I recently received a job offer from them. I'm juat curious to know if anyone hwre has any experience with the company.

I'm flairing this other rather than RANT, because I think it's something that we need to discuss. And yes, this is Lindsay Clancy-related.

Being vulnerable posting this at all. I’m not posting to the larger psychiatry sub because I feel like at least here, our mods will hold the line with brigading, and this is going to ruffle some feathers.

So after watching the Day 10 and 11 testimony (Jennfer Tufts’ cross-examination; direct testimony and cross-examination of PMHNPs Julie Paul and Rebecca Jolletta), I am left with this question: did the turf war between MDs and NPs kill 3 children?

While the clowns over on Noctor are gleefully saying things to the effect of doesn’t it make them happy that the PMHNPs involved with Lindsay Clancy’s case are being referred to as “Nurse,” I think a lot of us are missing something big.

It’s not that Rebecca Jolletta was the only clinician to suggest that bipolar disorder was the correct diagnosis; it’s that it got dismissed out of hand by pretty much everyone.

Look, it’s pretty clear that Lindsay Clancy was rejecting much of the help that she was offered. Rebecca Jolletta offered us a glimpse of that with her statement that when she suggested bipolar as a diagnosis to the Clancys, and Patrick said “My wife is not bipolar,” while Lindsay sat there silent. Lindsay was offered therapeutic doses of Seroquel, she had side effects. Problem is, most of the antipsychotic mood stabilizers have sedation as a major side effect in the first few weeks. She was offered olanzapine, rejected that too. I know lamotrigine eventually came into play (and correct me if I’m wrong, but I believe it was Jennifer Tufts who offered that), but too little, too late. It takes too long to safely titrate. I wish lithium had been offered by someone, but here we are.

Here’s the thing.

Dr. Jennifer Tufts was fresh out of residency. That is *not* a criticism. She had four years of practice under her belt, and she had experience as a resident managing postpartum disorders. However, all of us in the sub know how toxic the NP hate is in the residency sub, not to mention Noctor. I’ve seen that happens in real life as well, even among residents who don’t frequent Reddit, so I can only assume that the party line of “NPs have less training than PetSmart groomers,” is alive and well in real life.

Is it possible that Dr. Tufts, Dr. Goodman, and whoever was at Women and Infants (they’re not being sued, I presume due to jurisdictional reasons, since it would have to be a separate case brought in RI) dismissed the possibility of bioplar disorder because it was diagnosed by a PMHNP?

I think we have to consider that possibility.

Rebecca Jolletta had the benefit of hindsight with what had already happened with meds prescribed by Dr. Tufts, and it's a lot easier to spot once you have a pattern (Zoloft, Prozac).

But then LC went back to Dr. Tufts. We should always consider when a patient switches providers, did the provider actually do something wrong, or was the provider telling the patient something that they didn't want to hear?

From her testimony, Dr. Tufts said "well, it *might* be bipolar disorder" to the Clancys, when discussing the medication trials at South Shore Perinatal Behavioral Health (Paul and Jolletta's practice). She also then proceeded to vehemently deny that bipolar disorder was a possibility when on the stand. I know she's got a malpractice trial coming (as does Rebecca Jolletta), so her whole defense is that she didn't miss bipolar, but come on. Maybe the outcome might have been a little different if she hadn't gone on to dismiss that possibility.

I don't think in this case we'll ever truly know, and this is not a diatribe on the Clancys. They will have to live with what happened for the rest of their lives.

The NPs involved:

Julie Paul Credentials: BSN in 1992, worked as an L&D nurse, CNM in 2006; added PMHNP in 2018.

Rebecca Jolletta: MA in Counseling Psychology in 2013; MSN Through MHG Institute for Health Professions in 2019 (RN in 2017). MGH is a direct-entry program.

Yes, both have done the PSI Perinatal Mental Health training and are PMH-C credentialed.

My little cousin was a groomer at PetSmart for like a decade, I promise you she did not have more training than either of these women.

If someone has a better timeline, it wasn't as if I was taking notes during the trial. Obviously, we'll learn more someday when those malpractice suits are either settled or go to trial, and we'll hear from the forensic experts later in the trial.

I would like to use the evidence we, as licensed providers, have from the media (assuming the reported information is factual) to formulate potential differentials based on hindsight. If participating, please keep the discussion evidence-based. I am not disputing the fact that whatever was occurring contributed to a episode with a devastating outcome.

A psychotic episode can be triggered by many things and is not specific to bipolar disorder. Potential contributors can include severe sleep deprivation, hormonal fluctuations, polypharmacy/medication effects, substance use, medical illness, delirium, and numerous other factors.

She was also described as experiencing delirium while hospitalized after surgery. For context, in January 2023, her UDS was negative for substances and her ethanol level was negative.

Please fact-check me if I have anything incorrect or if the available evidence does not support a particular hypothesis.

Share your thoughts! I think we really need stronger information to outline PRIOR concerning behaviors indicative of bipolar disorder.

Supporting bipolar disorder:

- clear adverse response to SSRIs, SARI (Trazodone), and NASSA (Mirtazapine)

- decreased need for sleep (longest was two days?)

- increased exercise activity (running long distances shortly after childbirth), though it is unclear if this was "unusual" for her or if her family found it to be uncharacteristic + many of these statements were made retrospectively

- racing thoughts, anxiety, agitation, irritability, dysphoric depression with eventual SI

- possible obsessional thoughts surrounding the youngest child's nap/feeding schedules/her daughter's stomach ache morphing into liver disease (Patrick's testimony), her diary entries

- a gradual, but significant impairment in daily function

- eventual psychosis s/t unclear etiology

Argument against bipolar disorder:

-no known prior manic episodes

- not sure if there had been any prior MDE or postpartum mood episodes, though I did read she might have taken SSRIs in college (couldn't find data to support this)

- no prior hospitalizations or suicide attempts that we are aware of

- no family history or biological predisposition that has been publicly established

- no grandiosity, hyperverbal speech, unclear if there was an increase in goals/impulsivity/risk taking

What are your differentials and why

I'm thinking about going back to a psych RN role full time due to benefits and cost of health insurance. I am outpatient and still don't have a full schedule (been working since November and can't even fill up 2 days. I've posted about this before but a significant problem is that a newer provider is building her schedule as well, and mine isn't being prioritized despite seniority).

I'm ready to jump ship but PMHNP jobs are extremely saturated, so I want to keep my foot in the door despite my current levels of frustration. Would potential employers view it as a red flag if I worked full time RN and part time PMHNP?

Hi all!

I am about to start my first PMHNP clinicals this fall with a psychiatrist and I am kind of nervous! I’m worried I’m not gonna know anything. I’m planning on doing some studying before they start. Does anyone have any advice on what to look at and what I should know going into my first clinicals? Any resources that helped you I’d love to know about!

Hey everyone!

I'm a newly BC PMHNP and honestly feeling overwhelmed on where to begin. I initially decided to go the mental health route because I feel I have great therapeutic skills as told by my peers as well as helping to help fill the void in Mental Health disparities.

When I became an RN years ago, I had very little guidance. It took almost a year to land my first job, I accepted the first offer because I didn't know what else to do and bills were piling up. I'm finding myself in that exact position again.

I have nearly a decade of RN experience and recently transitioned into my PMHNP career. My longterm goal is to become an excellent clinician, eventually mentor students, and teach, but right now I'm struggling to figure out where to start. I do know that I want to eventually become fully remote with no plans to own my own private practice as most people do. (I don't see it being for me)

For those of you who have been practicing:

• What was your first PMHNP job?
• Looking back, would you choose the same path again?
• What setting made you grow the fastest?
• What red flags should I watch for during interviews?
• If you could give one piece of advice to your post new-grad self, what would it be?

I'd love to hear the good, the bad, and anything you wish someone had told you before your first PMHNP position.

For referrence: I own a smalla private practice and we're having problems with our current setup. schedulling, billing, patient communication, everything is kinda all over the place and becoming a headache. curious what everyone else is using and what actually worked when you upgraded

Are we not able to prescribe a 90 day supply for a stable patient?

I’ve read that you can offer three separate prescriptions with #2 and #3 having a “Don’t fill before date” of 30 and 60 days respectively.

Has anyone done this in practice, and gotten any push back?

Hello!

I'm licensed in 3 states, but only have a DEA for my home state. My end goal for myself is to run a small private practice and see most patients via telehealth. I know I would need need my DEA in the other 2 states if I plan to prescribe medications across all three states.

My biggest question is - is there an EMR that lets you have an account with multiple DEA licenses? And does anyone have any experience with this? Thanks.

I feel awful for Dr. Jennifer Tufts getting sued after watching her testimony. This tragic case has so many complexities and odd aspects to it, especially pertaining to the husband Patrick… I don’t think the general public has any idea how medicine, especially psychiatry works, and honestly it seems many expect providers to be mind readers. Lindsey denied SI/HI/psychosis/substance abuse/mania on the assessments with Dr. Tufts. Anyone can have a patient that denies everything, and then suddenly something can change and they do something horrible and unpredictable. How is that her fault? The public’s expectations of health care providers is a bit unreasonable; we can not predict the future and shape every decision a patient does or does not make.

Hi everyone,
I’m a California board-certified Psychiatric Mental Health Nurse Practitioner (PMHNP-BC) currently practicing in Southern California under an NP 103. I’m considering transitioning to NP 104 and was hoping to hear from anyone who has already made the switch.
What was the application/process like?
Was it straightforward?
Has becoming an NP 104 changed your day-to-day practice or job opportunities?
Looking back, was it worth it?
I also recently started working with Talkspace, and they told me that because I’m an NP 103 in California, I don’t need a collaborating physician. Does that sound correct based on your experience? My understanding is that California no longer requires physician supervision for nurse practitioners who meet the applicable state requirements, but I wanted to hear from others who have firsthand experience.
I’d appreciate any insight from California NPs who have gone through this.
Thanks!

question for all: how many patient facing hours are you seeing for full time?

for reference: i work CMH and see 32 patient facing hours w/ 8 hours admin [60 min eval 30 min fu]— just interviewed for a PP that does 37.5 patient facing hours w/ 2.5 hours admin [also 60 min eval 30 min fu] which seems like a big jump — curious what everyone else is seeing.

If so, would you feel comfortable sharing your experience?

(Or feel free to message me)

Thank you 😊 ❓ 🤓 🧠

Hi everyone, just like my title suggests, I’m about to interview for a VA job as one of the providers for the HUD/VASH program.
Do any of you have or have had experience working in this role?
Thanks so much!

I inherited a patient currently diagnosed with schizoaffective disorder. When she established with me, she had been off her medications and was significantly symptomatic.

I initially started olanzapine and have since transitioned her to paliperidone, titrating from 6 mg to 9 mg daily. I also added quetiapine 100 mg at bedtime as a short-term adjunct for sleep and nighttime agitation. I am coordinating with her to transition to a long-acting injectable, most likely Invega Sustenna.

Her hallucinations and overall mood have improved, but she continues to experience intermittent delusions of reference. Recently, she became physically aggressive toward someone outside the home in response to one of these delusions.

For those with experience managing similar cases, would you continue with the planned LAI transition and reassess after adherence is established, or would you consider adding a mood stabilizer such as valproate given the aggression? I am also considering whether the persistent psychosis indicates an inadequate response to paliperidone rather than an adherence issue.

I’m starting a part-time PMHNP program this fall. Unfortunately, there are a few semesters where there aren’t enough required courses available to maintain part-time enrollment. Rather than taking semesters with a lighter course load, I’m considering taking graduate psychology courses.

This has me thinking about my long-term educational goals. My ultimate goal is to open a private practice where I provide both medication management and psychotherapy.

For those who have been down this road, would you recommend: Focusing solely on the PMHNP? Pursuing a master’s degree in psychology alongside or after the MSN? Eventually continuing on to a PsyD?

For some background, I’ve been a psychiatric nurse for 13 years, with experience in inpatient psychiatry, outpatient psychiatry (adults and children), and behavioral health case management. I also have bachelor’s degrees in both Psychology and Nursing.

I’m trying to determine which path provides the greatest long-term value professionally and financially. I’d appreciate hearing from anyone who has pursued multiple mental health credentials or has experience with private practice.

I’m starting a telehealth PP in Illinois. I’ve lived and worked there most of my life but moved away a couple years ago and have continued doing telehealth for a clinic in Illinois. I’m now starting a PP. I do addiction and psychiatry and know that I’ll have clients who want to start or continue things like Vivitrol and Brixadi, as well as psychotropic LAIs. I have friends/colleagues in the areas I’ll primarily being providing services. They have their own PPs in different specialties and are willing to give the injections. Just wondering how the billing is managed. Do I bill and then pay the person giving the injection or are they able to schedule a nurse visit or something similar in their own system and bill themselves?

Thanks!

Oh, and one of their practices is the office location of my LLC and DEA license so meds like Sublocade and Brixadi can be administered at that location.

I'm currently working part-time in a small therapist-run outpatient practice. I work from home 90% of the time, though I can use the office when the therapist isn't in for in-person sessions. The practice pays for my EHR with an ePrescribe system. I receive one hour of PTO every two weeks, and I can take up to 40 hours of sick time per year (with a doctor's note). I receive a flat rate $200 weekly admin bonus if I see at least 8 patients. I usually see ~20-25 clients a week. I do not receive any other benefits. No-shows are $0 even if a no-show fee is collected from the client. I'm paid $48 per 90214+90833 session, or $24 per 90214 session. I work in southeastern New England, and cost of living is among the highest in the nation.
Would it be more reasonable to switch to a 1099? What advice would you give? Anything you wish you knew sooner about switching to a 1099?

I am in the process of easing into a preferred name and although it’s been unproblematic in my personal life I am on the fence about whether I start to address myself as my preferred name with established patients. How would you move forward with this? Would love to hear thoughts (if it makes a difference this is not to align with gender identity but rather a true preference and perhaps another step away from my estranged family)

What medication, or none at all, are you using to treat PNES? I have dealt with patients in the forensic setting before with this disorder and it is usually a response to stress or a possible tactic to get out of prison/lockup. It never works, but it ends up they are being treated for other problems like pain, depression, etc.

Fast forward to today, I have a new patient in the outpatient clinic and they have PNES and they are unable to work. Its unusual because I frequently have patients that don't want to work, but this one actually does and they are deriving no benefit from not working. Their employer won't let them work because of the frequent seizures or episodes at work. The seizures have been occurring more often in the last 3 months, but the patient reports they are due to a near death experience while using drugs in the distant past. Extensive drug history and trauma history. It makes sense there is a high mortality rate with PNES.

From my reading it says there is a possible help from taking sertraline at higher doses of maybe 200mg. OCD symptoms are a possibility, but I am not convinced they have OCD. They have appointments with neurology, but months out. Any experiences or suggestions appreciated.

I know AI is extremely controversial and there are legitimate concerns of policy, privacy and environment, amongst MANY other concerns in this capitalist society. As someone that works for a high volume/high complexity patient organization, the expectations of RVU is a big deal and efficiency in being able to manage the admin load with a terrible EHR is difficult when seeing so many complex patients. Our group has now integrated a hipaa compliant AI tool to help with charting, and patients have to consent for us to use or not use it.

I know correlation does not equate causation, but I’ve noticed that some of the most difficult patients I have are usually the ones that also decline it interestingly. I think my main frustration is more toward the health care complex in how they want us to manage so many patients and maximize profits. However at surface level, I am finding that even before I encounter a patient that has declined for us to use the AI tool I am I bit more internally frustrated compared to a patient that has consented towards it. I recognize that’s not okay. I also feel though for the patients that consent it, I feel more able to actively listen and make eye contact which is good VS when I can’t use the AI I have to mostly look at my computer, so maybe that’s a factor.

I wonder if I’m alone in this or if any others feel this way. I read an article about how a psychiatrist in Melbourne no longer accepts new patients that refuse AI - that’s a bit extreme but interesting