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Collaborative care provides the best possible patient outcomes.
As we approach the 2-year mark of the COVID-19 pandemic, the fourth wave that has swept through our country this past summer and fall continues to surge, moving from state to state. Medical teams in emergency rooms and ICUs continue to deal with the roller coaster of overfilled hospitals and exhausted personnel to periods of quiet to recover and process what is happening. For us in psychiatry, although there has been an upswing in anxiety, depression, posttraumatic stress disorder, and many other psychiatric complications of COVID 19—both directly and indirectly caused by the SARS-CoV-2 virus—the psychiatric impact of this pandemic will be with us for years, and likely decades, to come.
Prior to COVID-19, psychiatry was already experiencing a shortage of psychiatric providers. Throughout the United States, this shortage had been primarily addressed by an increasing number of psychiatric mental health nurse practitioners (PMHNPs).
Nationally, based on 2021 numbers, there are over 325,000 nurse practitioners (NPs) licensed in the United States.1 Of these, approximately 5% are primarily certified in psychiatric-mental health. This percentage has been steadily growing in response to the significant shortage of psychiatric providers. With more states legislating greater independence for NPs, there has been a strong pushback by some physician groups. The authors would like to share our positive experience working in a collaborative model, which includes psychiatrists and PMHNPs at a community mental health center (CMHC).
New Hampshire (NH) has 10 identified catchment areas, each with its own private nonprofit contracted community mental health center. An informal survey in February 2021 determined that of approximately 100 psychiatric prescribers at these CMHCs, half were psychiatrists and half were PMHNPs. At our CMHC, there are 9 psychiatrists and 4 PMHNPs with shared responsibilities, providing direct patient care in a variety of settings. The additional psychiatric hours—available by adding 4 full-time PMHNPs—have allowed a more direct psychiatric presence at our local homeless shelter, primary care clinics, and the emergency room of our affiliated hospital. Significantly, the wait time for a medication evaluation for a new or existing patient has decreased.
A larger and more diverse psychiatric group has created an environment for more collaboration, with different practitioners providing input from their own clinical interests and expertise. As our chosen profession of medicine is appropriately called a “practice,” there is always more to learn and more experience to gain. We would like to present a case that highlights the benefit of working in a collaborative psychiatrist/PMHNP setting, which ultimately resulted in good patient care, as well as increased clinical acumen by all involved.
An Unplanned Pregnancy on Lithium
While working as a PMHNP in a CMHC, one of my patients informed me of an unplanned pregnancy. She was in treatment for bipolar I disorder, with several prior psychiatric hospitalizations, but a recent, prolonged period of stability. Her maintenance regimen consisted of lamotrigine and lithium. Given the report of pregnancy, I knew it was necessary to reevaluate the appropriateness of the patient’s medication regimen to determine the need for any changes.
As I often do when faced with a challenging clinical situation, I consulted a colleague to discuss this case and the range of treatment options. Given the US Food and Drug Administration’s policy change in 2015 when they eliminated pregnancy categories for all approved drugs, it is important for all clinicians to continually revisit current pregnancy recommendations. A colleague initially recommended that I stop the lithium, which did not seem like an ideal option for my patient. Given the constantly evolving and changing recommendations in psychopharmacology, including during pregnancy, I consulted the current literature to review the most up to date recommendations. Additionally, I sought out my colleague at the CMHC, John Miller, MD, to discuss the case. Miller provided recommendations as to how he would proceed and shared articles from his library of psychopharmacology during pregnancy.
Given my patient’s personal psychiatric history, which included multiple hospitalizations in the past for mania and depression, discontinuation of the lithium during her pregnancy would be risky. Since she had responded well to lithium for many years, and lithium treatment during pregnancy is considered a reasonable option, I decided to recommend this to her.
I reviewed a thorough risk-benefit analysis of current treatment recommendations during pregnancy with the patient and discussed some additional perinatal testing that should be done if she were to stay on the lithium. Subsequently the patient chose to remain on the lithium during her pregnancy, agreeing to increased monitoring, and informed consent of her decision was documented. She appreciated the shared decision-making process and signed a release of information to allow for coordination of care with her OB-GYN, which was important to ensure a consistent team approach with clear communication. Due to the relationship between lithium and fluid status, careful and frequent monitoring of maternal lithium dosing and levels was required throughout the progressing pregnancy, as well as immediately following delivery. The pregnancy and delivery proceeded without complications, and her mood symptoms remained stable.
Beyond the patient outcome, which was of utmost importance, this case enhanced my interest in effective psychopharmacology during pregnancy. Over time, I became a resource for my colleagues at the CMHC, who called upon me to consult on cases with pregnant patients.
This case highlights one example of how collaborative teamwork serves to benefit the patient, improves patient outcomes, and provides a constant opportunity to learn from and teach one another during our busy daily practices. Competent physicians and PMHNPs know what they know, know what they do not know, and know when to obtain consultation. In a large mixed practice, there is a greater opportunity to consult and collaborate.
The largest unmet need for access to psychiatric treatment is in rural, underserved, and socioeconomically deprived settings. Moving forward, the shortage of psychiatric providers—both psychiatrists and PMHNPs—is expected to increase. Increasing the numbers of both psychiatrists and PMHNPs is essential. Creating a collaborative and mutually respectful working environment amongst all treatment team members is essential to deliver quality patient care, minimize provider burnout, benefit from an extended network of colleagues, expand interest in our profession, and continue our lifelong learning.
Mrs Robinson is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire area, and an clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham. Dr Miller is medical director, Brain Health, Exeter, New Hampshire; editor in chief, Psychiatric TimesTM; staff psychiatrist, Seacoast Mental Health Center, Exeter; consulting psychiatrist, Exeter Hospital, Exeter; and consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts.
1. NP Fact Sheet. American Association of Nurse Practitioners National Practitioners. Updated May 2021. Accessed December 9, 2021. https://www.aanp.org/about/all-about-nps/np-fact-sheet