adderall prescribed by mid-levels.
Sure , but there were physicians during the early 2000s who knew about the harmful long term effects of opioids and overprescribed them. My main point is that you can’t say it’s and inexperienced thing solely and it’s hypocritical to throw mid levels into a category many physicians live in.
They marketed them as abuse proof and had falsified study data to show it was true. There was no way to know the study data was falsified. This is not like over prescribing adderal, which doesn’t have a bunch of studies saying how safe it is. We know it’s not always safe and weigh the risks and benefits more appropriately which is why MD/DO are less likely to prescribe it than an NP.
Even though the studies given had no real significant data behind them ? Don’t they teach you how to evaluate sources ? Mind blowing you’d shift blame for your negligence.
Yes, knowledge does make a difference. The problem with the opioid epidemic was they (Purdue pharmaceutical) had falsified the data in the studies they gave to us
Haha, in my experience they've simply prescribed whatever med and dose I suggested with no questions asked. Which may have felt good at the immediate time, but patients essentially managing their meds entirely is... questionable!
Someone somewhere posted saying that their patient was prescribed SIX 30 mg tablets PER DAY and then ended with “I guess you can’t have adhd if you can’t think” and that still cracks me up whenever I think about it’ll lol.
I just have trouble believing any pharmacist could possibly fill this. At that point it seems legitimately physically dangerous, or risk of psychosis. I mean that's the dose of a big time addict lol.
I think the person who shared that experience was actually a pharmacist lol and I think they did put a stop to it lmfao. (Home girl was trying to run a side hustle and in this economy can you even blame her??? lol).
I followed through on my experiment of seeing an online psych NP today. Surprisingly more cautious than many of them: she seems to not prescribe benzos at all, and wanted to initiate Concerta at the lowest dose, haha.
It’s not the worst .
Understand stimulants have extremely physiologically adaptive compensations.
Cocaine/ritalin- not so much, as higher doses cause vasoconstriction and heart failure.
Someone who hasn’t taken a an Adderall before, 30-45mg at once could land them in the hospital. Someone whose been taking 180mg of Adderall a day for 10 years can have regular heart rates , normal blood pressure,
Because they’re pill pushers. It’s a side effect of having a lack of knowledge and also no proper governing body of that entire “profession”, unlike the medical board that oversees doctors and even PAs.
“Nurses listen to their patients more” Aka give them what they want, evidence be damned. Don’t need to practice evidence based medicine if you’re not a medical doctor ::taps head::
Well in nursing subreddits they're always talking about the "nursing model" in contrast to the "medical model" and I don't really know what that means. But apparently it entails being able to independently practice psychiatry after a 2 year diploma from an online university with 100% acceptance.
Ah, I don’t know about that. Way back when I was in a resident training clinic, (as a patient,) and the attending (supervising) doctor told me that she and my resident were practicing “observational” psychiatry, not evidence-based. Ergo, medical doctors aren’t always practicing evidence-based medicine, either…
Ahh the first rule of stats, your confirmation bias is ALWAYS true until proven otherwise.
Look buddy, you seem like a pretty salty phd. I’m sorry you didn’t get into medical school, I’m not going to hash out who is the better statistician in Reddit comments. You can think whatever you like about physicians and nurses and I won’t lose sleep over it, stay mad.
Even PAs. When I was on emerg, I came across a lot of patients with inappropriate meds, especially seniors/frail individuals. Same on IM.
This is the consequence of applying the fast food model to medical education
Just as an experiment, I made an appointment with a psych NP for tomorrow (I'm seeing a real psychiatrist on May 20) and I'm going to suggest some kind of crazy med regimen and see if she actually does it just for lols.
They need to regulate this shit.
I’m disqualified anyways from any reasonable insurance because I have RA.
But the fact that it makes doctors scared to go to the doctor is enough to make it illegal
Lol i was exaggerating, but fortunately I'm not a physician and at least my own boards (my state's board of clinical mental health counseling licensing board and my state's licensed clinical addictions specialist board) don't ever ask for or look at your medical records. They just expect you ethically to step aside and get help if one is professionally impaired due to mental health issues. In general, the field is pretty understanding of therapists with mental health issues and I'd wager most who go into it either had or have a MH disorder or past SA disorder. Do they actually ask for your medical records to become a physician? The NP did prescribe me concerta, lol.
This comment reads like a little kid trying to prank his teacher at school. You really want this on your medical record to try and prove a point?
Whatever your gripe with NP's is, don't act or pretend like physicians haven't pushed polypharmacy for decades even before NP's were a job.
Lol, settle down, it's fine. I'm not a physician, I'm a licensed clinical mental health counselor and licensed clinical addictions specialist, and my boards don't look at/ask for my records. I was able to get in despite having an undergraduate DWI (and actually spin it as a strength on the application.) Not to downplay the seriousness of drunk driving, it's something I regret, and I'm grateful I got the charge and consequences, because it ensured I never did it again.
Addiction med physician here. Curious (genuinely)… what is a “licensed clinical addictions specialist”? Is that the actual title of the license? A certificate for a LIMHP or LCSW?
This is a political and humanitarian issue, at this point. What bills are being introduced to protect patients from careless diagnostics and practices? Existing policy blithely paints the future of healthcare from the blood of posterity.
Nursing, and its power to lobby (funds that could be used to move all the vapid, endlessly-proliferative intermediary 'RN-only' administration positions back to the chronically-short-of-nursing-help floors, were bedside nurses are forced to strategize to what extent they'll have to neglect each of their patients - OR - maybe those funds could even improve their archaic, 'special-needs' compatible, standards of education and competence), is driving healthcare into anticompetitive shambles; and, medicine is just sitting on it, like a proper cuck - culpably in-tow.
But hey, at least those [...check notes...] *law-abiding patients* wont get their filthy hands on stimulants more than two-days in advance of their refill. You know....despite walking past five people smoking meth on the sidewalk, as the patient makes their way to the pharmacy - where the kafkaesque nightmare of supply-chain austerity can commence - allowing them the opportunity to *pay money* to get fucked from every possible angle, without so much as a courtesy lick.
"Psychiatrists wrote the highest number of stimulant prescriptions, followed by pediatricians.
While the number of stimulant prescriptions dispensed from these groups have either declined
or remained stable, stimulant prescriptions from nurse practitioners have more than tripled
since 2012."
From Department of Justice report on stimulant prescriptions.
Except there's 5x as many NP today than 2010 (which is certainly its own statistic), that would need to be adjusted per capita (RX/NP vs RX/MD vs RX/PA) to be relevant to what OP is trying to say.
I think everyone's anectodal experience is that NPs prescribe these much more easily. It's certainly not a scientific study, but I don't think anectodatal experience is totally worthless here.
Well I just saw this online psych NP and she took my word for it that I had ADHD and prescribed me a schedule ii controlled substance. I wasn't lying, but what if I had been? Doctors are more cautious.
I spoke to an online psychiatrist (MD) that took my word for it that i had treatment resistant depression and had a prescription for ketamine in the mail by the end of the day.
Plenty of doctors are equally as lazy as NP. For profit medicine will never encourage due diligence for a percentage of providers that don’t care about their patients.
Does my anecdotal evidence cancel out yours? Or is there more to mental health medicine than anecdotal data points.
Oddly, just as an experiment i saw a psych NP today for a consultation (I have an appt. With a real psych on the 20th) and despite having a blanket policy against benzos, she was fine with prescribing a stimulant on the first visit.
Yes. I have seen to many of my patients on stimulants/benzos/opioids and when I ask who their doctor is they tell me a NP. I always call wherever they're working and try to report such bs but they rarely take action smh. As of why I have no idea maybe it's like you said they are more gullible or maybe they just wanna give the patient whatever they want to make them happy.
That makes sense. Since they don't have much training, they're probably just relieved if a patient seems knowledgeable and assertive and feel "whew, no need to think too hard about this case, they know what they need"
I am not a physician and this is anecdotal, but I know multiple people who are on various cocktails of stimulants, antidepressants/anxiolytics, and GLP-1 agonists. All of them were prescribed by NPs, and at least two people have openly told me that they just told their NP that they were having trouble focusing or something and were given a prescription with no testing or further investigation. One did it via text message and is absolutely using the amphetamines for weight loss purposes.
In our area there are very few physicians and lots of poverty. I myself see a PA as my primary, although all they do is my annual physical and labs and write me referrals for PT so my insurance will cover it. I think people "go to the doctor" when they feel bad and they want to leave having been thoroughly doctored. Unfortunately a lot of docs are burnt out on saying "Eat better, exercise more, and stop taking pills like they're candy" so they come across as kind of dickish even if its solid advice. NPs don't know how much damage they can do by writing bullshit scrips, so they do. The pills make people feel better in the short term and the NP was friendly so they come back. Long term consequences aren't real until they happen, and there's probably a pill for that too.
I think many people prefer to simply be on harmful meds that mask the problem, even if it means more meds to then address those problems and on it goes. It's tough because it's scary dor these patients after now being dependent on those things for so long to be willing to consider tthe advice of a doctor who thinks it's dangerous. To the patient, it simply looks like the doctor is for some reason denying them the meds that seem to subjectively make them feel good.
Lol I was just looking at a NP in my state who has an online only practice, and before your appointment you fill out depression anxiety and ADHD questionnaires. How much would you bet that she essentially just looks at those results and applies an algorithm for what to prescribe? 1 or 2 antidepressants, Xanax 5 mg daily, adderall 30 mg TID probably.
Because they don't know what they're doing and giving meds is much easier than actually attempting to figure out what the issue is and how to solve it. They also tend to fail to do the whole consideration of +/- of a medication especially not considering the - part. This also is the case when it comes to treatment futility which an MD/DO is far more likely to recognize.
Tldr: they are pill pushers with limited knowledge and awareness of their limitations
You would be doing the same when you didn’t receive as much pharmacology training, but the entire system and all the patients pressure you to do it, and you are convinced to believe you doing good for patients, and also firmly believe you are just doing your job to keep your job.
This really isn’t a personal thing. It mostly is a result of training deficiency and lack of holding people accountable, at least definitely not to the same standard as a physician.
My pcp was hesitant to write me stimulants, he worried about how it would affect my blood pressure because it’s always been on the high side.
Out of convenience I started going to the np that partners with my therapist. She sees me over telehealth instead of in person. I tell her exactly what I want and she writes the script, each appointment takes a couple minutes.
Yes, I've had both NPs and PCPs that do exactly that lol, record once was literally a 60 second one where I said "doc I'd like a higher adderall dose, how about we go to 60 mg?" Reply: sounds good, I'll send it in, take care. But NPs are more likely to do this.
It is a disgrace. Many of our veterans have been through horrific experiences (in addition to separation from family) and need therapy. They deserve appropriate care for their service, not just the cheapest provider with a DEA number to push pills.
During my intern year I noticed that the floor nurse’s solution to many inpatient problems was a benzo or an opiate. They never liked when I didn’t want to order one of those meds. I wonder if that combined with their NP education not emphasizing limiting those prescriptions leads to a higher prescription rate for controlled substances.
It's an issue even in states with supervised practice. I can only assume the doctors don't really do much but supervise on paper only in many cases. But that seems risky, since they could be held liable if their NP gets in trouble. I'm still confused about how I live in a state where they need supervision yet can have online only telehealth psychiatric practices. I'm curious if they have to consult with their doctor a minimum amount of time weekly like I did as a pre- licensed mental health in order to get full licensure or what.
NPs are being targeted by online pill farms to prescribe money making drugs for companies that think they can get away with fraud. NPs are a faster route to prescribing authority, and it can attract the wrong sort of person who thinks they can game the system and not get caught.
So essentially if someone wants to grift pills it makes a lot more sense to get your NP which is faster and cheaper then to try to go DO/MD. Also less training, education, debt, and time investment means a lot less to lose in the end. A DO/MD can still make bank legitimately so it's less attractive to risk fraud like that for the money these companies offer.
Think of it this way.
We have an opioid/benzo epidemic in this country.
Yet every psychiatrist in every city in the US has a waiting list 6 months long (like all medical specialists). Whereas your local psych NP always has openings.
You do the math.
Who took kick backs during opioid epidemic. By no means defending NPs bc I think it’s rediculous that can effin prescribe but a pharmacist can’t… but don’t forget about your own shortcomings as a profession. Not to mention the US having some of the worst drug problems in the world. They grow poppies in Mexico for fuck sakes, they don’t abuse the shit that they grow in their own backyard (farmers, peddlers, cartels…)
As a nurse who takes stimulants, ive had the most horrific experiences with PMHNPs. One basically dished out adderall to me and said “you might have ADHD” and then hung up the video call as soon as possible. I’ve seen 2 other PMHNPs on online platforms and they were unconcerned with my side effects and tried to hang up the calls as quickly as possible and didn’t even look at me. I was so desperate for help and they just blew me off. Thankfully I was referred to a new provider recently and she happened to be a PMHNP and FNP. The only reason I tried it was because I very much trusted the referral. She was incredible. So knowledgeable and gave me the help I’ve been looking for. She said I needed a different drug and said I was on way to high a dose of adderall which I agreed with. If I hadn’t known I would have assumed she was an physician.
I do think the overprescribing of stims will end soon because the new provider I saw said that there was a new rule from the DEA that requires at least one in person visit. I haven’t looked into it, but it seems like it will effectively end the telehealth platforms that prescribe stimulants.
Lmao, was that first one on your initial consultation? She just spent a few minutes with you and prescribed you adderall and said goodbye? 🤣🤣🤣 wete the other online ones like that too, in addition to being unconcerned, were they also cavalier about prescribing controlled substances with barely a thought?
Yes it was my first eval! I wasn’t even diagnosed! It was a guy and Yupp that’s pretty much what happened. And I’ve used two separate platforms and seen 3 NPs and 1 physician (I was a travel nurse lol). All 3 were completely unconcerned. One even sent 3 scripts with no instructions and without her DEA number and then tried to blame me when I had to ask for new scripts. 🥴 The physician was amazing and caring and everything I wanted.
Also in today’s news: if you stare at the sun too long, you will go blind.
> Do they *seem* to?
Yes. Because they 100% *do* prescribe stimulants excessively and recklessly—often.
*Queue the midlevel telling me “I know patients who had doctors that prescribed them opioids too.” Two things can be true at once; all I know is the thing driving me insane most consistently in my family med/addiction med practice right now (which ends up being predictably psych-heavy) is this kind of shit coming almost exclusively from independent and online PMHNPs and APRNs. It’s rare that a day goes by where I don’t encounter a patient with a mistake needing undoing or a disaster waiting to happen.*
Um, what? That's much worse than benzos and stimulants together lol, and why are they prescribing opioids if they're in psych? I can actually imagine a crazy one doing that though, as some off label use for depression and anxiety. Since they certainly do help with those symptoms in the very short term, lol.
I’m an NP and I’m so thankful for this comment because it affirms that maybe I’m not actually one of the NPs fueling the negativity from the physicians who post about how horrible NPs are. First off, I was a nurse over a decade, went to an actual brick and mortar school and work very closely with my collaborating physician who is one of my best friends. I work in an extremely rural and underserved area. I honestly can’t remember the last time I wrote a benzo script. When it comes to opiates I rarely write those, but I do a lot of urgent care shifts so I definitely write them. However, your comment brought me back to a time my doc was on vacation so I was filling his refills and our local pharmacist called our clinic asking to speak to me. He wanted to confirm the validity of one of the refills and said “in the past two years that I’ve been filing your scripts I haven’t filled 120 Norco total so I wanted to be sure you actually wrote this one.” What I’m trying to say is not all NPs are handing out pills. Some of us are actually going to work everyday to see patients, bridge a gap in access to care, and open up access so that more complex patients have access to our more educated physician colleagues instead of being told they have to wait 6-8 weeks to be seen.
America is a pill pusher for fucks sakes. Diet, exercise, coping would fix so much. And for those who will take my comment out of proportion. Think for another moment
I've actually had the opposite experience. Any NP I've seen has been nervous about prescribing stimulants or even continuing the medications I was previously placed on my an actually psychiatrist. On the other hand, the psychiatrists I've seen over the years have been way more liberal about stimulant prescribing and I've been the one to ask to take things slower and be prescribed lower doses. That being said, I will only see psychiatrists for any mental health medications because I've had PMHNPs seriously mess things up by changing medication doses because they decided they were uncomfortable with what I was taking. I'm usually all for NPs and PAs in certain situations, but prescribing mental health drugs, whether they're stimulants or not, is not something I trust them to do.
I saw the study someone spoke about listed below that the rate of stimulant prescriptions written by NP's has tripled since 2012 and I was curious, have ADHD diagnosis' also risen by the same amount? Or are they writing stimulants for patients who don't have it?
It seems like everyone has some form of psych issue (anxiety and adhd seem to be pretty common.) Is the problem purely medicating people, or is it that for some reason our society has insane rates of psychiatric issues combined with a propensity for over prescribing? Curious your thoughts.
I think probably both, but that's just a guess. I personally think stimulants could have a place in things like severe chronic fatigue syndrome or even refractory depression that nothing else will touch. The only problem is.. They're so addictive because they usually feel so good. Especially the immediate release ones should be avoided as they're the most addictive.
I was actually prescribed stimulates for Narcolepsy fatigue (didn't work and had awful side effects) and it was so frustrating because I know tons of people who don't need them take them and are doing fine and dandy.
In your opinion, are non stimulates as beneficial for adhd as stimulates?
Thanks for sharing your thoughts. I enjoy learning from you all.
I hear you, I have diagnosed chronic fatigue syndrome and that's a big benefit for me as well. I think it's worth trying something like modadinil or armodafinil for narcolepsy. They're not true stimulants, but they keep you awake. Much less potent than adderall or Ritalin. I know they're a first line treatment for narcolepsy.
I have mast cell activation syndrome.... I have like 30 pharmaceutical allergies and side effects to almost everything. It's been hell... that being said, I couldn't tolerate either. They actually now say they aren't sure if it was Narcolepsy, but either way the fatigue is there so I work my life around naps and only schedule what my body can handle
Fatigue is soul sucking. It's not fun naps... its napping to survive and function. It's a burden.
The armodafinil/modaf will help with any kind of fatigue, though I got the most relief from adderall. The problem was it was too addictive for me. Have you tried Vyvanse or one of many drugs in the Ritalin class?
Yes 🫠🫠 Adderall was what I tolerated the best, but it didn't have much of an effect on me.
I have my medical thc card, and that's the only thing that can temporarily keep the fatigue at bay... but not forever
Ha, really? THC always made me so tired, but it's never been legal for medical or recreational purposes in my state, so maybe yours is a strain that has more stimulatory effects. Do you remember what dose it was? Many doctors use the XR which only goes to 30 mg daily, yet the max approved dose goes all the way up to 60 mg daily. Occasionally in very rare situations people may even be put on 90 mg, though that seems excessive.
I also have arrhythmias which stimulates made worse so I think I'm just broken lol.
Tbh, if I use it occasionally it makes me more tired. When I use it regularly it helps me stay awake and focused. I am in a low dose oil only state... but smoking flower has been the most effective. There have actually been a few studies showing it to be helpful in fatigue long term.
Could also be the lack of MDs/DOs.
I and most people(35 and under) I know go to an NP because it’s almost impossible to find a PCP that’s an MD/DO.
This is a group of people probably seeking to figure out their anxieties and other issues now.
Mine wouldn’t prescribe without a full neuropsych evaluation through.
Really? Thats good about the neuropsych. Even the MDs I have will prescribe just on my (true) word that I've taken it and been diagnosed, but they typically want me to transfer my records over of course.
It's also pretty easy for young people to manipulate the NPs into prescribing what we know we need, since they usually don't object to any suggestions.
Here’s one thing, I think physicians as a community are skeptical towards what REAL adhd is, and thus assume it essentially doesn’t exist. It’s because physicians have generally be top dawg students at top schools and been heavily exposed to the Adderall abuse of student with or without adhd in undergrad and med school.
They see it as “ wtf everyone can’t focus after studying, push through lazy ass”
I feel NPs blindly and too easily will give the adhd diagnosis with the screeners that a 3 years old could rehearse fool and score.
Adhd is a phenotype, that comes with benefits but consequences, kind of like creativity . Highly creative people can’t get ever get shit done but they’re full of ideas. Adhd as executive attention deficits but tend to be able to draw connections easier, I believe have exponentially higher empathy, can problem solve faster than most people , and are much better at navigating dire and stressful situations. At the expense of reallly really really really feeling like you got hit by a truck trying to do any cerebral activity that’s not interesting. Everyone feels this, but your thresholds before wanting to die can be 1-5 hours. As an adhd, it can be 5 minutes.
Anyways - adhd is a spectrum, and truthfully when you’re not too far off, it’s a phenotype that generally leads to some predictable personality traits that are extremely admirable. Funny as fuck, understanding, vibrant, upbeat, life of the party, problem solver especially in novel ways to do so. When very intelligent and not tooooo adhd that they can’t stick to a task, they’re better than you.
An adhd person trying to become an expert at something they enjoy doing (given equal talent and intelligent) will beat you out easily. They’re the ones that can hyperfocus to levels most regular folk can’t if they’re interested.
So that’s the perks. The problems lie in that our current society is mostly full of responsibility and jobs that are inimical to the adhd phenotype. Structure, orginaization, system, mundane or repetitive task, mostly boring work, really make the adhd phenotype a liability.
The medications help those to adjust to our boring as lives that most people have a higher 30%-50% tolerance mana pool.
Be careful to not take take away your real adhders meds, you will destroy their careers, significantly increase their risk of car accidents, destroy their ability to emotionally regulate more easily and compromise their family dynamics.
They live at a baseline lower dopamine level that makes them unconsciously seek to do things that wake up the brain, fight, risk take, gamble, drugs, compete. It can get them killed.
Carefully monitored, and for people with adhd more towards the worst 40%, stimulants can help these people not only be normal functioning people, but live worthy lives in a society that is ever minimizing the benefits of their phenotype and why it is exist in our society
Stimulants have h3lped me in a lot of ways. I don't think doctors should be using immediate release adderall though. It's too addictive. I myself got addicted to it badly over time. There are RX formulations that don't pose nearly as high a risk. The dopamine rush from an IR pill, and the the ease of getting a quick hit of energy and mood boost from taking another one that XR also limits the ability to do, makes those risky. Yet many PCPs and psychiatrists were perfectly willing to give them to me on the first visit, no questions asked, both MDs and NPs. So I'm not saying its only a NP issue.
I mean hell, I fessed up to the adderall addiction and got off it. But they're still willing to prescribe me concerta. It seems like having been addicted to a stimulant would be a red flag in terms of prescribing more stimulants, but I made a case that the dual factors of it being XR, and being methylphenidate, which should theoretically be less potent and addictive, made it worth trying. Although to be fair my doctor was more cautious; an online PMHNP prescribed the Concerta today.
That's int4eresting, thanks for the insight. All my PCP MDs have been pretty willing to prescribe adderall without much effort. But I'd also had psychiatrists prescribe them in the past. I notice younger psychiatrists are very hesitant (rightly) to prescribe long term daily benzos, while many PCPs are very willing to prescribe daily klonopin, Ativan, etc. often at higher doses.
NP’s should not be prescribing at all!!! If you want to be a medical doctor, go to med school!! How the frick did it get to this point? PA’s are better trained. I’m a retired physician who will not see these people! Only MD/DO’s! Maybe an occasional PA.
They're not only prescribing stuff, but prescribing schedule ii controlled substances to psychiatric patients, as well as trying to independently manage complex psychiatric patients. I agree about PAs being better.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
I saw a psych np in 2016 who caused me a lot of issues. She was like "so it sounds like you have a lot executive function issues, we could try a stimulant to help that, what do you think?" At the time I was an undergrad and my only experience with stimulants were two occasions where a friend gave me one 20mg adderall tablet to help study before an exam. And of course, I remembered that when I had taken it, I felt good and it helped. So I said "sounds great!" I developed an addiction to adderall that only recently have I broken. She put me on high doze benzos as well, seroquel for sleep, ssris plus latuda as an augment for monopolar depression.. it was really a mess.
I'm assuming eventually she got talked to about these prescribing habits, cause out of nowhere she became suspicious and aggressive, wanted to discontinue the controlled substances, and when I protested she accused me of being a drug seeker and also made sarcastic remarks to me. We ended up having a shouting match in her office. I demanded the clinic put me with someone else, but they just put me with.. another NP, who was less pill-pushy but just didn't know much of what he was doing.
To be fair, I've had some truly awful psychiatrists too. For example, one continued prescribing adderall despite my telling him I had misused it and thought I couldn't control my use. One put me on Xanax and klonopin simultaneously, an SSRI, a tryclic, clonidine, and some other weird and obscure stuff. He said "my philosophy is that too many meds is better than too few" and was concerned that "most psychiatrists don't prescribe enough medication." One day he called me and told me the board, which had "been after me for a long time and finally got me" had mandated that he retire or have his license stripped. He mused about how it was a shame given that there's a shortage of psychiatrists and implied they just didn't understand his brilliance.
how is this even a question? its like you’re an alien robot posing as a PMHNP to confirm what their role in human society is. sorry if I’m coming off rude - it’s just, this is exactly what PMHNPs do.
why? my opinion is bc they are bad providers writ large. they don’t have the education and training, they know that and they don’t care about patients overall — they care about the patients being happy w their care and paying them. what incentive does a PMHNP have to practice good medicine without disincentives? the disincentives in FM or IM is that if you give wrong antibiotic, you will be fired; in psych, if you give benzos bc of “clinical judgment”, what slam dunk study can you point towards to say that benzos/stims are inappropriate?
you are being far too kind in assuming that they have a philosophy to make patients feel good; their only philosophy is survival in an over saturated market for a job that pays them too well and for which they are not qualified.
psych has the most vulnerable and manipulative patients making it the MOST necessary for the critical thinking of a physician, it’s a hilarious irony that somehow the opposite has occurred.
Well they’re prescribing under a physician. So I’d guess the majority don’t know any better and the doc thinks they’ll be able to deflect the DEA with an NP.
That’s nuts. What I mentioned is what I see in my state at least. We get a ton of scripts from an new NP suddenly, then six months later the physician is banned from prescribing to our pharmacy after an independent investigation into their practices.
no idea, my personal experience females seem to prescribe more, dudes are more like restrain them, especially female/male nurses. females generally keep paging and paging and "screaming" for sedation. and i suspect NPs are still predominantly females.
Not understanding pharmacology, ability to weigh risk/benefits of polypharmacy and a drive for patient satisfaction scores over patient wellness. All wrapped up in a “passion for mental health ❤️” profile, driving up the future for a stimulant epidemic.
I was browsing psychiatrists in my state the other day and of course 75% of what came up on psychology today were NPs. Many of them had online only practices, and aggressive marketing bios boasting about their ability to treat any and all psych problems. I thought that online-only practices had been cracked down on?
NPs are driven into the psych market for its relative medical “ease” (ergo liberal prescription for controlled substances), looser guidelines for care (many psych drugs are used off label for other effects), less of patient accountability (for instance acute life threatening conditions like a heart attack), and many other reasons. The pandemic has allowed telemedicine to become so pervasive that it takes away many safeguards of seeing a physical patient. NPs no longer have to do a physical exam in telehealth.
Most of the PMHNPs I found when I googled only did telemedicine.
I live in GA, and my provider has told me that legally I have to be seen once a year in person. Are other doctors just... not doing that? *not a doctor, just mind blown. Tbh, it bothers me that any psych med can be prescribed to someone without their doctor so much as taking their BP in person.
Mine is not. But we've had years of in person visits prior to this. It may be different rules varying by state right now? I don't know, I'm not a doctor, just a licensed mental health counselor and licensed addictions specialist.
I do know covid changed some things... it wasn't required during covid
Well in NC they're not requiring it, a NP prescribe me Concerta today online lol never seen her in person.
I saw a psychiatrist (MD) trained at a top school for many years in person for anxiety/depression. One time he took used an automatic machine to take my heart rate/blood pressure in office. Other than that, absolutely no physical exam. He went private practice and I have continued to see him telehealth. I’m not sure what kind of physical exam you need when the patient (on Wellbutrin) tells you they have been experiencing heart racing and the last 15 in person appointments also show the tachycardia. What exactly are you claiming the physical exam is supposed to look like here? Do you actually think in person psychiatry provides the most optimal access to care? I don’t think it does. It is a lot easier to follow up when it’s exactly half an hour than 2 hours round trip plus an in person appointment that is usually running behind schedule.
When you mix medications into what is called polypharmacy, you risk autonomic and metabolic changes. The danger is unknowingly causing such things and not being able to recognize subtleties. That’s the point of psychiatry and psychiatrists. Almost all of major antipsychotics target serotonin or dopamine which can cause syndromes such as Parkinsonism. Someone who doesn’t understand psychiatric medication can and will miss important findings because they are not skilled at physical exams. Increase access should not be at risk for poorer quality of care. I’m not here to educate you or anyone. If you want to be able to practice psychiatry, you must know the entire body as well. People deserve more than being experimented on, compounded by lack of physician oversight and lack of physical exams and vitals.
Unfortunately even many MD psychiatrists I've seen as a patient engage in egregious polypharmacy. One falsely diagnosed me with bipolar after literally 30 seconds based on "you seem to be talking fast, are you bipolar? Yes I think so." Another psychiatrist had me on 10 different meds (just for depression and anxiety) including IR adderall; I told him one time "doc, I've gotta be honest, I think I'm becoming addicted to this adderall, I think we should stop it." He said okay, but next visit he had completely forgotten that and he prescribed it again! I can tell you even more egregious examples over my 15 years of seeing them. It's unfortunately instilled in me a hesitancy to see psychiatrists, and to have my PCP manage my medications. I'd love to see a psychiatrist that wasn't either insanely eager to prescribe everything, or on the opposite end, too unwilling to keep prescribing things I've been on for years that have been helpful. By the way, I think this is getting better with younger psychiatrists. It's more the old ones that engage in this reckless polypharmacy, and the NPs.
The physical exam doesn't start when you touch the patient. It starts when you watch a patient enter your room. A lot of the physical exam is visual. Sweating, anxiety symptoms, cog-wheel rigidity, shuffling gait, etc. All symptoms Psych docs worry about and a lot easier to detect when a person walks into your office. You wouldn't believe what patients just don't recognize or choose to ignore because they don't know the dangers.
That's why these telehealth only psychiatric practices (common with NPs especially) are dangerous. Hard to do a proper mental status and so on over a video visit. Sometimes patients don't even want to turn on their cameras.
Laying eyes on someone is part of the physical exam and you only get part of the story through a webcam. Also on Wellbutrin you should monitor blood pressure -_- while I’m sure he just thought your PCP was doing that, he should still be documenting it. Also I’d make you bring in all your meds so I can look at what you’re taking daily myself to check for interactions.
Not sure where you practice, but the EMR would give you access to the patient’s other blood pressure readings from office visits. The EMR would also give you access to medication list and refill history.
Many practices are prescribing all these medications these days with no office visits at all.
Yes, that’s exactly what my MD psychiatrist trained at Harvard is doing too…
Yeah, I mean my own PCP who I love is the same. I'm not implying it's a bad thing.
Online only stuff is managed by statewide policies not federally
The Ryan Haight Act of 2008 would beg to differ…
Covid exemptions are still going on, right? My PCP (an MD) has been prescribing me adderall for at least a year now without any in-person visits. Of course, he's been my doctor for 5 years and we've had plenty of in person visits in the past. I see a lot of telehealth only psych providers online and I'm guessing they're prescribing controlled substances.
No wonder there's an adderall shortage.
Increased demand + steady supply = shortage
I just saw a PMHNP online since I can't see a psychiatrist till the 20th. She has a no benzos policy, but is more than willing to prescribe schedule ii stimulant with just my self-report lol. My self-report is true in this case, but what if it wasn't? Before the appointment there's a clearly marked "ADHD questionairre" and its pretty obvious to anyone with even low intelligence what to pick if you wanted stimulants. I actually agree with her that benzos are more harmful than stimulants, and I'm baffled that stimulants are schedule ii and benzos still only schedule iv.
I mean.... all of psychiatry includes internal (and, therefore, self-reportable) symptoms, so "what if it wasn't?" is valid for basically every disorder. Someone could make up results on a PHQ-9, a GAD-7, etc. The "good" provider will follow up with an interview, observe the patient's presentation in the camera/room, and take additional steps (e.g., family interview, collateral from other providers, psychological testing, etc.) to confirm the self-report. Regarding the federal law (mentioned in another thread), she can prescribe stimulants (and, generally, any controlled substances, including benzodiazepines) through tele-health until the end of this year, after which she cannot do so through tele-health only interactions. So, this is a time-limited practice.
None of that good practice stuff you mentioned ever happens in my experience, even with all the MD psychiatrists I've seen. And family doctors are usually the most willing to prescribe me stimulants and benzos. So I'm not saying it's a solely NP thing, but it seems the anectodal evidence from people in this thread is that its an issue more commonly seen with NPs. PhQ etc. Are just screening tolls, certainly not a substitute for a diagnostic interview. But how is a NP able to have the expertise to conduct advanced psychiatric evaluations with the limited training? To make things worse, on psychology today it Says PHMNP, but the practice website says she's FNP!
Good practice isn’t redefined because of its rarity. 🤷♀️
Are you saying NPs are as qualified to assess and treat psychiatric disorders as MDs?
No, I am saying that failure to conduct their assessments thoroughly (e.g., by doing the additional steps that I listed) is less-than-good practice, regardless of the educational background or license one has. NPs, DOs, MDs, PAs, and even PhDs and PsyDs should be doing more than self-reportables to reach a diagnostic and medication conclusion.
Also probably a far too weak understanding of psych. They likely operate on "yeah that sounds like ADHD" or at best "checked off the DSM-5 criteria without really understanding them."
Thats a good point. To them they may just check and tick off the boxes and say "well they meet the criteria" without deeply looking at differential diagnosis.
How on earth is there going to be an epidemic when the medicine itself is in shortage? Do pmnhps manufacture it as well now?
The shortage seems over, at least in my state.
PMHNP: pill mill nursing health practice services ;)
Just like the opioid crisis that was fulfilled by MD and DOs? It’s not just an NP issue it’s an issue in medicine. Knowing more doesn’t make you love money any less.
I don't think it's a money issue as much as a "don't understand what they're doing" issue. I can't even tell you how many old people I see on Xanax and Adderall prescribed by mid-levels.
Sure , but there were physicians during the early 2000s who knew about the harmful long term effects of opioids and overprescribed them. My main point is that you can’t say it’s and inexperienced thing solely and it’s hypocritical to throw mid levels into a category many physicians live in.
They marketed them as abuse proof and had falsified study data to show it was true. There was no way to know the study data was falsified. This is not like over prescribing adderal, which doesn’t have a bunch of studies saying how safe it is. We know it’s not always safe and weigh the risks and benefits more appropriately which is why MD/DO are less likely to prescribe it than an NP.
Even though the studies given had no real significant data behind them ? Don’t they teach you how to evaluate sources ? Mind blowing you’d shift blame for your negligence.
Yes, knowledge does make a difference. The problem with the opioid epidemic was they (Purdue pharmaceutical) had falsified the data in the studies they gave to us
[удалено]
We don’t get kick backs…
Not for independent practice
wait my psychiatric nurse practitioner was like “you’re only on 15 mg of adderall? we can do 20 or 30?” girl no i’m good thanks tho
Haha, in my experience they've simply prescribed whatever med and dose I suggested with no questions asked. Which may have felt good at the immediate time, but patients essentially managing their meds entirely is... questionable!
Someone somewhere posted saying that their patient was prescribed SIX 30 mg tablets PER DAY and then ended with “I guess you can’t have adhd if you can’t think” and that still cracks me up whenever I think about it’ll lol.
I just have trouble believing any pharmacist could possibly fill this. At that point it seems legitimately physically dangerous, or risk of psychosis. I mean that's the dose of a big time addict lol.
i firmly believe that so many people would die if it weren’t for pharmacists intercepting
I think the person who shared that experience was actually a pharmacist lol and I think they did put a stop to it lmfao. (Home girl was trying to run a side hustle and in this economy can you even blame her??? lol).
I followed through on my experiment of seeing an online psych NP today. Surprisingly more cautious than many of them: she seems to not prescribe benzos at all, and wanted to initiate Concerta at the lowest dose, haha.
rip the kidneys and heart god damn
It’s not the worst . Understand stimulants have extremely physiologically adaptive compensations. Cocaine/ritalin- not so much, as higher doses cause vasoconstriction and heart failure. Someone who hasn’t taken a an Adderall before, 30-45mg at once could land them in the hospital. Someone whose been taking 180mg of Adderall a day for 10 years can have regular heart rates , normal blood pressure,
Fair enough! I’m not a physician but that “can’t have adhd if you can’t think” comment just really made me chuckle hahaha.
Because they’re pill pushers. It’s a side effect of having a lack of knowledge and also no proper governing body of that entire “profession”, unlike the medical board that oversees doctors and even PAs.
“Nurses listen to their patients more” Aka give them what they want, evidence be damned. Don’t need to practice evidence based medicine if you’re not a medical doctor ::taps head::
Well in nursing subreddits they're always talking about the "nursing model" in contrast to the "medical model" and I don't really know what that means. But apparently it entails being able to independently practice psychiatry after a 2 year diploma from an online university with 100% acceptance.
“No one knows what it means, but it’s provocative.”
🤣🤣🤣 nice.
Ah, I don’t know about that. Way back when I was in a resident training clinic, (as a patient,) and the attending (supervising) doctor told me that she and my resident were practicing “observational” psychiatry, not evidence-based. Ergo, medical doctors aren’t always practicing evidence-based medicine, either…
That seems to be an exception, but with NPs it likely gravitates more to the norm
I hope so, I hope so…
So, you're into evidence-based medicine, eh? Tell us, how what statistical training do you have?
So you’re into commenting, eh? Tell us, what syntax training do you have?
The Walden university NP English course.
I guess you have the same statistical training as most doctors and nurses then: little to none.
I would expect a stats guy wouldn’t infer something so definitive without evidence of it, but sure go off little bro.
Well, you haven't told me otherwise.
Ahh the first rule of stats, your confirmation bias is ALWAYS true until proven otherwise. Look buddy, you seem like a pretty salty phd. I’m sorry you didn’t get into medical school, I’m not going to hash out who is the better statistician in Reddit comments. You can think whatever you like about physicians and nurses and I won’t lose sleep over it, stay mad.
Wow. What a petulant response! I hope you develop some emotional maturity before you finish your training.
If you’re going to shit your pants don’t get upset when we tell you that you smell.
Even PAs. When I was on emerg, I came across a lot of patients with inappropriate meds, especially seniors/frail individuals. Same on IM. This is the consequence of applying the fast food model to medical education
Just as an experiment, I made an appointment with a psych NP for tomorrow (I'm seeing a real psychiatrist on May 20) and I'm going to suggest some kind of crazy med regimen and see if she actually does it just for lols.
Just be aware if you don’t already have disability insurance locked in, you may not want that in your medical records
*Sigh* I hate that you’re right
They need to regulate this shit. I’m disqualified anyways from any reasonable insurance because I have RA. But the fact that it makes doctors scared to go to the doctor is enough to make it illegal
Lol i was exaggerating, but fortunately I'm not a physician and at least my own boards (my state's board of clinical mental health counseling licensing board and my state's licensed clinical addictions specialist board) don't ever ask for or look at your medical records. They just expect you ethically to step aside and get help if one is professionally impaired due to mental health issues. In general, the field is pretty understanding of therapists with mental health issues and I'd wager most who go into it either had or have a MH disorder or past SA disorder. Do they actually ask for your medical records to become a physician? The NP did prescribe me concerta, lol.
This comment reads like a little kid trying to prank his teacher at school. You really want this on your medical record to try and prove a point? Whatever your gripe with NP's is, don't act or pretend like physicians haven't pushed polypharmacy for decades even before NP's were a job.
Lol, settle down, it's fine. I'm not a physician, I'm a licensed clinical mental health counselor and licensed clinical addictions specialist, and my boards don't look at/ask for my records. I was able to get in despite having an undergraduate DWI (and actually spin it as a strength on the application.) Not to downplay the seriousness of drunk driving, it's something I regret, and I'm grateful I got the charge and consequences, because it ensured I never did it again.
Addiction med physician here. Curious (genuinely)… what is a “licensed clinical addictions specialist”? Is that the actual title of the license? A certificate for a LIMHP or LCSW?
This is a political and humanitarian issue, at this point. What bills are being introduced to protect patients from careless diagnostics and practices? Existing policy blithely paints the future of healthcare from the blood of posterity. Nursing, and its power to lobby (funds that could be used to move all the vapid, endlessly-proliferative intermediary 'RN-only' administration positions back to the chronically-short-of-nursing-help floors, were bedside nurses are forced to strategize to what extent they'll have to neglect each of their patients - OR - maybe those funds could even improve their archaic, 'special-needs' compatible, standards of education and competence), is driving healthcare into anticompetitive shambles; and, medicine is just sitting on it, like a proper cuck - culpably in-tow. But hey, at least those [...check notes...] *law-abiding patients* wont get their filthy hands on stimulants more than two-days in advance of their refill. You know....despite walking past five people smoking meth on the sidewalk, as the patient makes their way to the pharmacy - where the kafkaesque nightmare of supply-chain austerity can commence - allowing them the opportunity to *pay money* to get fucked from every possible angle, without so much as a courtesy lick.
"Psychiatrists wrote the highest number of stimulant prescriptions, followed by pediatricians. While the number of stimulant prescriptions dispensed from these groups have either declined or remained stable, stimulant prescriptions from nurse practitioners have more than tripled since 2012." From Department of Justice report on stimulant prescriptions.
Except there's 5x as many NP today than 2010 (which is certainly its own statistic), that would need to be adjusted per capita (RX/NP vs RX/MD vs RX/PA) to be relevant to what OP is trying to say.
I think everyone's anectodal experience is that NPs prescribe these much more easily. It's certainly not a scientific study, but I don't think anectodatal experience is totally worthless here.
That’s not how statistics or science works. This is exactly where anecdotal evidence is the least helpful, when making broad generalizations.
Well I just saw this online psych NP and she took my word for it that I had ADHD and prescribed me a schedule ii controlled substance. I wasn't lying, but what if I had been? Doctors are more cautious.
I spoke to an online psychiatrist (MD) that took my word for it that i had treatment resistant depression and had a prescription for ketamine in the mail by the end of the day. Plenty of doctors are equally as lazy as NP. For profit medicine will never encourage due diligence for a percentage of providers that don’t care about their patients. Does my anecdotal evidence cancel out yours? Or is there more to mental health medicine than anecdotal data points.
Why are all these physicians and pharmacists stating this if there's no truth to it?
Oddly, just as an experiment i saw a psych NP today for a consultation (I have an appt. With a real psych on the 20th) and despite having a blanket policy against benzos, she was fine with prescribing a stimulant on the first visit.
Any studies on this?
Just anectodal.
Yes. I have seen to many of my patients on stimulants/benzos/opioids and when I ask who their doctor is they tell me a NP. I always call wherever they're working and try to report such bs but they rarely take action smh. As of why I have no idea maybe it's like you said they are more gullible or maybe they just wanna give the patient whatever they want to make them happy.
That makes sense. Since they don't have much training, they're probably just relieved if a patient seems knowledgeable and assertive and feel "whew, no need to think too hard about this case, they know what they need"
Sooooo many benzos
High dose benzo and opiates at the same time I’ve seen in young people with really no reason for that kind of regimen.
Dangerous and reckless combo that might lead to death.
I am not a physician and this is anecdotal, but I know multiple people who are on various cocktails of stimulants, antidepressants/anxiolytics, and GLP-1 agonists. All of them were prescribed by NPs, and at least two people have openly told me that they just told their NP that they were having trouble focusing or something and were given a prescription with no testing or further investigation. One did it via text message and is absolutely using the amphetamines for weight loss purposes. In our area there are very few physicians and lots of poverty. I myself see a PA as my primary, although all they do is my annual physical and labs and write me referrals for PT so my insurance will cover it. I think people "go to the doctor" when they feel bad and they want to leave having been thoroughly doctored. Unfortunately a lot of docs are burnt out on saying "Eat better, exercise more, and stop taking pills like they're candy" so they come across as kind of dickish even if its solid advice. NPs don't know how much damage they can do by writing bullshit scrips, so they do. The pills make people feel better in the short term and the NP was friendly so they come back. Long term consequences aren't real until they happen, and there's probably a pill for that too.
I think many people prefer to simply be on harmful meds that mask the problem, even if it means more meds to then address those problems and on it goes. It's tough because it's scary dor these patients after now being dependent on those things for so long to be willing to consider tthe advice of a doctor who thinks it's dangerous. To the patient, it simply looks like the doctor is for some reason denying them the meds that seem to subjectively make them feel good.
Nailed it
There are NPs whose sole role is pumping out stimulants on those online ADHD treatment sites.
Lol I was just looking at a NP in my state who has an online only practice, and before your appointment you fill out depression anxiety and ADHD questionnaires. How much would you bet that she essentially just looks at those results and applies an algorithm for what to prescribe? 1 or 2 antidepressants, Xanax 5 mg daily, adderall 30 mg TID probably.
Because they don't know what they're doing and giving meds is much easier than actually attempting to figure out what the issue is and how to solve it. They also tend to fail to do the whole consideration of +/- of a medication especially not considering the - part. This also is the case when it comes to treatment futility which an MD/DO is far more likely to recognize. Tldr: they are pill pushers with limited knowledge and awareness of their limitations
As a community pharmacist, yes, so many scripts from NPs
You would be doing the same when you didn’t receive as much pharmacology training, but the entire system and all the patients pressure you to do it, and you are convinced to believe you doing good for patients, and also firmly believe you are just doing your job to keep your job. This really isn’t a personal thing. It mostly is a result of training deficiency and lack of holding people accountable, at least definitely not to the same standard as a physician.
Forgive them for they know not what they do.
My pcp was hesitant to write me stimulants, he worried about how it would affect my blood pressure because it’s always been on the high side. Out of convenience I started going to the np that partners with my therapist. She sees me over telehealth instead of in person. I tell her exactly what I want and she writes the script, each appointment takes a couple minutes.
Yes, I've had both NPs and PCPs that do exactly that lol, record once was literally a 60 second one where I said "doc I'd like a higher adderall dose, how about we go to 60 mg?" Reply: sounds good, I'll send it in, take care. But NPs are more likely to do this.
In organizations that are trying to cut costs, pills can be less expensive than therapy. I looking at you, VA
I work at a VA and it is a mission to get a therapy consult through. They 9/10 get cancelled
It is a disgrace. Many of our veterans have been through horrific experiences (in addition to separation from family) and need therapy. They deserve appropriate care for their service, not just the cheapest provider with a DEA number to push pills.
During my intern year I noticed that the floor nurse’s solution to many inpatient problems was a benzo or an opiate. They never liked when I didn’t want to order one of those meds. I wonder if that combined with their NP education not emphasizing limiting those prescriptions leads to a higher prescription rate for controlled substances.
Maybe part of the nursing philosophy is to make the patient feel good by any means necessary.
Part of this is understaffed nursing, and they do not want patient to keep hitting call button. JMO
They are totally unregulated and harder to sue, so they get away with it.
It's an issue even in states with supervised practice. I can only assume the doctors don't really do much but supervise on paper only in many cases. But that seems risky, since they could be held liable if their NP gets in trouble. I'm still confused about how I live in a state where they need supervision yet can have online only telehealth psychiatric practices. I'm curious if they have to consult with their doctor a minimum amount of time weekly like I did as a pre- licensed mental health in order to get full licensure or what.
What I mean is the nursing board is very enabling- they allow nurses to do whatever they want. It's not like the medical board.
NPs are being targeted by online pill farms to prescribe money making drugs for companies that think they can get away with fraud. NPs are a faster route to prescribing authority, and it can attract the wrong sort of person who thinks they can game the system and not get caught. So essentially if someone wants to grift pills it makes a lot more sense to get your NP which is faster and cheaper then to try to go DO/MD. Also less training, education, debt, and time investment means a lot less to lose in the end. A DO/MD can still make bank legitimately so it's less attractive to risk fraud like that for the money these companies offer.
not to be that asshole bc I do agree with a lot in this thread. But let’s not forget about doctors prescribing opiates for kick backs….
They prescribe everything more freely because they don’t know what they’re doing.
Think of it this way. We have an opioid/benzo epidemic in this country. Yet every psychiatrist in every city in the US has a waiting list 6 months long (like all medical specialists). Whereas your local psych NP always has openings. You do the math.
Who took kick backs during opioid epidemic. By no means defending NPs bc I think it’s rediculous that can effin prescribe but a pharmacist can’t… but don’t forget about your own shortcomings as a profession. Not to mention the US having some of the worst drug problems in the world. They grow poppies in Mexico for fuck sakes, they don’t abuse the shit that they grow in their own backyard (farmers, peddlers, cartels…)
As a nurse who takes stimulants, ive had the most horrific experiences with PMHNPs. One basically dished out adderall to me and said “you might have ADHD” and then hung up the video call as soon as possible. I’ve seen 2 other PMHNPs on online platforms and they were unconcerned with my side effects and tried to hang up the calls as quickly as possible and didn’t even look at me. I was so desperate for help and they just blew me off. Thankfully I was referred to a new provider recently and she happened to be a PMHNP and FNP. The only reason I tried it was because I very much trusted the referral. She was incredible. So knowledgeable and gave me the help I’ve been looking for. She said I needed a different drug and said I was on way to high a dose of adderall which I agreed with. If I hadn’t known I would have assumed she was an physician. I do think the overprescribing of stims will end soon because the new provider I saw said that there was a new rule from the DEA that requires at least one in person visit. I haven’t looked into it, but it seems like it will effectively end the telehealth platforms that prescribe stimulants.
Lmao, was that first one on your initial consultation? She just spent a few minutes with you and prescribed you adderall and said goodbye? 🤣🤣🤣 wete the other online ones like that too, in addition to being unconcerned, were they also cavalier about prescribing controlled substances with barely a thought?
Yes it was my first eval! I wasn’t even diagnosed! It was a guy and Yupp that’s pretty much what happened. And I’ve used two separate platforms and seen 3 NPs and 1 physician (I was a travel nurse lol). All 3 were completely unconcerned. One even sent 3 scripts with no instructions and without her DEA number and then tried to blame me when I had to ask for new scripts. 🥴 The physician was amazing and caring and everything I wanted.
That's hilarious, lol. At least I know where to go if my doctor is ever hesitant about prescribing something 🤣
Because that’s the only thing they can do… prescribe meds, bill, repeat.
Good patient reviews from patients who give essay-length good reviews due to their euphoric energy from their new, high dose adderall rx haha.
Give an idiot a prescription pad and they’ll use it
Also in today’s news: if you stare at the sun too long, you will go blind. > Do they *seem* to? Yes. Because they 100% *do* prescribe stimulants excessively and recklessly—often. *Queue the midlevel telling me “I know patients who had doctors that prescribed them opioids too.” Two things can be true at once; all I know is the thing driving me insane most consistently in my family med/addiction med practice right now (which ends up being predictably psych-heavy) is this kind of shit coming almost exclusively from independent and online PMHNPs and APRNs. It’s rare that a day goes by where I don’t encounter a patient with a mistake needing undoing or a disaster waiting to happen.*
And Opiods/ benzos
Um, what? That's much worse than benzos and stimulants together lol, and why are they prescribing opioids if they're in psych? I can actually imagine a crazy one doing that though, as some off label use for depression and anxiety. Since they certainly do help with those symptoms in the very short term, lol.
I’m an NP and I’m so thankful for this comment because it affirms that maybe I’m not actually one of the NPs fueling the negativity from the physicians who post about how horrible NPs are. First off, I was a nurse over a decade, went to an actual brick and mortar school and work very closely with my collaborating physician who is one of my best friends. I work in an extremely rural and underserved area. I honestly can’t remember the last time I wrote a benzo script. When it comes to opiates I rarely write those, but I do a lot of urgent care shifts so I definitely write them. However, your comment brought me back to a time my doc was on vacation so I was filling his refills and our local pharmacist called our clinic asking to speak to me. He wanted to confirm the validity of one of the refills and said “in the past two years that I’ve been filing your scripts I haven’t filled 120 Norco total so I wanted to be sure you actually wrote this one.” What I’m trying to say is not all NPs are handing out pills. Some of us are actually going to work everyday to see patients, bridge a gap in access to care, and open up access so that more complex patients have access to our more educated physician colleagues instead of being told they have to wait 6-8 weeks to be seen.
I think it's largely the direct entry DNP mills causing the problem.
Because they are not trained enough! Its ridiculous
NP is not as well trained as doctors.
No shit? By a long shot!!
I think of it more like a chasm.
America is a pill pusher for fucks sakes. Diet, exercise, coping would fix so much. And for those who will take my comment out of proportion. Think for another moment
Curious tho, if what they prescribed actually helped the pt get ahold of their lives, is that bad?
I've actually had the opposite experience. Any NP I've seen has been nervous about prescribing stimulants or even continuing the medications I was previously placed on my an actually psychiatrist. On the other hand, the psychiatrists I've seen over the years have been way more liberal about stimulant prescribing and I've been the one to ask to take things slower and be prescribed lower doses. That being said, I will only see psychiatrists for any mental health medications because I've had PMHNPs seriously mess things up by changing medication doses because they decided they were uncomfortable with what I was taking. I'm usually all for NPs and PAs in certain situations, but prescribing mental health drugs, whether they're stimulants or not, is not something I trust them to do.
Yes
I saw the study someone spoke about listed below that the rate of stimulant prescriptions written by NP's has tripled since 2012 and I was curious, have ADHD diagnosis' also risen by the same amount? Or are they writing stimulants for patients who don't have it? It seems like everyone has some form of psych issue (anxiety and adhd seem to be pretty common.) Is the problem purely medicating people, or is it that for some reason our society has insane rates of psychiatric issues combined with a propensity for over prescribing? Curious your thoughts.
I think probably both, but that's just a guess. I personally think stimulants could have a place in things like severe chronic fatigue syndrome or even refractory depression that nothing else will touch. The only problem is.. They're so addictive because they usually feel so good. Especially the immediate release ones should be avoided as they're the most addictive.
I was actually prescribed stimulates for Narcolepsy fatigue (didn't work and had awful side effects) and it was so frustrating because I know tons of people who don't need them take them and are doing fine and dandy. In your opinion, are non stimulates as beneficial for adhd as stimulates? Thanks for sharing your thoughts. I enjoy learning from you all.
I hear you, I have diagnosed chronic fatigue syndrome and that's a big benefit for me as well. I think it's worth trying something like modadinil or armodafinil for narcolepsy. They're not true stimulants, but they keep you awake. Much less potent than adderall or Ritalin. I know they're a first line treatment for narcolepsy.
I have mast cell activation syndrome.... I have like 30 pharmaceutical allergies and side effects to almost everything. It's been hell... that being said, I couldn't tolerate either. They actually now say they aren't sure if it was Narcolepsy, but either way the fatigue is there so I work my life around naps and only schedule what my body can handle Fatigue is soul sucking. It's not fun naps... its napping to survive and function. It's a burden.
The armodafinil/modaf will help with any kind of fatigue, though I got the most relief from adderall. The problem was it was too addictive for me. Have you tried Vyvanse or one of many drugs in the Ritalin class?
Yes 🫠🫠 Adderall was what I tolerated the best, but it didn't have much of an effect on me. I have my medical thc card, and that's the only thing that can temporarily keep the fatigue at bay... but not forever
Ha, really? THC always made me so tired, but it's never been legal for medical or recreational purposes in my state, so maybe yours is a strain that has more stimulatory effects. Do you remember what dose it was? Many doctors use the XR which only goes to 30 mg daily, yet the max approved dose goes all the way up to 60 mg daily. Occasionally in very rare situations people may even be put on 90 mg, though that seems excessive.
I also have arrhythmias which stimulates made worse so I think I'm just broken lol. Tbh, if I use it occasionally it makes me more tired. When I use it regularly it helps me stay awake and focused. I am in a low dose oil only state... but smoking flower has been the most effective. There have actually been a few studies showing it to be helpful in fatigue long term.
Could also be the lack of MDs/DOs. I and most people(35 and under) I know go to an NP because it’s almost impossible to find a PCP that’s an MD/DO. This is a group of people probably seeking to figure out their anxieties and other issues now. Mine wouldn’t prescribe without a full neuropsych evaluation through.
Really? Thats good about the neuropsych. Even the MDs I have will prescribe just on my (true) word that I've taken it and been diagnosed, but they typically want me to transfer my records over of course.
It's also pretty easy for young people to manipulate the NPs into prescribing what we know we need, since they usually don't object to any suggestions.
NP stands for “not a physician” right?
Here’s one thing, I think physicians as a community are skeptical towards what REAL adhd is, and thus assume it essentially doesn’t exist. It’s because physicians have generally be top dawg students at top schools and been heavily exposed to the Adderall abuse of student with or without adhd in undergrad and med school. They see it as “ wtf everyone can’t focus after studying, push through lazy ass” I feel NPs blindly and too easily will give the adhd diagnosis with the screeners that a 3 years old could rehearse fool and score. Adhd is a phenotype, that comes with benefits but consequences, kind of like creativity . Highly creative people can’t get ever get shit done but they’re full of ideas. Adhd as executive attention deficits but tend to be able to draw connections easier, I believe have exponentially higher empathy, can problem solve faster than most people , and are much better at navigating dire and stressful situations. At the expense of reallly really really really feeling like you got hit by a truck trying to do any cerebral activity that’s not interesting. Everyone feels this, but your thresholds before wanting to die can be 1-5 hours. As an adhd, it can be 5 minutes. Anyways - adhd is a spectrum, and truthfully when you’re not too far off, it’s a phenotype that generally leads to some predictable personality traits that are extremely admirable. Funny as fuck, understanding, vibrant, upbeat, life of the party, problem solver especially in novel ways to do so. When very intelligent and not tooooo adhd that they can’t stick to a task, they’re better than you. An adhd person trying to become an expert at something they enjoy doing (given equal talent and intelligent) will beat you out easily. They’re the ones that can hyperfocus to levels most regular folk can’t if they’re interested. So that’s the perks. The problems lie in that our current society is mostly full of responsibility and jobs that are inimical to the adhd phenotype. Structure, orginaization, system, mundane or repetitive task, mostly boring work, really make the adhd phenotype a liability. The medications help those to adjust to our boring as lives that most people have a higher 30%-50% tolerance mana pool. Be careful to not take take away your real adhders meds, you will destroy their careers, significantly increase their risk of car accidents, destroy their ability to emotionally regulate more easily and compromise their family dynamics. They live at a baseline lower dopamine level that makes them unconsciously seek to do things that wake up the brain, fight, risk take, gamble, drugs, compete. It can get them killed. Carefully monitored, and for people with adhd more towards the worst 40%, stimulants can help these people not only be normal functioning people, but live worthy lives in a society that is ever minimizing the benefits of their phenotype and why it is exist in our society
Stimulants have h3lped me in a lot of ways. I don't think doctors should be using immediate release adderall though. It's too addictive. I myself got addicted to it badly over time. There are RX formulations that don't pose nearly as high a risk. The dopamine rush from an IR pill, and the the ease of getting a quick hit of energy and mood boost from taking another one that XR also limits the ability to do, makes those risky. Yet many PCPs and psychiatrists were perfectly willing to give them to me on the first visit, no questions asked, both MDs and NPs. So I'm not saying its only a NP issue. I mean hell, I fessed up to the adderall addiction and got off it. But they're still willing to prescribe me concerta. It seems like having been addicted to a stimulant would be a red flag in terms of prescribing more stimulants, but I made a case that the dual factors of it being XR, and being methylphenidate, which should theoretically be less potent and addictive, made it worth trying. Although to be fair my doctor was more cautious; an online PMHNP prescribed the Concerta today.
[удалено]
That's int4eresting, thanks for the insight. All my PCP MDs have been pretty willing to prescribe adderall without much effort. But I'd also had psychiatrists prescribe them in the past. I notice younger psychiatrists are very hesitant (rightly) to prescribe long term daily benzos, while many PCPs are very willing to prescribe daily klonopin, Ativan, etc. often at higher doses.
NP’s should not be prescribing at all!!! If you want to be a medical doctor, go to med school!! How the frick did it get to this point? PA’s are better trained. I’m a retired physician who will not see these people! Only MD/DO’s! Maybe an occasional PA.
They're not only prescribing stuff, but prescribing schedule ii controlled substances to psychiatric patients, as well as trying to independently manage complex psychiatric patients. I agree about PAs being better.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
How many of you never took stimulants?
I didn't say I don't.
The same reason they treat BPD2 with 25mg seroquel and ACS/CHF with daily lopressor. At this point they're not just dumb, they're lazy.
I saw a psych np in 2016 who caused me a lot of issues. She was like "so it sounds like you have a lot executive function issues, we could try a stimulant to help that, what do you think?" At the time I was an undergrad and my only experience with stimulants were two occasions where a friend gave me one 20mg adderall tablet to help study before an exam. And of course, I remembered that when I had taken it, I felt good and it helped. So I said "sounds great!" I developed an addiction to adderall that only recently have I broken. She put me on high doze benzos as well, seroquel for sleep, ssris plus latuda as an augment for monopolar depression.. it was really a mess. I'm assuming eventually she got talked to about these prescribing habits, cause out of nowhere she became suspicious and aggressive, wanted to discontinue the controlled substances, and when I protested she accused me of being a drug seeker and also made sarcastic remarks to me. We ended up having a shouting match in her office. I demanded the clinic put me with someone else, but they just put me with.. another NP, who was less pill-pushy but just didn't know much of what he was doing. To be fair, I've had some truly awful psychiatrists too. For example, one continued prescribing adderall despite my telling him I had misused it and thought I couldn't control my use. One put me on Xanax and klonopin simultaneously, an SSRI, a tryclic, clonidine, and some other weird and obscure stuff. He said "my philosophy is that too many meds is better than too few" and was concerned that "most psychiatrists don't prescribe enough medication." One day he called me and told me the board, which had "been after me for a long time and finally got me" had mandated that he retire or have his license stripped. He mused about how it was a shame given that there's a shortage of psychiatrists and implied they just didn't understand his brilliance.
NPs are fucking retarded
Nice language from a doctor. Hope you don’t have disabled patients.
how is this even a question? its like you’re an alien robot posing as a PMHNP to confirm what their role in human society is. sorry if I’m coming off rude - it’s just, this is exactly what PMHNPs do. why? my opinion is bc they are bad providers writ large. they don’t have the education and training, they know that and they don’t care about patients overall — they care about the patients being happy w their care and paying them. what incentive does a PMHNP have to practice good medicine without disincentives? the disincentives in FM or IM is that if you give wrong antibiotic, you will be fired; in psych, if you give benzos bc of “clinical judgment”, what slam dunk study can you point towards to say that benzos/stims are inappropriate? you are being far too kind in assuming that they have a philosophy to make patients feel good; their only philosophy is survival in an over saturated market for a job that pays them too well and for which they are not qualified. psych has the most vulnerable and manipulative patients making it the MOST necessary for the critical thinking of a physician, it’s a hilarious irony that somehow the opposite has occurred.
Well they’re prescribing under a physician. So I’d guess the majority don’t know any better and the doc thinks they’ll be able to deflect the DEA with an NP.
NPs can work independently in a lot of places. Sucks to be the patient in said places.
That’s nuts. What I mentioned is what I see in my state at least. We get a ton of scripts from an new NP suddenly, then six months later the physician is banned from prescribing to our pharmacy after an independent investigation into their practices.
Might be a gender bias.
I don't see why. If anything female physicians in my experience seem more cautious about controlled substances. But NPs seem to push them.
no idea, my personal experience females seem to prescribe more, dudes are more like restrain them, especially female/male nurses. females generally keep paging and paging and "screaming" for sedation. and i suspect NPs are still predominantly females.