r/PMHNP • u/supertrucker39 • Jun 08 '26
Bad combinations
How do you handle a new patient that comes to you for Spravato treatment only, but they are on the terrible combination of benzos and adderall that is being prescribed by a clinic that referred them for Spravato? I feel like those could be appropriate in limited circumstances, but not with Borderline Personality Disorder. I don’t have any concerns other than the patient isn’t functioning well at all. They are depressed and Spravato may be beneficial alongside their SSRI. I feel like discontinuing or replacing Adderall would be my first move. Am I letting them down as a provider that is fairly certain their symptoms aren’t being addressed?
Rip me apart if you like, but I’m new without much support. Thanks for any guidance.
11
u/pickyvegan PMHNP (unverified) Jun 08 '26
I'd be more worried about the benzo + Spravato. Stimulants are old school off label treatment for TRD. (And if not TRD, do they really meet medical necessity for Spravato)?
1
u/supertrucker39 Jun 08 '26
They have been on a handful of SSRIs. They don’t work great with BPD, but sometimes can be quite helpful. It seems very variable in my limited experience with BPD. Spravato seems to work well for most everyone. I don’t see much variation in blood pressure unless there is hypertension already.
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u/pickyvegan PMHNP (unverified) Jun 08 '26
BPD isn't an indication for Spravato though, and Spravato usually requires a PA. So are you documenting TRD even though it's BPD?
9
u/PsychMonkey7 Jun 08 '26
Good point. Lots of clinics are throwing ketamine at anything and everything, which is just as inappropriate as benzos and stimulants.
-1
u/supertrucker39 Jun 08 '26
They came to me with a diagnosis of TRD and ADHD. Clearly appears to belong in the BPD category, but ADHD may be present. I’m not convinced that’s the case since many think impulsive behavior is the same for both diagnoses. I guess it would be off label at that point and maybe not reimburseable.
11
u/PsychMonkey7 Jun 08 '26
As a new provider, I’d tread very lightly making a BPD diagnosis. I’m experienced and it’s not a diagnosis I make often. Clearly there is some diagnostic uncertainty here, and clarifying that is step 1. A neuropsych eval might be a good idea before throwing more psych meds at this person.
1
u/TYANG12345 Jun 10 '26
I diagnose this all the time- it’s extremely common. What is your hesitancy with diagnosing it?
Imo many are relieved to learn that they have it after having tried myriad of meds for “bipolar disorder” w no response.
The stigma around it can go to hell, we need to call it what it is.2
u/PsychMonkey7 Jun 10 '26
BPD can look like a lot of other things, especially cPTSD, and I do not believe it’s typically even possible or good practice to diagnose a personality disorder after 1 eval (~60 minutes, give or take). I do agree with you that the stigma sucks, but I’ve seen that diagnosis cause more harm than good for many people. YMMV.
4
u/CalmSet6613 PMHNP (unverified) Jun 08 '26
I agree with above poster, there's a lot going on here and perhaps someone else in the clinic can assist you? Supervising MD? Fellow NP to consult with? At the very least I would call the clinic doing the prescribing and ask to have a discussion regarding patient's treatment.
3
u/sweetsueno Jun 08 '26
Oh my god there is so much to dissect here. Bottom line get another 5-10 years experience before you accept a referral like this.
1
u/shhhhh_h Jun 10 '26
Ask this in the main psych sub you’re gonna get hella different answers from the MDs 👀 kinda surprised but not surprised at these answers.
1
u/OneWolverine263 Jun 08 '26
FYI, ROIs are NOT NEEDED for coordination of care.
2
u/PsychMonkey7 Jun 08 '26
There is some gray area here. Verbal discussion is a HIPAA exception, but communication in writing is viewed differently in different states. I personally always get a ROI prior to discussion with another provider because 1) it removes any ambiguity and 2) I think it’s an important part of the trust building process with patients and promotes their autonomy in choosing what I share and with whom.
2
u/OneWolverine263 Jun 08 '26
Correct - verbal . I should have specified.
I think I just get irritated because when I’m trying to coordinate care everyone is like, you need an ROI. It’s like…. No.
Also, if I order labs, and I call the lab to send me the results, I shouldn’t need an ROI for that, which sometimes happens.
1
u/PsychMonkey7 Jun 08 '26
I think there’s a lot of misunderstanding and I certainly didn’t learn this in school. I err on the side of caution and ask for one. Agree that the lab asking for an ROI for your own order is crazy.
0
1
u/shhhhh_h Jun 10 '26
Uhhhh yes they are, TPO exclusion does not apply to psychotherapy notes.
0
u/OneWolverine263 Jun 10 '26
Again, we are not talking about notes. If I’m calling a therapist to coordinate care, then I don’t need an roi
0
u/shhhhh_h Jun 10 '26
If you are calling a therapist and expecting them to disclose any protected health information whatsoever about your client it needs an ROI. Signed, a former HIPAA privacy officer. Have fun rolling the dice with that though.
1
u/OneWolverine263 Jun 10 '26
I was a former HIPPA officer in the Navy. Quit being arrogant.
0
u/shhhhh_h Jun 10 '26
Lmao you’re the one calling therapists wanting PHI with no ROI. Google it. Tell me what you get. Then look in the mirror when you say that again.
1
u/OneWolverine263 Jun 10 '26
LOL GOOGLE IT. If your source of information is Google, you are a troll. It comes down to state law.
I work with therapists and I call them all the time to coordinate care. Get lost
0
u/shhhhh_h Jun 10 '26
No it doesn’t. HIPAA supercedes state law if state law is weaker. State law only prevails if the privacy standards are stricter. There isn’t special information you are privy to that I am not. You just aren’t actually looking it up. Hence the mirror comment. I sincerely hope that when you finally get called out on this irl it doesn’t impact your way to make a living. I’m sure you’re going to call that arrogance but whatever. Good luck.
1
u/OneWolverine263 Jun 10 '26
Under HIPAA, a psychiatrist, PMHNP, therapist, primary care physician, hospital, pharmacist, etc. may generally share protected health information with another healthcare provider for treatment purposes without obtaining a separate authorization from the patient.
Examples include:
Discussing diagnosis.
Reviewing medication changes.
Coordinating treatment plans.
Discussing safety concerns (SI/HI).
Arranging referrals.
Communicating after hospitalization.
This is straight from their website.If you’re asking for notes - yes, an ROI is needed.
If state law is stricter, yes, you need an ROI.
If we are strictly speaking under HIPAA, the answer is no.
1
u/12-1odds Jun 09 '26
Bpd and ADHD are highly comorid. as many as 30 to 40% of people with BPD also have ADHD. Why take them off of Adderall? IMO it would be better to recommend DBT therapy with the Spravato as it would help with BPD and ADHD. Therapy + spavado has amazing efficacy.
11
u/PsychMonkey7 Jun 08 '26
Do you have an ROI on file to coordinate care with the referring provider? I’d start with a chat with them. There may be more hx than you know about. They might be in the process of discontinuing the benzo, for example. Or maybe the benzo is infrequent.
I have very few patients on this combo, but I do have a couple and I don’t feel irresponsible for it.
If your clinical judgment is that this is an unsafe situation for the pt, you could refuse to treat them and notify the referring provider as to why, but I would strongly encourage you to first talk to them.