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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by Geaux Tigers! on December 9, 2012, at 18:46:32
I'm an Associate Professor at a nursing college. I only teach two courses. I teach Nursing 4004 - Mental Health Nursing and Nursing 4005 - Advanced Adult Health Nursing. These are classes that every nursing graduate must complete. Basically, I train my students how to evaluate a patient's mental health and how to provide first line treatment using psychotropics (e.g. midazolam for anxiety, quietipine for a violent patient). I tell them the best way to write a proper referral to a PDOC.
I am a PDOC in a way. APRNs here are allowed to write scripts with a doctor's approval. Some have their own offices where they rely on the patient to correlate care with their own physician which is a pain the *ss. I did not want to have to set up an office. So that only left me working under a psychiatrist at a clinic. I don't like the idea of working below somebody; therefore, I gave up 'professional' life in a way and be a nursing school professor. It's not a bad career, I enjoy it.
Yes, I write scripts. The hospital, in addition to the college, pays me to be there as well as a consultant at an hourly rate anytime I am there, including teaching my class. I literally treat patients in that hospital who need help. There are no psychiatric physicians at the hospital, but there is one that is also hired as a consultant that signs my legal papers so I can manage care and prescribe drugs. He operates his own clinic. Because I am hired as a consultant, the hospital requires me to 'bill' my hours to their outsourced psychiatrist. The insurance process is too wild. Trust me, I want it to be this way, it's like I'm working under him -- sure -- but only so it's legal. If a patient pays out of pocket they write a check to the "real" psychiatrist but I get 90% of the monies. If a patient's insurance pays for my fee to the psychiatrist who will pay my monies out at the end of the month.
My life is working out well. I get paid by the college, by the hospital, and then I make my own money treating patients as if I were a real psychiatrist.
The hospital is kind enough to give me an office. For me to keep my hospital consultant pay, I treat all patients who seek psychological care during treatment. Of course, these patients could go to any psychiatrist if they had a referral, but I am suggested because the hospital indirectly makes money off of my treatment. The hospital can't afford their own psychiatrist. A lot of people's insurance won't pay for a psychiatrist and I live in a rural area -- so my office visits are cheaper than in a lot of areas.
Basically, what happens is, a patient requests psychological help during their stay at the hospital-- say for trauma -- for say, PTSD. The doctors have no idea what to do in this case but they can add me to their bill and I can diagnose and prescribe. I treat around ten or so new patients every week at the hospital until they are discharged. But I have "permanent" patients. I take my repeat patients whom need counseling and do monthly visits with them. I do around 30min. sessions only, depending on volume less. It is around 12-18 people a day.
tl;dr: I am a PMH-APRN who has regular and irregular temporary patients at the hospital
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Questions:
1. What combination of psychiatric drugs has worked to improve your lifestyle? What are you diagnosed with?
2. What drugs do you abuse and what prescription drugs help with your abuse problem?What I'm interested in, professionally, is what drug cocktails have worked you? I like to study how each interacts with each other. This is would be beneficial for my knowledge and may help future patients.
THANK YOU FOR YOUR TIME
Also, if you have any questions for me, feel free to ask!
Any advice for me for treating patients?
Posted by Geaux Tigers! on December 9, 2012, at 18:47:11
In reply to What combination of psychiatric drugs has worked?, posted by Geaux Tigers! on December 9, 2012, at 18:46:32
A lot of PDOCs rely on polypharmacy, including myself the rationale behind this is that we are medicinally trying to solve their psychological problems instead of using therapy. If the patient were to utilize therapy, mind development, etc. then our role as drug providers should lessen with time and ideally approach zero. In a perfect world, these psychiatric drugs would only be prescribed on a temporary basis; however, we know that this isnt the case. The majority of psychiatric drugs are toxic in some way and cause addiction and withdrawal behavior. The patient must decide if the trade-off between mental alleviation with psychiatric drugs is worth the addiction and, for the most part, neurotoxicity a PDOC will write *something*. Philosophically and scientifically, there are a lot of different and very reasonable arguments that attack the field as a whole, and I definitely understand the rationale.
As a psychiatrist (or in my case, PMH-APRN), you should strive to prescribe the fewest amount of drugs possible needed to alleviate symptoms, and there are always excess meds yes, I prescribe excess in a lot of cases. If a patient comes back and claims they are more depressed, even with ADs prescribed, you have to decide between whether he is simply going through a bad time (everyone, no matter what drug you can conjure up, will suffer depression as a part of being a mammal, imo), or has actually suffers TRD. Clinically, I presume TRD and may write yet an unnecessary script that might be one which he may be on for years and years. Its definitely different from traditional medical fields in a lot of ways.
Psychiatrists kill themselves, etc. (I abuse drugs) I sometimes wonder, like the critics, if the medications are really worth it versus therapy and self-discovery, and most of all-- the extent of the scientific knowledge that allows us to properly prescribe medicine. There is always research coming out saying this and that, e.g. oh the only reason this AD works is because of BDNF, etc.
Another amazing thing, you can almost look at the world as a computer, its amazing that we are only ourselves, one unit, doing one particular role with different schemas. I think ones schema is the key to unlocking mental problems. As I said with the medications, it is easy to do affinities of neurotransmitters, etc. but it is difficult what processes they are inhibiting in worlds most complex computer the human brain.
Posted by Geaux Tigers! on December 9, 2012, at 18:48:32
In reply to Re: What combination of psychiatric drugs has worked?, posted by Geaux Tigers! on December 9, 2012, at 18:47:11
I've developed this chart: http://oi45.tinypic.com/14dge1u.jpg
As you can tell, I am a fan of old school TCA's. They seem to have a better response rate than SSRI/SNRI in my experience if they work well, but a lot of time the side effects are just too much.
What do you suggest I should do to improve this chart? I have a lot of ideas and want to completely re-do it.
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Let me defned my use of TCA's
OK, with the Anafranil, you have a drug that is a potent enough SRI that has the same potency as the SSRIs. WHILE at the same time have strong NRI due to its desmethylclomipramine metabolite. This makes it way better than the SNRI venlafaxine which has negligible NRI effects except at ridiculously high doses. I think the NRI + SRI combination is important for depression; also, like venlafaxine and the other TCAs, it may interact with the opioid system in a beneficial way. It is a mild 5HT2A antagonist, which is good to reduce anxiety and improve mood and probably sleep too (and appetite). It does increase prolactin levels a lot so you have to watch out for that and its inhibiting effect there can interfere with the breakdown of melatonin so it might increase drowsiness but Im not sure how clinically relevant that is. Great TCA.
I recently stabilized a patient on:
#60 900mg. lithium; PO, 1 tablet QAM, 1 tablet QPM for 296.5
#90 10mg. dextroamphetamine sulfate; PO, two tablets QAM, 1 tablet QPM for 314.01
#30 125mg. imipramine PO QHS for 296.3/309.81
#60 0.5mg. clonazepam PO BID PRN for 300.02/300.23
#30 80mg. lurasidone PO QD CF for 301.83/312.30
#60 100mg. modafinil PO BID QD for 327.15/296.80
#120 150mg. pregabalin PO, two tables QAM, 1 tablet PM, 1 tablet QHS for 293.83/296.80
#30 0.5mg. alprazolam PO QD PRN for 292.84//309.81
Posted by jono_in_adelaide on December 9, 2012, at 22:07:27
In reply to What combination of psychiatric drugs has worked?, posted by Geaux Tigers! on December 9, 2012, at 18:46:32
I have the neurotic holy trinity of GAD, panid desorder and (endrogenous) depression
What fixed me was the combination of an SSRI and an NARI (I have used reboxetine, nortriptyline and bupropion as NARI's, and have found them all effective) along with risperidone 1mg at bedtime and Alprazolam 1mg three times a day as needed.
This combination has allowed me to rebuild my life after not working for a year, not leaving the house, and eventuualy losing my house and career
Posted by jono_in_adelaide on December 9, 2012, at 22:10:30
In reply to Re: What combination of psychiatric drugs has worked?, posted by jono_in_adelaide on December 9, 2012, at 22:07:27
Can i just say that most psychiatric drugs arnt addictive - if you arnt a troll and realy are an associate professor of nursing, i suggest to learn the difference between addiction and dependence, and also realise that a withdrawl symptom doesnt neswecerily mean that a drug produces dependence.
Posted by Phillipa on December 10, 2012, at 8:57:41
In reply to Re: What combination of psychiatric drugs has worked?, posted by jono_in_adelaide on December 9, 2012, at 22:10:30
Troll is good. Phillipa
Posted by gadchik on December 10, 2012, at 9:25:30
In reply to Re: What combination of psychiatric drugs has worked? » jono_in_adelaide, posted by Phillipa on December 10, 2012, at 8:57:41
zoloft 25mg,remeron 7.5mg, and klonopin .5mg.This combo worked for me.But also had to put forth effort to get over my breakdown too, exercise,nutrition,massage,meditation,cbt,etc...was able to taper off all after 2 yrs,except have remained on .5mg klonopin.
Posted by baseball55 on December 10, 2012, at 17:40:10
In reply to Re: What combination of psychiatric drugs has worked?, posted by gadchik on December 10, 2012, at 9:25:30
I have been stable for some time on lamictal and parnate. Parnate causes insomnia, so I also take 1mg xanax at bedtime. I know this isn't such a popular position on this forum, but ultimately what has helped most in treating repeated bouts of depression and suicidality is regular dynamic therapy plus DBT therapy. If you've cost your insurance company a small fortune in hospitalization costs, as I have, they are happy to pay for therapy if it keeps me out of the hospital. All studies I've seen find therapy and good as drugs and even more effective in treating TRD.
Posted by schleprock on December 10, 2012, at 18:40:36
In reply to What combination of psychiatric drugs has worked?, posted by Geaux Tigers! on December 9, 2012, at 18:46:32
I can tell you what combinations of drugs destroyed me.
(wonders which Babbler is responsible for suggesting this little visit...)
Posted by schleprock on December 10, 2012, at 18:43:28
In reply to Re: What combination of psychiatric drugs has worked?, posted by schleprock on December 10, 2012, at 18:40:36
Posted by Phillipa on December 10, 2012, at 19:07:50
In reply to Re: What combination of psychiatric drugs has worked?, posted by schleprock on December 10, 2012, at 18:40:36
I have a different thought on this visit. Phillipa
This is the end of the thread.
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