NP Notes: Leveraging the Extended Care Team (MDD Episode 7)

Craig Chepke, MD, DFAPA: Hello, and welcome to the Great Exchanges in Mood Disorder podcast. I'm your host, Craig Chepke. I'm the medical director of Excel Psychiatric Associates and the scientific director for Psych Congress. Joining me today is my friend and colleague and fellow steering committee member on Psych Congress, Andrew Penn. Andrew, tell us a little bit about yourself.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Hey Craig. I'm Andrew Penn. I'm a psychiatric nurse practitioner by training and a clinical professor at UCSF. I divide my time there between teaching psychopharmacology, treating patients at the San Francisco VA, and doing research, primarily on psilocybin for mood disorders.  

Craig Chepke, MD, DFAPA: So today, Andrew, I want to talk about the way that we can try to leverage our relationships with others beyond ourselves in treating depression. I mean, I think a lot of clinicians, especially if you're—I'm no longer in solo practice; I've got some support staff and some other people surrounding me—but for a long time it was a solo private practice, and I think it can be very easy to fall into the trap of thinking I'm this person's only hope and it's me and them and the depression, and that's it. So, let's talk about other people that we can bring into the extended depression care team.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Yeah, I mean, I start with thinking about, where did this patient come from? If they weren't self-referred, who referred them? Was it their therapist? Was it primary care? Was it at the urging of their family? And those are all obviously invested stakeholders, right? Because they cared enough to say, ‘I think you should go talk to this person about possibly adjusting or starting medication.’ And so I always like to try and close that loop. And some of the important privacy regulations around mental health treatment in form of HIPAA can also create these sort of barriers to communication. And so, when I was in an office practice, I'm mostly telehealth now so this is done digitally, but when I was in an office practice, I used to just keep a stack of release of information forms in my desk drawer just so I could say, “Oh, you're seeing therapist so and so; that's great. I know her. Would it be okay with you if she and I talk about your treatment so we can get on the same page?” And 99% of patients say, ‘That would be great. The last person I talked to, they never talked.’  

Craig Chepke, MD, DFAPA: Exactly.

Andrew Penn, RN, MS, NP, CNS, APRN-BC: And so, I said, “Well, in order for me to do that, I need you to sign this form that says that we have permission to talk about your care. Could you just do that?” And I just do it right then when I'm thinking of it. And then typically what I would do, I would either fax or scan an email that release of information to that clinician, and I would follow up with a phone call or an email. And I'd say, ‘I just want to check in with you briefly about our shared patient.’ And I intentionally use the term ‘shared patient’ because it shows that we're both caring for this person. We both have an investment in their outcome. And honestly, most clinicians, really, we're all kind of slammed with work, but that ability to collaborate and feel like you know the person who's taking care of your patient is a good feeling. And I think it leads to better care.

Craig Chepke, MD, DFAPA: Yeah, absolutely. And similar experience. If I say that, oh, I spoke with your therapist or anyone else, like, oh my god, really? Oh, that's amazing. Thank you. And just that, Hey, that's an antidepressant effect right there. Wow, this person cares enough about me to take the time out to give my therapist whoever a call or whatever it is. It's really powerful, I think. So, you mentioned therapy, a therapist. Who else is, do you consider enlisting in the depression care team?  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Well, I think about family members too. This can be a little more delicate because people understandably have concerns about their privacy. And so, I think it's worth talking about that head on and saying, so I saw that your spouse was in the waiting room. Would you like me to touch base with them about your treatment? And a lot of times the way I would do that in in-person practice, I'd say if they say, yeah, that sounds good, say, why don't we bring them in the last five minutes of our session just so I can introduce myself and they can ask any questions and we all know who each other is. And so just kind of facilitating a warm handoff is really important. And I think that we know that when patients have greater faith in their treatment, it works better. And so it's funny, I used to be down the hall from my chief who was really good in my old clinic, and I would hear almost like in-person Yelp reviews as a patient and their family member was walking down the hall.  

Well, he was really good. He seemed really seemed really nice. I get these little reviews in the hallway of what people thought of my colleague, but we that, we want people to leave our offices feeling like that we're competent and that we're caring and that we're thorough. I think that thoroughness piece is, and I understand why we don't always have the luxury of being thorough because we're being pulled in 10 different directions and we're on the phone for 20 minutes with a prior authorization and all the things that kind of waste our time and pull it away from direct patient care, which is why honestly, I've yet to meet anybody in this work who says, you know what? I got into this work because I love prior authorization.  

Craig Chepke, MD, DFAPA: Exactly.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: So really taking that, even if it's just a couple minutes to create that relationship with the larger circle of people, and even with patients that more patients with psychotic disorders where maybe the person doesn't want to have a release of information, I always make sure that the caregiver knows they can release information to me. The voicemail as antiquated as a technology as that is, or even email, I can receive any message you want to send me. I can't respond back. So I make it really clear, if you don't get a message back from me, it's not that I didn't hear it, it's that I don't have a release to speak to you, so I can't acknowledge the message, but I appreciate the information. And so you can send that to me. I can receive it. I just can't release information.  

Craig Chepke, MD, DFAPA: Yeah, I think a common misconception and just because just, I think two weeks ago, a colleague that I was talking to was asking, a relatively new clinician, was asking about that. ‘Well, if a family member calls up, I have to just hang up or something, right?’ You can listen, you just say, I can't confirm whether this is a person that’s in my practice or not, but I'm listening. Something like that, more or less.  

So, I go even further with family engagement. So, a lot of psychiatrists have the feeling that, oh, I only treat above the neck and only the patient in the room. I think maybe going back to Freudian days where the shrink sits behind the person even, and oh, you can't have anyone else but the—in my training program, we had a child and family study center that there was a one-way mirror and the one trainee was in front of the glass, and it was with couples or with families including children. And then the entire rest of the supervisors, the other trainees, sat behind it. And we just got to where we really saw, wow, when you bring a whole family system into the same room, things happen differently. And so, I offer that to patients. If I go into the waiting room and there's two people that are there for the one appointment, and often as you said, one will be just sitting there while the other gets up, and I'll offer right then and there.  

So, I often practice in a family systems model where the person whose name's on the paperwork brings in their spouse, sibling, parent, child, best friend, whatever, someone who knows them real well. And I'd say probably two thirds or three fourths of my patients are seen with that person in the room on a regular basis. That's up to you. You're in the driver's seat as the patient. You can have as much or as little involvement of that other person as you want. And almost every time people are like, ‘Oh, that'd be fantastic. I can't remember all the details. My wife would remember the dates and the meds or various different things.’ They're just relieved very often. And so, I found that to be very helpful. Occasionally I'll get some people who, maybe not push back necessarily, but they seem a little cautious. And I'll say, ‘It's not that I don't trust you, but think about it. The difference between an x-ray and a CAT scan: An x-ray is two dimensions, and a CAT scan is three. If I have two people in the room, it's like I'm getting three dimensions of what your life is, instead of just the two dimensions. And that's not your fault. I just want to get as much information as I can about you and your life because the more information I have, the better I can help you.’  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Right, absolutely. And I also often wonder sometimes if we're kind of broadcasting unconsciously that by not having family members there that maybe there's something to be ashamed of.  

Craig Chepke, MD, DFAPA: Exactly. I agree.

Andrew Penn, MS, CNS, ANP, PMHNP: Whereas, maybe there are things, there are parts of the conversation that the patient obviously wants to be private because they're things they haven't shared with their spouse, and we certainly want to make space for that. Or if a child hasn't shared with their parents or something like that, we don't want to have the entire session with the other person there necessarily because we want to make sure there's room, or God forbid, maybe there's domestic violence or something going on that they can't talk about…

Craig Chepke, MD, DFAPA: Absolutely.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC:…if the person is in the room. But really taking that whole family systems approach really broadcasts that there's nothing to be ashamed of here and that we're all working together to get all of you to where you want to be. And that's really, that's our intended goal.  

Craig Chepke, MD, DFAPA: Yeah. We're all on the same team. And especially I find for people with depression who have cognitive dysfunction, then they can't remember some of the tactics and strategies and techniques. Even just simple medication instructions might not seem simple to them. And so, if I have someone in the family in the room, well, they hear it too, and they will remember it and they can remind them, I can enlist them as a cheerleader or as someone to watch out for potential warning signs that they might be headed towards a relapse. Just all these different potential advantages. But again, there's no one size fits all.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Yeah, and it's a helpful part of safety planning too, where, if there are concerns around suicide that we can have those conversations. Because I think what we do as clinicians is, we’re role models, so we model how do you talk about difficult things without getting freaked out about it. And I'm thinking, going back to the earlier part of our conversation about working with primary care clinicians or therapists, we're also educators. So being these pharmacology experts, if that's how we practice, psychiatry experts—for example, I work with a lot of great therapists who are fantastic at understanding dynamics and family systems and things like that, but there wasn't a lot of focus on diagnosis, on differential diagnosis in their training programs because maybe that's a little bit out of their scope of practice. And so when I walk through my, ‘Well, this is how I'm thinking about this diagnosis, and this is why I chose this treatment….’ By explaining that, not only am I being a collaborative colleague, I'm also introducing the opportunity to learn from them and say, ‘Well, I spend a lot of time talking about their symptoms and their history, but it sounds like you know a lot about their family and their relationship, so could we learn from each other here?”  

And so, we'll give the patient better care as a result of that if we're learning the different perspectives. I mean, it kind of reminds me a little bit of that old Indian parable of the blind men and the elephant, that each one of the blind men is feeling a different part of the elephant and quite convinced the guy holding the tail thinks it's a rope and the guy touching the tusks thinks it's a spear, and we're talking about the same elephant, we're talking about the same patient. But a lot of times we see it through these very different lenses. And I don't think that one is necessarily superior and correct all the time. I think we can learn a lot from each other. I mean, I've seen, certainly, people that are more biologically oriented completely miss interpersonal dynamics because they didn't ask about them. And I've seen people that are really focused on interpersonal dynamics totally miss objective symptoms of something like mania or something like that.  

And so, we're all learning, and I think we can all learn, and psychiatry is so specialized that we can learn from our immediate colleagues as well. And I think primary care really appreciates it too, because primary care is a tough job. You're trying to treat seven different problems in seven minutes, and so they really sometimes appreciate these little micro learnings of like, ‘Well, this is why I chose this antidepressant and not this one.’ And if somebody has the bandwidth to take in a little bit of new information, we are these clinical experts in psychiatry, so we can offer that to our colleagues so that they can feel more confident and more up to date in their own practice as well.  

Craig Chepke, MD, DFAPA: Absolutely. I know that, too, because my own personal primary care provider, every time I go in for my annual physical, he says, ‘Okay, so what are you going to teach me this time?’ So, as he's dapping on my belly or whatever, I'm telling him about it, a new antidepressant or what have you—they really want to learn and be able to help their patients better.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: What a great collaboration.  

Craig Chepke, MD, DFAPA: Yeah, and an even better collaboration is the therapist in my practice is my wife, who's a social worker. And, not only does it help the patient outcomes, those are the most fulfilling interactions, is that when we are working together and we put our heads together and kind of—I don't want to say crack the case—but we come up with a realization that we think, ‘Oh, I've been missing this. I've been missing that.’ Or, ‘Oh, let's try this that I hadn't thought of.’ The satisfaction that I get with doing my job just skyrockets. And so, I think it's very fulfilling. Sure, it might take some time. I mean, not really when it's your wife, but if it's not your spouse still, it just feels great to be able to do that because you just know that their outcome is going to be better.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Oh, yeah. For years, I worked in a multidisciplinary treatment team in an intensive outpatient program, and we met—we had social workers and marriage family therapists and psychologists, and I was on that team, and those conversations were so fruitful because I might get sort of myopically focused on a set of symptoms, and my colleague who was a social worker would say, ‘You know they're going to be evicted next month.’ It's like, ‘Oh, completely missed that!”  

Craig Chepke, MD, DFAPA: I can see one of their anxieties.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Exactly right. So having those multiple perspectives, I think, only makes us better clinicians. And ultimately, creates better care for our patients, which really should be the final common pathway

Craig Chepke, MD, DFAPA: Exactly. We want to think about the whole person, and we need a whole treatment team in order to do that, I think. So that's our time for today, but I want to thank you for joining me today, Andrew. As always, it was a joy.  

Andrew Penn, RN, MS, NP, CNS, APRN-BC: Thanks for having me, Craig.  

Craig Chepke, MD, DFAPA: And that wraps up today's Great Exchanges in Mood Disorders podcast. Thank you for listening.