Bipolar 2 From Inside and Out

Posts tagged ‘psychiatrists’

What Does PMHNP Mean?

What the initials mean is Psychiatric-Mental Health Nurse Practitioner (also known as Psychiatric Nurse Practioner or PNP). What that may mean for mental healthcare is the potential for more treatment and access to therapy. Increasingly, nurse practitioners are taking over some of the duties of psychiatrists and providing services to people who have mental disorders, or even serious mental illness (SMI).

What qualifications do nurse practitioners have? They must have a master’s or doctorate in nursing with a psychiatric nurse practitioner concentration, plus two years of work experience. Unlike psychiatrists, they aren’t MDs.

Psychiatric nurse practitioners perform many of the same functions that psychiatrists do. They work in hospitals, rehab facilities, outpatient mental health centers, and even in private practice in many states. (Other states require that they work under the supervision of a physician.) In addition to providing psychotherapy, PNPs can write prescriptions – including for controlled substances – regulated by state boards of nursing. They work with other professionals and with families to meet patients’ needs and create a holistic care plan that typically includes therapy, counseling, and medication.

There’s a crying need for PNPs. It’s no secret that it’s difficult to find psychiatrists and psychotherapists and that the waiting list is long for a new patient seeking treatment. Last year, 151 million Americans lived in mental health professional shortage areas, according to the U.S. Health Resources and Services Administration (HRSA). They reported that those areas need 7,584 mental health care practitioners to fill the gap.

It’s a good field to go into, too. Salaries are reported as ranging from $81,000 up to $140,000 per year. And in 2021, the unemployment rate was less than 1%. Currently, there are over 10,000 PNPs in the US, of which 80% are women. The U.S. Bureau of Labor Statistics (BLS) projects that the employment of all nurse practitioners will grow by 52% between 2020 and 2030! They anticipate 29,400 new job openings across the U.S. every year between 2020 and 2030. 

Minority Nurse magazine reported in 2020 on why there’s such a strong demand and positive job outlook for PNPs. They cited expanded insurance coverage for mental healthcare under the ACA, increased awareness of the importance of mental health, and the mental healthcare needs of veterans who served in Iraq and Afghanistan. The aging population of Americans may be another factor, as more and more people require services for disorders such as Alzheimer’s and dementia.

How good are PNPs? Psychiatric Times says that “patients report favorable experiences working with nurse practitioners.” Findings from one study determined that patients had “greater satisfaction with their care provided by nurse practitioners when compared with their MD colleagues….Investigators found that patient outcomes from nurse practitioners working independently or with MD collaboration had similar outcomes, when compared with the patients working with MDs alone.”

Although it seems that psychiatrists and PNPs ought to be natural allies, Psychiatric Times also notes that “national initiatives and some agencies have encouraged an us vs. them mentality, pitting psychiatrists against nurse practitioners and other advanced care providers.” That’s unfortunate for so many reasons.

I’ve never used the services of a psychiatric nurse practitioner, though there are several near me. If I had known about them when I was between psychiatrists, I certainly would have investigated the option. There’s something appealing about getting my therapy and my meds all from one person, a situation that hasn’t occurred since my previous psychiatrist retired. (I had to spend six months on a waiting list before I found another.)

For anyone in the same situation, I would suggest looking into it. I am convinced that PNPs have an important role to play in mental healthcare. If their presence reduces the problem of scarcity of mental health professionals, they should be welcomed, and awareness of their availability should be publicized. If more people knew about PMHNPs, it would expand the choices that mentally ill persons have. It would also benefit organizations, inpatient and outpatient facilities, and community-based care.

Is there a downside? I don’t see one.

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Adjusting the Dosage

I go to a psychiatrist four times a year for med checks and a psychotherapist every month to six weeks or so for my ongoing mental health care. When I think a change in medication dosage might help, I always ask my therapist if she thinks I need to consult the psychiatrist and ask the psychiatrist if he thinks my medication should be adjusted.

Recently, I noticed that I had been in a hypomanic phase for a period of several months, something that doesn’t usually happen to me. At first, I thought it was the winter holiday shopping season that was the cause of my overspending. But as January rolled through and I was still running up the credit cards with online purchases, I had to admit that I was definitely in the clutches of full-blown hypomania.

I discussed this with my therapist, who approved my plan of telling my psychiatrist about it and asking if adjusting my medication was appropriate.

So I did. While we were discussing the problem, I asked whether upping my anti-anxiety med might help.

After considering it, Dr. G. said he didn’t think that would help, but that increasing the dosage of my atypical antipsychotic might. He wrote me a new prescription and instructed me to call him right away if it had unexpected side effects.

In one of the Facebook mental health groups I belong to, another member said that he thought titration (trying to find the right dosage by adding and subtracting) led to overmedication. That hasn’t been my experience.

My first experience with psychotropics was with Prozac, back in the day when that was the new wonder drug. It worked great for me – until it didn’t anymore. (This was, no doubt, partly due to the fact that it treated only my depression but not the other symptoms of bipolar disorder.) After that, a succession of drugs came along, until I started going to Dr. R.

My second psychiatrist, Dr. R., titrated my medication for literally years before we found a level and a combination that worked for me. He would start me on a new medication and then slowly and carefully increase the dosage until either it helped or didn’t help, or the side effects became intolerable. Then he would titrate the medication downward, again gradually, to prevent withdrawal symptoms. This made the process long and slow, but ultimately safer. Eventually, we found a “cocktail” that worked for me.

If titration means only upping the dosage of a medication rather than adjusting it both up and down or discontinuing it entirely, then I admit that the process can lead to overmedication. But I think that’s bad psychiatric practice. (The group member commented that I had had a good psychiatrist once I explained his process.)

My current psychiatrist has adjusted my dosages several times in conjunction with my changing needs. Over the years, my sleep aid has been entirely discontinued and my anti-anxiety med reduced from twice a day to as needed. The most recent change has been only a slight bump in dosage, carefully monitored, with a promise of attention in between my regular sessions if I experience problems.

That’s my idea of a good relationship between practitioner and patient and a sensible approach to changing medication. I do admit that it has been luck that put me in touch with psychiatrists who had the wisdom and regard for safety to change my meds only when necessary and only gradually. Now that I know what to look for, I feel better about changing psychiatrists should Dr. G. retire (which is why I needed a change after Dr. R.).

Will the change in my current meds help in curbing my hypomania? That’s still up in the air. It may be that the hypomania will subside on its own and the meds will have nothing to do with it. Or it may be that the higher dosage will prove ineffective and I’ll have to ask Dr. G. if starting a higher dosage or a different medication would be sensible. Either way, I have learned to trust the process.

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Going Off (Some) Meds

I regularly tell people not to go off their meds without consulting their psychiatrist. I yell at them, in all caps. It’s not just a bad idea, it can result in withdrawal and even lessening the meds’ effectiveness if you do go back on them. Yet recently, I went off two psych meds without my psychiatrist’s prior approval.

Here’s what happened.

My husband and I recently had COVID – probably the Delta or Omicron Variant, as we have both been triple-vaxxed. That is to say, my husband tested positive for COVID and I have close contact with him, plus I had the same symptoms that he did.

Since we didn’t need expensive and rare treatments or hospital stays and ventilators, we relied on over-the-counter medication to treat the symptoms, which included sore throat, coughing, fever, congestion, and fatigue. We recovered in a couple of weeks to a month and my husband is back to his job, where he regularly interacts with numbers of people. I work at home, so I didn’t have that problem. I just needed to take some time off when I felt truly crappy.

When we read the directions on the OTC symptom-relief pills, however, there was a warning that said not to take anti-anxiety agents or sleep aids with them. My regular routine has been to take a sleeping aid at bedtime and an anti-anxiety pill in the morning and at bedtime, with an extra dose allowed if I have an anxiety attack during the day. I have been taking both of the meds literally for years and have never had any problems with them. (I won’t say what any of the medications are, since everyone has different reactions to different medications, and my reactions, while fairly typical, won’t hold true for everyone.)

Perhaps out of an excess of caution, I decided not to take the anti-anxiety and sleeping meds while on the OTC ones. When I quit taking them, though, I was worried that I might experience some of the ill effects that were possible.

Throughout the course of my bout of COVID, I didn’t notice any withdrawal symptoms, excess anxiety, or difficulty sleeping as I feared I might. In fact, I slept better than usual and had fewer attacks of anxiety. So I decided that I would try going off the two meds for a while, even after I felt better. It was about six weeks until my next med check with my psychiatrist.

Of course, when my med check came around, I told my psychiatrist what I had done and why. I thought he might react badly when I said that I did this on my own, without his advice and consent.

Instead, he seemed thrilled.

“Good for you,” he said. “You’ve stopped taking the two addictive ones, too.”

I had known those drugs were potentially addictive, which was why I was watching for withdrawal symptoms. I took the lack of these as signs that, though the drugs were addictive, I was not addicted. (My psychiatrist has to regularly have an analysis done to show whether his patients have a high risk of abusing psych meds or taking more than needed. My score was 0%.)

It felt good to have my psychiatrist validate that I had done a good thing and not a bad one. But even more, it felt good to be taking fewer pills each day. I’ve never minded having to take pills or felt ashamed of taking them, but it was still significant to me that I had lowered my medication schedule to just the ones that had beneficial psychotropic effects, such as antidepressants and mood stabilizers. I was delighted to find that I didn’t need as many pills as I had once thought.

All in all, my experiment was a success, but I was lucky, and my experience is not medical advice. I don’t recommend it to anyone else. Consult your prescribing physician before you cut back on or stop any medication. I MEAN IT!

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The Difference a Diagnosis Makes

I thought I had depression and that’s what I was first diagnosed with. Later, I learned that I really had bipolar disorder, type 2, with an anxiety disorder on top of it. Here’s what I learned on my journey to a proper diagnosis.

Understanding. Once I was diagnosed with bipolar disorder, a lot of things from my life started making more sense. I finally realized that some of the inane things I thought and did as a child/teen were attributable to hypomania. Being idiotically happy when I won a goldfish at a carnival, carrying it before me, grinning like a loon. Near-constant mirth when I read a novel parody, laughing long and loudly every time someone used a word or phrase that reminded me of it. Luckily, I didn’t have any money to spend, or I would have done that too, based on my later behavior. Even things I did as an adult before my proper diagnosis made more sense – flight of ideas, pressured speech, and the like.

Second opinion. Going to a different psychiatrist and finally getting the right diagnosis was, in many ways, like getting a second opinion. We don’t often hesitate to get a second opinion on matters concerning our physical health (and insurance companies may require it). Why is it different when it comes to our mental health? I’m not saying that doctor-shopping is a good idea or that a diagnosis of depression did me no good at all. It just took a different psychiatrist to put together all my symptoms in a way that made sense to me as well as to him.

The “Aha Moment.” When I got my bipolar diagnosis, it was like a wake-up call. I instantly understood that my psychiatrist was right. Once I had that insight, I was able to explore my actual disorder in various ways – further sessions with him and with my psychotherapist, reading books and reliable online sources, sharing with other people who have the same diagnosis and listening to their experiences.

Getting the right meds. I had been taking medications for depression for many years. Then I learned that I might – did – need treatment with anti-anxiety medications, mood levelers, and other kinds of drugs that specifically targeted bipolar symptoms. I still needed meds for depression, but I needed a “cocktail” of drugs that addressed all my difficulties, not just one.

Going on maintenance meds. The process of settling on that cocktail of meds took a long and difficult time, but once I had the right diagnosis and the right meds, I was able to cut back to seeing a psychiatrist four times a year to get renewals on my “maintenance” medications. The process that stabilized me also allowed me and my doctor to make “tweaks” to the dosages to correspond with increased or lessened symptoms.

A new revelation. My learning about my disorder didn’t stop with my new diagnosis. Recently I learned that my depression could be what is called “dysthymia,” a type of depression that is roughly equivalent to the difference between mania and hypomania in bipolar 2. I wasn’t sure this applied to me, as my depressive episodes seemed long enough and severe enough to be considered major depression, but after consulting my therapist and other reliable sources, I began to see how a dysthymia diagnosis actually did correspond to my symptoms.

Having hope. The most important thing that the right diagnosis gave me was hope. Properly understanding my disorder and the correct treatments for it allowed me to hope that I could achieve stability and healing from all the years when I didn’t realize I was suffering from hypomania as well as depression. I could at last look forward to a life where my disorder didn’t control me. With help from my psychiatrist and the medications he prescribed, I have been able to live a contented and productive life. Work, stable relationships, and the other benefits of having proper treatment are achievable – and I have largely achieved my goals in life.

And my new diagnosis has been responsible for it.

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On the Couch From the Couch

(Actually, from my desk chair, but you get the idea.)

This week I tried teletherapy, one of the workarounds that psychiatric patients have turned to in order to promote their own mental health, especially during the pandemic.

I know there are various online companies that specialize in teletherapy, or other health conditions plus psychiatric ones. Among these are Talkspace, Betterhealth, and Brightside, plus meditation and mindfulness apps such as Insight Timer. I wrote about the phenomenon back in January (https://bipolarme.blog/2021/01/10/distance-psychotherapy-is-it-for-you/).

In that post, I said that I hadn’t needed to try teletherapy yet, though I did mention having had telephone sessions with Dr. B., my psychotherapist. These were set up when I was unable to make it to my sessions, whether for transportation or psychological reasons. They helped but were not ideal, of course, because we couldn’t see each other’s faces and body language. Now, of course, with the proliferation of tablets, smartphones, and apps like Zoom, that’s no longer a hindrance,

Lately, I’ve been feeling a need to go back into therapy and by default I had to use teletherapy, as Dr. B. still isn’t seeing clients in person. (I had done Zoom calls for various other purposes, so I knew the drill.) We set up a Webex appointment and I thought about what topics to bring up, since I hadn’t seen her in so long.

I still don’t know all the advantages and disadvantages of commercial teletherapy, but I wasn’t tempted to try it.

First of all, I hate breaking in a new psychiatrist/therapist under any circumstances, as I had to do when my regular psychiatrist retired and moved. At this point, even the Reader’s Digest version of my life – or even just my mental health journey – would take several sessions. And I don’t trust therapy that starts without knowing my diagnosis, my medications (including the ones I’ve tried that didn’t work), what triggers me, at least a summary of my major depressive episodes, what therapy I’ve had so far, what I learned from it, my family and childhood and relationships, and more.

Not to say that a person couldn’t help me at all with my current situation (possible onset of a major depressive episode) without the backstory, but all that history informs what I’m going through now and why. Going through it would take several tele-sessions before we ever got to my current problem.

So, Dr. B. agreed to see me promptly and I appreciated it greatly. I was able to skip all the history and just get to the meat of my problems. She was able to remind me of some of the things that have helped me in the past and suggest some new things as well. And we set up another appointment for next week. One of the things she recommended was that I check with the psychiatrist who prescribes my meds, as I’ve been having some trouble with sleep. (Fortunately, my next appointment with Dr. G. was within the week. I see him only four times a year for maintenance.)

I had my appointment with Dr. G. He refilled all my meds, but had little to suggest about any of my other problems. He heartily agreed with my decision to go back to seeing Dr. B. He told me that one of my meds which I thought I might switch from nighttime to daytime was the kind that built up to a certain level in the bloodstream and it didn’t matter when I took it. And he suggested I make an appointment with my primary care physician regarding a matter that seemed not to be psychiatric in nature. (I agreed, and will do that as soon as the holiday weekend is over.)

So, where does this leave me? In touch with three doctors who know me and know my conditions. Set up with regular appointments to keep an eye – and an ear – on my symptoms. Reassured that my meds are functioning as they should, even if my brain isn’t.

All in all, I don’t feel better, but I feel better about it, if you know what I mean.

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The Quest for a Psychiatrist

I have been seeing Dr. R. for eight years. He helped me through my major meltdown and skillfully, gradually mixed the cocktail of medications that would get me and keep me functioning at an acceptable, livable level. He got me through my near-brush with ECT (although he also suggested it).

Dr. R. is moving to another state. He sent all his clients a letter listing half a dozen or so local psychiatrists he could recommend, though he didn’t know if they were accepting new patients or what insurance plans they took. This week was my last appointment with him.

I looked at the inch-thick file he was holding. “I was really messed up back then,” I said.

“Yep,” he replied.

I left with a hearty handshake, good luck wishes, a paper stating my diagnosis (bipolar disorder, anxiety disorder – I guess there was no insurance code for bipolar 2) and six months of refills on my prescriptions. That’s how long I have to find a new psychiatrist.

So where will my inch-thick file end up next? That’s a good question.

I’ve written before about finding a psychotherapist (http://wp.me/p4e9Hv-1m), but oh, I hate the process of finding and breaking in a new shrink.

At least this time I probably won’t have to go through the whole Reader’s Digest Condensed Version of my screwed-up life, since what I really need at this point is someone who will prescribe and monitor my meds, though it will also be nice to have someone standing by in case of another major meltdown, should I have one.

My first avenue of exploration is whether my primary care physician will prescribe my psychotropics, so I can continue with just a psychotherapist. Dr. R. says that most GPs would shy away from the somewhat lengthy list of meds, but every time I see Dr. S. I update him on what meds I am taking, and I always mention the psychotropics, which have mostly been the same for years.

I have an appointment to see Dr. S. next month and sent a query about the prescription issue (his office has a robust online presence), so with luck, I may have a solution before Halloween.

My next step would be to start with the list that Dr. R. provided. Only one of the offices is at all close to me and I’ll likely start there. Does the doctor accept new patients? Does the practice take my insurance? What’s the charge if they don’t?

I’ll also need to contact my insurance provider for a list of local psychiatrists who do take that insurance, but with that I’ll be flying blind. Dr. R.’s recommendations are people he knows, and knows are good.

I hope they’re as good as Dr. R.

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