Any care provider should allow you or your brother to see a physician. You have to be adamant and be ready to take your care elsewhere if they refuse or tell you (your brother) the physicians are full.
When they try to tell you that the APRN is just as good as the physician you should explain to them that your brother is newly diagnosed, he had adverse reactions to medications while he was in patient, he's literally been involved with the law and has had severe personal and legal ramifications from his illness, and given the complexity and complications he suffered you would feel most comfortable with him seeing a physician. Perhaps after he's been stable for several years he can transition to the APRN.
If they refuse you need to find a physician that will take him. You can leave feedback with their risk management department that the office refused to allow your brother to see a physician and your reasons for leaving include your brother being prescribed a medication that he had an adverse effect from while inpatient that was discontinued and your concerns with the competency of the care provided by the APRN given your brother's serious situation.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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It is completely inappropriate for a nurse to manage a patient like your brother. PNP's still only have 6 years of education before coming into the clinical world. Is there any way for you to get in with the supervising physician/psychiatrist for this APRN? Bottom line is **no** you are not overreacting here. If this was closer to something truly simple I still would not recommend an APRN given their lack of education (we don't know what we don't know). Bottom line is he has been arrested, become homeless and literally freaked the fuck out for a full month (and it sounds like this is the third time in his life this has occurred). No, of fucking course an APRN cannot manage this.
Further, the paradoxical rxn to the hydroxyzine (on the heels of some extreme psychotic behavior) is concerning for SLE and it does not sound like your brother has been appropriately worked up for lupus. If you have any way to get him in with a rheumatologist (either pull some strings yourself or see if there is anything through his insurance) I would do so immediately. Those symptoms seem rather bang on for neuropsychiatric SLE and I would hate for your brother to suffer any more if indeed it is lupus not bipolar. Such extreme psychotic outbursts and his life literally falling apart in a matter of weeks fully warrants eliminating SLE from the ddx.
Best of luck. Good news is your brother seems to have a solid support system.
Here is a scattering of research just in case the SLE psychotic manifestations sound out of left field:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981404/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981404/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361854/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361854/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353684/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353684/)
https://www.medicalnewstoday.com/articles/lupus-psychosis#:\~:text=A%20study%20from%202019%20using,Learn%20more%20about%20lupus.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877619/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877619/)
[https://pubmed.ncbi.nlm.nih.gov/11865567/](https://pubmed.ncbi.nlm.nih.gov/11865567/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522607/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522607/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791452/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791452/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9793111/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9793111/)
If you’re implying that this individual may have developed drug-induced lupus as a consequence of hydroxyzine, or experienced an otherwise potentiated reaction, (as I assume you are), this is incorrect. You have conflated hydroxyzine for hydralazine, two entirely different categories of medication.
I surely have not implied drug-induced anything here, thanks though. If you bothered to take a look at any of the linked research you would see how SLE can masquerade as mental illness in just this very way. Sorry for your confusion.
Bruh. You mentioned a paradoxical reaction to hydroxyzine being especially concerning (and as additional evidence) for SLE. None of your linked hodge-podge articles provide evidence of a reaction to hydroxyzine serving as a validated diagnostic tool for SLE. Just don’t want you running around thinking hydroxyzine is synonymous with hydralazine, which your comment appears to suggest (as hydralazine has been shown to both induce SLE of its own accord and potentiate underlying lupus; hydroxyzine has not).
All the reaching and projection on your end indeed do indicate a lack of depth awareness on your part here. The belligerence here is odd. I'll stick with my Lebowski references and primary source material, not some 'psych pharmacist' desperate for a bickerfest.
I am a medical student and not a doctor, but I also have SLE that indeed manifests neuropsychiatrically. I was incorrectly diagnosed as “bipolar” by a PMHNP. She nearly killed me 5 years ago (kidney failure and thyroid toxicity due to 900mg lithium which she stuck me on, no prior of psych meds, and never monitored). While NPSLE is a rarity, things like of this nature are not impossible to have happen and are an example of the necessity of thorough medicine. I suffered for years of mistreatment EVEN AFTER I left because some random bp diagnosis got slapped into charting and took heaven and earth to get taken off. It’s been a fucking nightmare and only being on my way to become a doctor has become a way of putting a stop to it. Please find your brother adequate care in the hands of a doctor. If it is true bipolar, they will help. If it is not, they will sus it out under proper supervision.
Absolutely they have. There’s a study that came out that something like 80% of the newer drugs that are not generic are prescribed by NPs, who we currently outnumber 3:1.
Someone here has to have that. Link please.
There are some doctors like that as well though. I have the misfortune to be acquainted with one who tried to prescribe Leqvio to a couple of patients who were on low doses of a statin (and had never tried higher doses) and whose bloodwork wasn't too bad (one patient hadn't actually had her lipids checked in over three years). This family doctor had the audacity to be pissed off with me because I dared to do my actual job and questioned why he was prescribing this new, highly expensive drug for patients who did not need it.
The covariant there is that NPs tend to be younger and/or newer to prescribing, and new MDs also tend to prescribe newer treatments due to familiarity.
you are far, far, far more qualified than any psych NP. For the somnolence and appetite, without knowing your brother, I might try reducing the risperdal or change dosing around to see if that helps. hilarious that someone with a bipolar diagnosis coming off a manic episode was started on wellbutrin. pretty sure every psych exam in medicine ever asks about anti-depressant induced mania.
As pharmacists we are far more trained to treat people than NPs are because we specialise in drugs. Thankfully more jurisdictions are recognising this and extending prescribing privileges for pharmacists.
My husband has bipolar 2, with an awesome GP and Psychiatrist. But his Pharmacist is a key person in his treatment and is a 100% legend. I don't know what I would do without him. You guys rock, thank you for helping us all 🙌🏼
Just because one group of people (PMHNPs) who shouldn't be prescribing drugs are able to legally, doesn't mean that another group (pharmacists) who shouldn't be prescribing drugs, should get those privileges.
I agree but as a pharmacist I would say we have a far more thorough knowledge and understanding of pharmacology and appropriate medication management which is highly prevalent particularly in within the psych realm. Diagnosis? Nah not our thing would never argue it is. Appropriately managing meds? Absolutely we spent 4-6 years pending residency learning to be the medication experts…
Pharmacists are the experts on medicines, it's literally what we spend years studying. Given the physician shortage in many places, an aging and increasingly complex patient population, health care systems should make much more use of pharmacists' expertise to proactively manage patients in a team based approach.
Physicians should keep diagnosis and setting goals of care, pharmacists should manage medication to achieve those goals.
Wellbutrin shot my cousin with bipolar I into orbiting around Pluto. That was with a mood stabilizer on board. The only thing that made her more manic was unopposed Zoloft.
Use your doctor pull and get someone who actually had to see patients in inpatient psych and not just day dreamed through webnairs.
Jesus grab the wheel.
As a psychologist who also has difficult to treat bipolar disorder (but I've been stable on an appropriate regimen for 25 years -- I do NOT do NPs), holy fuck. That's asking for another manic episode. And why would you re-challenge with something you know has intolerable side effects? This NP is beyond dumb.
Risperdal and depakote together are ok, especially if that resolved the manic episode.
Latuda or seroquel are better.
Starting wellbutrin is a dumbfuck move.
Literally a dopamine agonist. In someone on an antipsychotic with a history of hallucinations.
I also can't think of a great justification for hydroxyzine. Risks outweigh benefits in someone coming off a manic episode.
Not psych. Family med, but I manage my own bipolar patients. I got sick of PMHNPs trying to kill my patients. I was still admitting my own patients, and they weren't the ones who got called to the hospital when my patients tried to kill themselves.
Non-prescriber here, but I have heard from prescribers that Risperdal is better for managing aggression than seroquel. Is that true? Perhaps that could be a consideration here?
I’m not a doctor just a fellow psych patient with allergies to psych meds as well. I was very hungry, sleepy, extremely stiff and gained 35lbs on risperdal but it kept my psychotic symptoms at bay. I was told that they were side effects of risperdal and after 6 months my psychiatrist was able to convince my insurance company to pay for lurasidone (latuda) It works similarly to risperdal but has fewer side effects. I’ve been on the newer medication for 6 weeks now and I feel a lot better physically and mentally.
While waiting for the insurance approval my pcp put me on metformin to help with the hunger and a muscle relaxer for the stiffness.
I also have bad anxiety and I’m on a low dose of buspirone and propranolol with minimal side effects.
I am a nurse myself and I will only see psychiatrists, not midlevels.
To me, psych problems can be as critical as cancer or a stroke (in terms of capacity to wreck one’s life or have something terrible happen while manic or depressed). So your brother needs a board certified physician.
I am sorry. Can we please emphasize how stupid it is to start a dopaminergic medication (bupropion) on a patient on a dopamine antagonist (antipsychotic). We are only lowering his dopamine to prevent him from flipping into a life-threatening manic episode.
Holy shit.
Psych resident here. For reference, psych NPs need 500 clinical hours. That’s about 3 months, and most 4th year med students interested in psych have more experience than that…. Please get your brother to an MD. Bipolar is clearly a very serious diagnosis that can ruin someone’s life if mismanaged. It requires good training and experience.
TID Atarax seems a little bit heavy handed. Especially if it makes him even more agitated. And it’s not a treatment for depression. It’s a potent antihistamine that’s meant to knock people out.
I would probably try to find a psychiatrist instead. It may be more difficult, but I don’t think a real doctor would do things like this.
DON'T STOP fighting for your brother! Don't question yourself. Even if he does end up seeing an actually MD, keep advocating for him. Not as a physician, but as a family member.
No way he should be seeing an NP, particularly while he’s still figuring out what works for him. Bipolar can be complex to treat, he really needs a psychiatrist.
It's worth it to find a reputable psychiatrist who is cash only and just pay it if possible. NPs in psych have no training. It's the wild West. Severe bipolar disorder is a life or death matter.
He should see an MD. He’s been seriously ill and it could end up dangerous. He needs psych. No NPs do not have training they tx pts from a cookbook and don’t know why they are doing it. Please advocate for him to see a psychiatrist especially since this is an initial dx and it was dramatic. I wish you and your brother all the best.
I’m a psych intern, so definitely do NOT take this as professional medical advice. I just want to share my initial thoughts out loud.
Id avoid poly pharmacy. There is no need to have him on 4 medications of different drug classes (mood stabilizer, antidepressant, antipsychotic, and anticholinergic… oh my!)
For antipsychotic induced weight gain, lifestyle changes are first line and if that doesn’t work then metformin can be offered.
Time of day for taking the meds can be adjusted to address sedation. Like risperdal and depakote can both be consolidated into one evening dose so the sedation kicks in at night, which should also help him sleep.
I’d remove hydroxyzine for a patient with a known paradoxical reaction to it. I’d figure out the source of the anxiety before prescribing anything extra. Sounds like he’s been going through a lot lately, so I’d get to the bottom of it. And, of course, emphasize CBT if needed.
Id also order labs due to the recent weight gain if hasn’t been done already. A1C, lipid panel, etc.
Again, this is NOT official medical advice. I’m still very new and learning. Plus it’s impossible to know someone’s full history via an online post.
Id be curious to know what other providers who are more experienced have to say. Please feel free to comment your thoughts!
And 100000% he should see a MD.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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This is all great info and supports my thought process as well. I’m not sure he’s been on the meds long enough for lab work to be super useful yet (A1c etc) but otherwise I agree with lifestyle management attempts first with sleep hygiene and eating. I like the idea of taking the meds in the evening if he’s not already doing that, I’ll check with him. He’s always had anxiety and has had anxiety in between his psychotic manic episodes as well. He was briefly on venlafaxine after his second manic episode 3 years ago which seemed to help a little bit (with the anxiety specifically, in retrospect it maybe wasn’t the best medication option but he wasn’t diagnosed with BMD yet) but he stopped it after a few months.
Thanks everyone for all the suggestions and support. We called today and apparently they are booking a full year out to see the physicians. It’s so frustrating. I think we’ll see if we can get him elsewhere and in the meantime I strongly suggested he not take the Wellbutrin and hydroxyzine until speaking with a psychiatrist.
can the inpatient facility connect him to a real physician? were they the ones that did the referral to the np? i think if you called them and described what the np did, knowing how serious your brother’s case is, maybe they’d pull some strings? this is depressing, your brother is super sick and in need of good care.
They referred him to the county mental health place in his town but since he was evicted he has been staying with our mom who lives in a different county so they had to transfer the referral there. Indigent mental health access is truly limited, at least where we live. Even the private places we could find are booking a month out and refuse to see him even with private pay guarantee from me, knowing he has Medicaid pending. The only way to get him seen sooner than 6 months is to get him in with a different NP next week at a private psychiatry office, pay half the $350 session fee up front, and not disclose that he’s applied for Medicaid, and then he can see the actual psychiatrist next month. I certainly can’t afford to pay for his care out of pocket long term but for one visit I’ll do it while we try to get him somewhere he can see a doctor on Medicaid. I guess beggars can’t be choosers and if you have Medicaid (or even Medicaid pending) you are stuck seeing nurse practitioners.
hmm this is terrible. does he have a pcp? if so could the pcp manage this? or at least try? i guaranfuckingtee that almost no pcp would do the dumb shit that np did. and maybe a pcp could call on some psychiatrists they know or went to med school with or whatever. and obviously you’d be in the picture too, collaborating. all this just as a stopgap until he can get in with a psychiatrist
ugh i’m so sorry about this whole situation. there’s a lot of serious mental illness in my family so i know what it’s like to navigate this stuff, but i never had to in a place that’s quite so resource poor. all the best, feel free to reach out if you need any advice, im a child, adult, and forensic trained psychiatrist
Not a doctor either but I see a lot of people for med side effects. I would have been thinking to change his risperidone to another antipsychotic if he is overly sleepy and hungry.
As a Psych NP they probably should have had referred the patient to a psychiatrist. I can manage a good number of patients with Bipolar 1, but definitely difficult. I am better at minor adjustments and knowing atleast what to avoid. Not sure how they don’t know to avoid Wellbutrin with it still having a slight chance of induction of mania and worsened agitation and anxiety - even if the patient has some signs of depression in Bipolar I. Something like Quetiapine to replace the Risperidone probably would’ve been better option. As it does a better job at managing anxiety and depression than risperidone.
Does he have Akathisia from the Risperidone? If not, is his anxiety symptoms more in terms of "racing thoughts and in his head" or is it psychical symptoms of anxiety?
Omg this is awful. There could be some kind of withdrawal from stopping thrbirimeds but buspar and wellbutrin Weil treat not much related to bipolar. You'd be better if prescribing his meds tbh. Like everyone else's comments, get thee brother to a MD and no more quacks. I hope he doesn't have another episode with the abrupt change of meds. So dangerous. You could probably sue if he did have another episode because of the med changes...
Still ack but less awful. Ideally, add one med at a time so you see how it works and have the least amount of variables running. I'm sorry. Medicine today is so confusing.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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Sweet Jesus. Please have your brother see a real doctor.
Any care provider should allow you or your brother to see a physician. You have to be adamant and be ready to take your care elsewhere if they refuse or tell you (your brother) the physicians are full. When they try to tell you that the APRN is just as good as the physician you should explain to them that your brother is newly diagnosed, he had adverse reactions to medications while he was in patient, he's literally been involved with the law and has had severe personal and legal ramifications from his illness, and given the complexity and complications he suffered you would feel most comfortable with him seeing a physician. Perhaps after he's been stable for several years he can transition to the APRN. If they refuse you need to find a physician that will take him. You can leave feedback with their risk management department that the office refused to allow your brother to see a physician and your reasons for leaving include your brother being prescribed a medication that he had an adverse effect from while inpatient that was discontinued and your concerns with the competency of the care provided by the APRN given your brother's serious situation.
This is a great response, thank you so much!
.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Yes, Otto, I know I said the bad word.
It is completely inappropriate for a nurse to manage a patient like your brother. PNP's still only have 6 years of education before coming into the clinical world. Is there any way for you to get in with the supervising physician/psychiatrist for this APRN? Bottom line is **no** you are not overreacting here. If this was closer to something truly simple I still would not recommend an APRN given their lack of education (we don't know what we don't know). Bottom line is he has been arrested, become homeless and literally freaked the fuck out for a full month (and it sounds like this is the third time in his life this has occurred). No, of fucking course an APRN cannot manage this. Further, the paradoxical rxn to the hydroxyzine (on the heels of some extreme psychotic behavior) is concerning for SLE and it does not sound like your brother has been appropriately worked up for lupus. If you have any way to get him in with a rheumatologist (either pull some strings yourself or see if there is anything through his insurance) I would do so immediately. Those symptoms seem rather bang on for neuropsychiatric SLE and I would hate for your brother to suffer any more if indeed it is lupus not bipolar. Such extreme psychotic outbursts and his life literally falling apart in a matter of weeks fully warrants eliminating SLE from the ddx. Best of luck. Good news is your brother seems to have a solid support system. Here is a scattering of research just in case the SLE psychotic manifestations sound out of left field: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981404/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981404/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361854/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361854/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353684/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353684/) https://www.medicalnewstoday.com/articles/lupus-psychosis#:\~:text=A%20study%20from%202019%20using,Learn%20more%20about%20lupus. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877619/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877619/) [https://pubmed.ncbi.nlm.nih.gov/11865567/](https://pubmed.ncbi.nlm.nih.gov/11865567/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522607/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522607/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791452/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791452/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9793111/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9793111/)
Thank you so much!
If you’re implying that this individual may have developed drug-induced lupus as a consequence of hydroxyzine, or experienced an otherwise potentiated reaction, (as I assume you are), this is incorrect. You have conflated hydroxyzine for hydralazine, two entirely different categories of medication.
I surely have not implied drug-induced anything here, thanks though. If you bothered to take a look at any of the linked research you would see how SLE can masquerade as mental illness in just this very way. Sorry for your confusion.
Bruh. You mentioned a paradoxical reaction to hydroxyzine being especially concerning (and as additional evidence) for SLE. None of your linked hodge-podge articles provide evidence of a reaction to hydroxyzine serving as a validated diagnostic tool for SLE. Just don’t want you running around thinking hydroxyzine is synonymous with hydralazine, which your comment appears to suggest (as hydralazine has been shown to both induce SLE of its own accord and potentiate underlying lupus; hydroxyzine has not).
Donny, you are out of your element.
Cool red herring. Yeah. Ya got me. Psych pharmacist out of her league here 🙄
All the reaching and projection on your end indeed do indicate a lack of depth awareness on your part here. The belligerence here is odd. I'll stick with my Lebowski references and primary source material, not some 'psych pharmacist' desperate for a bickerfest.
^lols okay my dude; your primary sources don’t reference hydroxyzine, but you hunker down 🫡
Sorry about that prefrontal cortex friend. 👏🤡
I am a medical student and not a doctor, but I also have SLE that indeed manifests neuropsychiatrically. I was incorrectly diagnosed as “bipolar” by a PMHNP. She nearly killed me 5 years ago (kidney failure and thyroid toxicity due to 900mg lithium which she stuck me on, no prior of psych meds, and never monitored). While NPSLE is a rarity, things like of this nature are not impossible to have happen and are an example of the necessity of thorough medicine. I suffered for years of mistreatment EVEN AFTER I left because some random bp diagnosis got slapped into charting and took heaven and earth to get taken off. It’s been a fucking nightmare and only being on my way to become a doctor has become a way of putting a stop to it. Please find your brother adequate care in the hands of a doctor. If it is true bipolar, they will help. If it is not, they will sus it out under proper supervision.
The classic psych NP “treatment” algorithm: polypharmacy.
I wonder if the pharmaceutical industry lobbies for independent NP practice?
Absolutely they have. There’s a study that came out that something like 80% of the newer drugs that are not generic are prescribed by NPs, who we currently outnumber 3:1. Someone here has to have that. Link please.
There are some doctors like that as well though. I have the misfortune to be acquainted with one who tried to prescribe Leqvio to a couple of patients who were on low doses of a statin (and had never tried higher doses) and whose bloodwork wasn't too bad (one patient hadn't actually had her lipids checked in over three years). This family doctor had the audacity to be pissed off with me because I dared to do my actual job and questioned why he was prescribing this new, highly expensive drug for patients who did not need it.
There are always bad apples. And as always, evidence >>>> anecdotes (dammit I could REALLY use that study right now)
The covariant there is that NPs tend to be younger and/or newer to prescribing, and new MDs also tend to prescribe newer treatments due to familiarity.
Lol, Yes. Been happening since the 2000's iirc. And now 20 years later lobbying monies have jumped nearly 70%.
you are far, far, far more qualified than any psych NP. For the somnolence and appetite, without knowing your brother, I might try reducing the risperdal or change dosing around to see if that helps. hilarious that someone with a bipolar diagnosis coming off a manic episode was started on wellbutrin. pretty sure every psych exam in medicine ever asks about anti-depressant induced mania.
Not to mention if it IS anxiety, bupropion isn't even indicated lol...
Yes. Buspirone *would* be indicated, and isn't going to flip him into mania.
BuSPIRone is not the same as BuPROPion...capitalized because that's how they are on the label because they're a look alike sound alike.
Oh, I know that. I was bemoaning the NP's appalling choice of drugs.
Haha...I misunderstood your comment! My bad!
But they both start with B. How can anyone keep track?! /s
Just put them both in a bottle, shake it up, and feel all your depression melt away...
Lol I’m not trained to diagnose or treat, but even I know not to treat side effects with more medication
As pharmacists we are far more trained to treat people than NPs are because we specialise in drugs. Thankfully more jurisdictions are recognising this and extending prescribing privileges for pharmacists.
My husband has bipolar 2, with an awesome GP and Psychiatrist. But his Pharmacist is a key person in his treatment and is a 100% legend. I don't know what I would do without him. You guys rock, thank you for helping us all 🙌🏼
Just because one group of people (PMHNPs) who shouldn't be prescribing drugs are able to legally, doesn't mean that another group (pharmacists) who shouldn't be prescribing drugs, should get those privileges.
I agree but as a pharmacist I would say we have a far more thorough knowledge and understanding of pharmacology and appropriate medication management which is highly prevalent particularly in within the psych realm. Diagnosis? Nah not our thing would never argue it is. Appropriately managing meds? Absolutely we spent 4-6 years pending residency learning to be the medication experts…
Pharmacists are the experts on medicines, it's literally what we spend years studying. Given the physician shortage in many places, an aging and increasingly complex patient population, health care systems should make much more use of pharmacists' expertise to proactively manage patients in a team based approach. Physicians should keep diagnosis and setting goals of care, pharmacists should manage medication to achieve those goals.
Lol idk about prescribing, but I’m all for managing chronic diseases and authorizing refills by FOLLOWING SET PROTOCOLS
And how does the patient get their medication without you prescribing it in this scenario?
I “prescribe” it under a protocol. All the conditions need to be met and they need to have seen and diagnosed already.
There will be a sub about how pharmacists are bad if that happens 😂
Wellbutrin shot my cousin with bipolar I into orbiting around Pluto. That was with a mood stabilizer on board. The only thing that made her more manic was unopposed Zoloft. Use your doctor pull and get someone who actually had to see patients in inpatient psych and not just day dreamed through webnairs. Jesus grab the wheel.
It's a literal dopamine agonist in some whose dopamine needs to be therapeutically suppressed.
That’s what I was thinking, too!
As a psychologist who also has difficult to treat bipolar disorder (but I've been stable on an appropriate regimen for 25 years -- I do NOT do NPs), holy fuck. That's asking for another manic episode. And why would you re-challenge with something you know has intolerable side effects? This NP is beyond dumb.
Risperdal and depakote together are ok, especially if that resolved the manic episode. Latuda or seroquel are better. Starting wellbutrin is a dumbfuck move. Literally a dopamine agonist. In someone on an antipsychotic with a history of hallucinations. I also can't think of a great justification for hydroxyzine. Risks outweigh benefits in someone coming off a manic episode. Not psych. Family med, but I manage my own bipolar patients. I got sick of PMHNPs trying to kill my patients. I was still admitting my own patients, and they weren't the ones who got called to the hospital when my patients tried to kill themselves.
This is really helpful, thank you so much!
Non-prescriber here, but I have heard from prescribers that Risperdal is better for managing aggression than seroquel. Is that true? Perhaps that could be a consideration here?
I’m not a doctor just a fellow psych patient with allergies to psych meds as well. I was very hungry, sleepy, extremely stiff and gained 35lbs on risperdal but it kept my psychotic symptoms at bay. I was told that they were side effects of risperdal and after 6 months my psychiatrist was able to convince my insurance company to pay for lurasidone (latuda) It works similarly to risperdal but has fewer side effects. I’ve been on the newer medication for 6 weeks now and I feel a lot better physically and mentally. While waiting for the insurance approval my pcp put me on metformin to help with the hunger and a muscle relaxer for the stiffness. I also have bad anxiety and I’m on a low dose of buspirone and propranolol with minimal side effects.
This psych pt has a better treatment plan than the NP.
🤣
I am a nurse myself and I will only see psychiatrists, not midlevels. To me, psych problems can be as critical as cancer or a stroke (in terms of capacity to wreck one’s life or have something terrible happen while manic or depressed). So your brother needs a board certified physician.
I am sorry. Can we please emphasize how stupid it is to start a dopaminergic medication (bupropion) on a patient on a dopamine antagonist (antipsychotic). We are only lowering his dopamine to prevent him from flipping into a life-threatening manic episode. Holy shit.
I’ve said it before and I’ll say it again: psych NPs are chimps with machine guns.
Yes, thank you!
Psych resident here. For reference, psych NPs need 500 clinical hours. That’s about 3 months, and most 4th year med students interested in psych have more experience than that…. Please get your brother to an MD. Bipolar is clearly a very serious diagnosis that can ruin someone’s life if mismanaged. It requires good training and experience.
Thank you for this information!
TID Atarax seems a little bit heavy handed. Especially if it makes him even more agitated. And it’s not a treatment for depression. It’s a potent antihistamine that’s meant to knock people out. I would probably try to find a psychiatrist instead. It may be more difficult, but I don’t think a real doctor would do things like this.
DON'T STOP fighting for your brother! Don't question yourself. Even if he does end up seeing an actually MD, keep advocating for him. Not as a physician, but as a family member.
No way he should be seeing an NP, particularly while he’s still figuring out what works for him. Bipolar can be complex to treat, he really needs a psychiatrist.
It's worth it to find a reputable psychiatrist who is cash only and just pay it if possible. NPs in psych have no training. It's the wild West. Severe bipolar disorder is a life or death matter.
Didn’t consider this option. It’s a good one.
He should see an MD. He’s been seriously ill and it could end up dangerous. He needs psych. No NPs do not have training they tx pts from a cookbook and don’t know why they are doing it. Please advocate for him to see a psychiatrist especially since this is an initial dx and it was dramatic. I wish you and your brother all the best.
I’m a psych intern, so definitely do NOT take this as professional medical advice. I just want to share my initial thoughts out loud. Id avoid poly pharmacy. There is no need to have him on 4 medications of different drug classes (mood stabilizer, antidepressant, antipsychotic, and anticholinergic… oh my!) For antipsychotic induced weight gain, lifestyle changes are first line and if that doesn’t work then metformin can be offered. Time of day for taking the meds can be adjusted to address sedation. Like risperdal and depakote can both be consolidated into one evening dose so the sedation kicks in at night, which should also help him sleep. I’d remove hydroxyzine for a patient with a known paradoxical reaction to it. I’d figure out the source of the anxiety before prescribing anything extra. Sounds like he’s been going through a lot lately, so I’d get to the bottom of it. And, of course, emphasize CBT if needed. Id also order labs due to the recent weight gain if hasn’t been done already. A1C, lipid panel, etc. Again, this is NOT official medical advice. I’m still very new and learning. Plus it’s impossible to know someone’s full history via an online post. Id be curious to know what other providers who are more experienced have to say. Please feel free to comment your thoughts! And 100000% he should see a MD.
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This is all great info and supports my thought process as well. I’m not sure he’s been on the meds long enough for lab work to be super useful yet (A1c etc) but otherwise I agree with lifestyle management attempts first with sleep hygiene and eating. I like the idea of taking the meds in the evening if he’s not already doing that, I’ll check with him. He’s always had anxiety and has had anxiety in between his psychotic manic episodes as well. He was briefly on venlafaxine after his second manic episode 3 years ago which seemed to help a little bit (with the anxiety specifically, in retrospect it maybe wasn’t the best medication option but he wasn’t diagnosed with BMD yet) but he stopped it after a few months.
Thanks everyone for all the suggestions and support. We called today and apparently they are booking a full year out to see the physicians. It’s so frustrating. I think we’ll see if we can get him elsewhere and in the meantime I strongly suggested he not take the Wellbutrin and hydroxyzine until speaking with a psychiatrist.
can the inpatient facility connect him to a real physician? were they the ones that did the referral to the np? i think if you called them and described what the np did, knowing how serious your brother’s case is, maybe they’d pull some strings? this is depressing, your brother is super sick and in need of good care.
They referred him to the county mental health place in his town but since he was evicted he has been staying with our mom who lives in a different county so they had to transfer the referral there. Indigent mental health access is truly limited, at least where we live. Even the private places we could find are booking a month out and refuse to see him even with private pay guarantee from me, knowing he has Medicaid pending. The only way to get him seen sooner than 6 months is to get him in with a different NP next week at a private psychiatry office, pay half the $350 session fee up front, and not disclose that he’s applied for Medicaid, and then he can see the actual psychiatrist next month. I certainly can’t afford to pay for his care out of pocket long term but for one visit I’ll do it while we try to get him somewhere he can see a doctor on Medicaid. I guess beggars can’t be choosers and if you have Medicaid (or even Medicaid pending) you are stuck seeing nurse practitioners.
hmm this is terrible. does he have a pcp? if so could the pcp manage this? or at least try? i guaranfuckingtee that almost no pcp would do the dumb shit that np did. and maybe a pcp could call on some psychiatrists they know or went to med school with or whatever. and obviously you’d be in the picture too, collaborating. all this just as a stopgap until he can get in with a psychiatrist
No PCP
would it be easier to get a pcp than a psychiatrist?
Maybe. He’s on a wait list for that too.
ugh i’m so sorry about this whole situation. there’s a lot of serious mental illness in my family so i know what it’s like to navigate this stuff, but i never had to in a place that’s quite so resource poor. all the best, feel free to reach out if you need any advice, im a child, adult, and forensic trained psychiatrist
There are lots of resources, major metropolitan area…the problem is he’s Medicaid.
Not a doctor either but I see a lot of people for med side effects. I would have been thinking to change his risperidone to another antipsychotic if he is overly sleepy and hungry.
Wellbutrin for bipolar 1 holy fuck. That's like the first thing you learn.
As a Psych NP they probably should have had referred the patient to a psychiatrist. I can manage a good number of patients with Bipolar 1, but definitely difficult. I am better at minor adjustments and knowing atleast what to avoid. Not sure how they don’t know to avoid Wellbutrin with it still having a slight chance of induction of mania and worsened agitation and anxiety - even if the patient has some signs of depression in Bipolar I. Something like Quetiapine to replace the Risperidone probably would’ve been better option. As it does a better job at managing anxiety and depression than risperidone.
Does he have Akathisia from the Risperidone? If not, is his anxiety symptoms more in terms of "racing thoughts and in his head" or is it psychical symptoms of anxiety?
No akathisia as far as I know. Mental anxiety not physical I don’t think. But probably gets racing heart rate as well as racing thoughts. Why?
Omg this is awful. There could be some kind of withdrawal from stopping thrbirimeds but buspar and wellbutrin Weil treat not much related to bipolar. You'd be better if prescribing his meds tbh. Like everyone else's comments, get thee brother to a MD and no more quacks. I hope he doesn't have another episode with the abrupt change of meds. So dangerous. You could probably sue if he did have another episode because of the med changes...
He’s on the risperidone and Depakote still, she just added wellbutrin and hydroxyzine on top because he’s extra tired and having some anxiety.
Still ack but less awful. Ideally, add one med at a time so you see how it works and have the least amount of variables running. I'm sorry. Medicine today is so confusing.
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We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*