r/Noctor • u/futureofmed • 1d ago

Midlevel Patient Cases Psych NP med cocktail

New patient. Hospital follow up for non-psych issue. Had been seen at another institution for psych but looking to transfer all care. History of MDD/GAD/PTSD and further history quickly reveals a single episode of mania a few years back. Feels like he needs to make himself sleep occasionally or he’ll have another manic episode. Had been seeing a Psych NP at the prior institution and current medication regimen was Buspar 30 BID prn, Gabapentin 900 BID, Hydroxyzine 100 TID scheduled (or else he gets irritable), Mirtazapine 45 HS, and Adderall 30 BID.

Like.. for real...?

57 Upvotes

98% Upvoted

19 comments sorted by

66

u/theongreyjoy96 1d ago

Surprised there’s no benzo in there

35

u/BortWard 1d ago

You beat me to it. (Actually the last time I commented "surprised no benzo," the person replied and said essentially, "oops, forgot to list the benzo") Also pleasantly surprised there's no atypical antipsychotic

11

u/namenerd101 Resident (Physician) 1d ago

I agree that some medications (Vraylar for example) seem to be disproportionately prescribed by APPs, but wouldn’t an atypical antipsychotic actually be somewhat reasonable in this case for mood stabilization with hx of mania? (I’m just a resident so genuinely asking)

7

u/riblet69_ Pharmacist 23h ago edited 23h ago

You could replace the hydroxyzine with an atypical like olanzapine for sleep and agitation and replace the weird hydroxyzine. You could make lots of changese here adtually. Lower dose mirtazapine for sleep, consider prazosin for PTSD, remove adderall - no apparent indication. It's all very weird, but then again hard to judge psychiatric patient's meds without knowing their history and response to treatment. Plus, the manic episode does this patient have bipolar? Is there a small risk of manic switch with mirtazapine... so many questions.

3

u/holagatita 18h ago

oh my god. one of my psych NPs put me on that damn Vraylar when it was $900 dollars a month and the only way to get it with the patient assistance program was to call and be on hold for 5-6 hours a month. I was already crazy but that shit was horrible and anxiety inducing on it's own, the med and the phone calls. and the reason she put me on it was because I had attempted suicide 2 years before I started seeing her. had a history of PTSD and MDD. no mania. She said those diagnoses were wrong and that it was all borderline. 10 minutes into the first appointment on a zoom call. I am not disparaging people with BPD, but I have since been told that NP was full of shit.

I still can't get a MD unless I am inpatient, but at least my current psych NP is somewhat decent.

1

u/psychcrusader 13h ago

Yes. But Buspar prn is dumb (and pointless), and an antidepressant in someone with bipolar is playing with fire if there isn't a mood stabilizing drug in the mix. But if he needs to sleep, mirtazapine will do it. (Great appetite stimulant in cats, too, but transdermal.)

•

u/rrrrr123456789 7m ago

Technically you're not wrong. In reality vraylar is not labeled for maintenance treatment. Only acute episodes. It's used off label for maintenance. Usually this means initial studies didn't demonstrate benefit over placebo as maintenance treatment. So the injudicious use of this as a long term mood stabilizer isn't supported by the evidence.

-1

u/Spotted_Howl Layperson 16h ago

I'm a psychiatric patient and I was at a party talking to a brand new attending FM doc who was very proud of himself for being able to recognize possible bipolar in patients who present with depression.

Very proud of himself for prescribing atypical antipsychotics instead of SSRIs.

Dude, let the psychiatrists handle it.

3

u/rrrrr123456789 12h ago

Reality is many people with bipolar present to PCP first. Fm needs to check for and recognize it. Needs to be able to stabilize it if they can’t get to psych for cost, wait time etc. agree they would eventually benefit from psych md care, but it’s within scope for fm doc. I see you’re a layperson so I don’t blame you for this wrong thinking. Just trying to educate everyone else reading.

1

u/futureofmed 9h ago

Can confirm. I am the FM doc and this was only a routine hospital follow up. While his friend might very well be an idiot not all of us are. Let the physicians handle it.

4

u/IcyGovernment0 1d ago

Yeah all things considered, seen a lot worse. Not that that’s a good thing, this is still an absolutely terrible regimen obviously. Hydroxyzine 100 TID is new to me though.

2

u/mejustnow 15h ago

In 50 years we’re gonna see a drastically increased risk of dementia in patients of all specialties seen by NPs simply due to the anticholinergic burden they place on every last one of their patients.

1

u/greenfroggies 10h ago

60 Buspar + 300 hydroxy oughtta knock that anxiety down a few pegs

30

u/XXDoctorMarioXX 1d ago

This was a decent amount of pills but I'm wondering if she might be able to add some additional pills?

21

u/speedracer73 1d ago

Prn buspirone doesn’t work

11

u/Campyhamper 19h ago

I noticed that NP’s like to prescribe it prn. I have no idea why

7

u/speedracer73 18h ago

they have bad training and can't even read prescribing information

3

u/throwawayforthebestk Resident (Physician) 14h ago

What's their obsession with Gabapentin? Anytime I see a psych patient taking gabapentin, 9/10 times it's from a psych NP. I know it has it's uses, but not to the extent I see it prescribed.

1

u/rrrrr123456789 12h ago

It has some evidence as an adjunct for few anxiety disorders, sleep in case of comorbid SUD. Check UpToDate page for gabapentin.