The art of communicating with patients
Working as a psychiatric nurse practitioner in a rest home setting, John cringes whenever the lead nurse tells him a patient wants to see him about medications.
John is a skilled diagnostician and competent prescriber who generally enjoys his interactions with patients. What bothers him is when a patient requests to see him, they often have a particular medication in mind and are uninterested in telling him their symptoms and accepting his recommendation about the medication that will be most helpful.
John doesn’t mind hearing about a medication that was helpful in the past – if it worked then, it might be suitable now. He will take a history of symptoms and medications, then look at the whole picture and seek a more lasting benefit rather than a short-term fix.
Thus he is not surprised when Melissa complains of anxiety and requests the benzodiazepine Ativan to treat this symptom. John’s review of her record indicates a long history of anxiety and substance abuse. He decides to treat her anxiety with a Selective serotonin reuptake inhibitor (SSRI) called Zoloft (sertraline), approved for anxiety along with depression. He bases this on the fact that it is one of the most tolerated medications in this class, is relatively cheap compared to other SSRIs and the fact that Melissa is of child-bearing age (Zoloft is a better choice should she get pregnant, as she reports being sexually active.)
Melissa will only have to take it Zoloft once a day, preferably in the morning. John explains that it will take a few weeks to work and will need to be tapered to the right dose. He offers to give her VISTARIL (hydroxyzine) in the meantime, a short-acting non-benzo medication. He recommends counseling for Melissa to work on her coping skills to lower her anxiety.
John feels good about his treatment plan, targeted for long-term anxiety control and not just a quick fix. But Melissa is not accepting it.
“Ativan is the only thing that will work! I’ve tried other things such as counseling and it didn’t work!”she protests.
John points out that she hasn’t tried an SSRI, she has had an addiction problem in the past, and the counseling she had was generic in nature – more geared toward substance abuse. John will refer her to a cognitive therapist, an evidence-based treatment for anxiety. While Melissa still balks and expresses anger at John, he remains firm but caring, following not only his clinical expertise but also his state Department of Public health guidelines.
Due to the epidemic of opioid and benzodiazepine-related deaths in his state, John must go to the state website to see if the patient has received any other scripts for benzos within a certain time frame from another provider.
Melissa is fed up and tells John, “If you won’t give [Ativan] to me, I’ll find someone who will,” and leaves his office. Upon checking the database, John finds Melissa received a script two weeks prior for Ativan from another community-based prescriber.
Case #2
John meets with a second patient, Bob, who has schizoaffective disorder. Bob has just developed a relationship with a woman he met, and is now concerned about his ED (erectile disorder). He sees commercials for ED drugs on TV, but is taking two antidepressants along with other psychotropic medications, which are likely contributors to his ED.
John doesn’t want to destabilize this patient, so he suggests a script for Viagra or Cialis. But Bob’s insurance company will not pay for this medication. Bob doesn’t want to pay out of pocket for it, so he insists John reduce or take him off his antidepressant medication. John suggests tapering one antidepressant and/or switching to another antidepressant regimen, but tells Bob this might risk decompensation.
John decides to take the chance. Three weeks later, Bob’s relationship is over, his medication has been cut and he is starting to show symptoms of depression. John notes this and quickly puts Bob’s medication back up to the previous dose. Luckily, he stabilizes.
A Range of Considerations
These two cases are just an example of what prescribers deal with in treating patients. John must take into consideration what will be financially covered, TV commercials that prompt requests, other interacting drugs and side effects. drug reps pushing products and consumers who read about certain medications and feel they know what should be prescribed.
John likes an educated consumer and working with patients to get the best treatment response. He enjoys collaborating with other disciplines. The days of patients simply telling him their symptoms and trusting their doctor or nurse practitioner are over. Aware of the role of social media and the internet in today’s medical climate, John realizes he benefits from the continuing education his patients receive, and the access to the information that can aid compliance and understanding. Patients will challenge him, but their knowledge and questions will only make him a better nurse prescriber.
Michael C. LaFerney, PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.
(1) Zoloft vs. Paxil taken form the www September 1, 2009 at: https://www.iodine.com/compare/zoloft-vs-paxil
