When I decided to work in mental health, I knew that there would be heartbreak and frustration. I knew that there would be people who did not follow through, patients who were not ready to heal, and illnesses I could not help. What I was not aware of was that I would have people who wanted and needed treatment to stay alive who would have few options of places with beds available. Even worse, there would be beds available in places that could harm rather than help.

It is a weekly, at minimum, and sometimes daily conversation…so and so needs inpatient/residential/detox, what options do we have? After several phone calls we find ourselves considering how we can keep someone safe when we are an outpatient setting. We simply do not have the resources needed. Ask anyone working in mental health about this and they will all agree, but despite this, things are not changing.

North Carolina, where I work, is not known to have good access for those needing mental health care. There are waitlists for psychiatric providers and therapists, there are no beds available in inpatient settings and there are treatment facilities where people who are already in crisis experience inhumane treatment. A few months ago, I needed to have a patient admitted to keep her safe. She stayed in an ER for more than 24 hours. She was asked to wear paper scrubs. Her parents were told not to visit. She was sedated. She was discharged home by the on-call staff with no communication to me, her outpatient provider, despite numerous phone calls and a treatment plan that had been arranged for her post discharge. Another facility made headline news when several patients on the adolescent unit eloped and were missing for over 24 hours and in yet another facility, staff preyed on female patients taking advantage of those already vulnerable.

Outpatient clinics are not equipped to manage crisis cases. There are limited slots on schedules, no access to onsite medications, crowded waiting rooms without security. All too often the providers in outpatient clinics are faced with impossible decisions. The decision to see the crisis patient outpatient or risk they don’t seek care at all. The decision to send a patient home placing responsibility on their family rather than admitting to a dangerous facility. The decision about which medicine to use to most quickly stabilize a person because it’s safer than admission. The decision to detox a person using substances at home because treatment centers are often either full or cash pay with expensive price tags that are not affordable to many.

And here is the thing about being faced with these decisions in the outpatient world…

Because we care about our patients and want the best for them, we make these decisions. We spend hours calling inpatient facilities and investigating new facilities to see if there is a better choice. We calculate the risk versus benefits and ask our peers what they suggest. BUT, every hour we are on the phone looking for a bed, or having an extended visit with someone in crisis, or even allowing some recently discharged from a poor inpatient experience we are away from other patients. We are away from patients who are still early in their mental health journey that could avoid needing inpatient treatment if they had early intervention. We are not taking new patients desperate for help off our waiting lists. We are not researching new medications or getting more education. And all if these things perpetuate the cycle of poor access to care and a lack of beds for patients who need a higher level of care.

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If I saw patients for 15-minute visits and only prescribed medications I could make a much higher salary, up to twice what I make now. I would be recruited by many clinics and insurance companies would reimburse for services. Would I know my patients well? Most likely not. Would my patients feel connected in times of crisis? Not likely. Could I be as safe or thorough as I am now? Absolutely not. Would I feel like a successful PMHNP? Definitely not. I instead see patients for 45-60 minutes. I both prescribe medications and do psychotherapy. I do not rush to make decisions. I know my patients well. I remember their medical conditions and their health history. I got a trauma certification because I saw the tremendous need. I read about therapies and medicines constantly. I am good at my job and part of a strong, dedicated team. In my clinic I also have the benefit of an entire team with all different specialties—therapy, eating disorders, pediatrics. recreation therapy, health and fitness, addiction, veterans, and crisis. If I am not sure how to help one of my patients, I have so many resources to turn to.

So why are we always talking about how to sustain the model? The reasons are revenue related and insurance related. Practicing the way we want to does not bring in large reimbursements from insurance. If I see my patients for 60 minutes doing both psychotherapy and medication management, my clinic is reimbursed only $8 more than if I see them for 30 minutes. This level of reimbursement does not help cover clinic overhead, fund necessary pro bono cases, cover malpractice insurance or pay the fee for a collaborating psychiatrist. When I want to enlist the help of a recreational therapist or our health coach insurance companies refuse to reimburse so the burden falls on the patient or if they are unable to pay, the clinic. Even if I want to call in another nurse practitioner to help me assess and treat a patient to prevent hospitalization only one of use is reimbursed by insurance, despite how much is saved if a hospital stay is not required. I am fortunate to work in a place where we provide the care regardless, because we are invested in quality care, but because of this there are financial obstacles. When I think about how many more people we could help if this wasn’t the case it makes our efforts seem small.

The concerns in our industry however are not only financial. There are concerns about the lack of mental health facilities. There are concerns about places who treat those with mental health concerns in ways that are inhumane. There are concerns about waiting lists to get care and the lack of clinics that will accept patients with certain insurance. For example, when a clinic accepts Medicaid that can be audited at any time. While this has the potential to be an effective way to assure quality it is actually a process that is distressing an unfair. The audits are based on minimal information and providers only need to check the box to pass. The patients are never spoken to, the clinics are not toured, and the auditors are not interested in the work that is being done. What if these audits looked, not at a checklist but at the interactions that are taking place and the patient perceptions and outcomes? The stress of the audits and negative interactions are leading clinics to stop accepting Medicaid resulting in an even greater problem with access to care for those who are most vulnerable.

There are further problems with people who are in the industry for the wrong reasons and the pop up “universities” churning out students who are not prepared to practice in the mental health arena safely and humanely. It is more than a little disheartening to see providers who jam their schedules and prescribe medications without thought just to increase income. These providers care more about the paycheck than the purpose and often do more harm than good with the way they practice. Our jobs are so much more than our prescription pads and 15 minutes every 3-6 months is certainly not enough time to fully evaluate how a patient is doing, especially when trust and rapport are crucial. And then there are those entering the mental health industry that have attended pop-up, low quality schools that can memorize enough to pass boards but don’t have nearly enough knowledge to practice solo and don’t realize what they don’t know. For graduates from reputable universities and rigorous programs there is still so much to learn after graduation and beyond, but when the foundation isn’t there how are patients not at risk?

And lastly, let’s talk about the competition in the mental health industry. The competition between clinics. The competition between psychiatrist and nurse practitioners or physician assistants. The competition between prescribers and therapists. The competition between those who believe in medication assisted treatment for addiction and those who see this as trading one addiction for another. The competition between inpatient and outpatient care providers. The bottom line is this…there are more than enough people for all of us to care for. There is not a shortage of people who require ongoing services and resources. We do not need to speak ill of others or be stubborn about our way being the right way. Each of us can have our ideas and areas of expertise. Each of us can recognize when we are not the best fit for someone. Each of us can seek the help of another professional who might know more or better. We are operating in a broken system and each of us who attack another member of the system is damaging it further. Competing with others in the profession instead of supporting them is only moving the system farther away from the ideal and hurting those who need us most.

I do not pretend to have all the answers, not even some of them, but I do know that MASSIVE changes are needed, and I know that just going with what is happening is not only ignoring the problems but perpetuating them. I challenge each person working in mental health to keep talking. To reach out to colleagues and make connections. To write to your government or participate in calls to action. But mostly I challenge you to remind yourself every day of your why. Why is your work important. Why the quality of the care you provide is your responsibility. Why each of us needs to be part of a solution and a movement to change things.

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I can remember talking about ethics briefly in high school. I definitely had a course during my first undergraduate program. I remember a few other ethics discussions, a paper about an ethical dilemma during covid, and a couple posts to student discussion boards. There were certainly some in class mentions and brief debates. When I actually think about how much time was actually spent on this during my formal education, it seems almost laughable considering the areas where I have worked; sexual assault nursing, obstetrics. insurance, and mental health. Certainly, these are areas where ethical dilemmas happen often. It got me thinking about how many times during the day I am making decisions that are really based in ethics. For those of us working in mental health, it is quite honestly, all day most days. According to the American Medical Association, decision fatigue is the idea that the more decisions you make throughout the course of a day, the less ability you to make decisions. The more decisions you make, the more fatigued you become and the harder it gets to make decisions. It is estimated that in regular daily life the average person makes 35,000 decisions per day. No surprise we are tired! No surprise that when i go home after a day of seeing clients, choosing medications, ordering lab tests and deciding which client issue to tackle first I can’t even decide what to make for dinner.

So, how do decision fatigue and ethics interact and how do we make sure that when we make a decision it is ethical, and responsible even when it might be decision number 34,999 of the day? In my career I make decisions like to admit someone to the hospital or not, to call children’s services or not, to commit someone involuntarily or not, to order a drug screen or not, to change medications or not. These are not decisions I take lightly and they are not decisions I want to make without a clear mind, but if I am honest about the way we practice healthcare, (even though I work in am incredible place) that is not reality.

It’s quite troublesome, wondering how a provider can ever know all the things they need to know about ethical practices. It seems as simple as doing the right thing but it is so much more than that. Its recognizing that sometimes what seems right doesn’t take in to account a client’s right to choose their own path. Its understanding that a new medicine might be the best option but there are insurance and cost considerations outside of your control. Its understanding that even when you want to save a life there are boundaries that you can’t cross. Its realizing you aren’t the best provider for a particular case. Its even knowing its time to end your relationship with a client because they are better and you have a waiting list. And its so much more. There are caveats and grey areas. There are differing state laws and exceptions to most of it. There is just no way as providers we can know everything. Its not possible, and even if it was things change so often you still could not keep up.

All of this leads to the question of how you protect yourself as a provider.

• First off, join a practice or find colleagues where others have different experiences than you. Maybe you have not faced every situation but you can call on others who may have.

• Don’t rush. Rarely, is a decision needed in the next 3 seconds. If it is, call 911. When in doubt, stop for a minute. Find a way to center yourself and then decide. If you can, wait to decide until you have labs back. Its a good stall tactic and you probably need then anyway.

• Debrief after complex cases.

• Get out of your own way. Don’t ever feel bad for asking for help and other opinions. It is not a sign of weakness to ask how someone else would proceed. If you ask for advice you are not obligated to follow it BUT you are obligated to thoughtfully consider it.

• In the really complicated situations have a collaborator and document that you did.

• Read anything you can!

• Schedule your most complex clients early in the day or after lunch if possible. 5pm on Friday you will not be at your freshest.

All of the suggestions above are helpful, but I would also argue that decision making and ethics need to be larger parts of the formal education process. I realize, adding more to programs that are already intense might sound impossible but I firmly believe the change could make the early years of practice less exhausting and the quality of practitioners better.

• Bring ethical discussions into every course. Constantly remind students that making hard choices will be a large part of every day.

• Have a weekly ethical dilemma posted. It will give students a glimpse at different ways of handling situations.

• Set up practice scenarios where there isn’t one right answer, but you need to defend your choice.

• Encourage students to meet in small groups to talk ethical issues through.

• Add some ethical curveballs into simulations; a child who reports something that may or may not be reportable, a person living with addiction that wants a stimulant, a 17 year old who needs to be inpatient but is days from their 18th birthday or a sex offender who needs an antidepressant.

• Challenge your students when they start wanting to fix everything and when they seem to see only 1 right path.

When I look back at my first 8 months in practice the thing that stands out is how mentally exhausted I am after a day seeing clients. I wasn’t nervous to talk with clients or their parents, I felt I had a good knowledge base with medications, my previous work had taught me some valuable psychotherapy techniques and I knew I had a good education. BUT, I would arrive home at the end of the day and fall asleep on the couch. More than anything it was the weight of all the decisions I made each day. Its getting better. I am starting to understand not every decision requires extensive processing. I am starting to have a process I follow for clients in certain categories. I am becoming more confident in my gut and instincts and I have some clients I have seen for several months so not every appointment is a new intake. What I have come to realize though, is that the decisions are most likely always going to be the thing that makes me the most tired and I have to be very mindful of when I need to press pause and regroup to keep everyone safe.

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Working in mental health is challenging! Often it is hard to know exactly what the right path forward is, which medicine to prescribe, which patient has maintained sobriety, what might trigger or activate a particular patient or how a parent will react to their child’s diagnosis. A lot of what we do is uncertain. Of course decisions are made based on current research, a strong base of knowledge, education and best practices but there is rarely only one right answer, even then. Often we ask patients a question with an idea of what the answer is, but every now and then we take a risk with a question. And that is just where I found myself last week.

I sat in an appointment with a person in crisis and I knew it was time to try something different. The crisis cycle had been playing on repeat. Moods were up and down. There had been times without sleep and multiple relapses. Something needed to change and so in plain, direct language I explained we were at a fork in the road. I let my patient tell their story, express their emotions and feel like they were in a safe space. Then, without knowing what the response would be I got out of my chair, sat in front of them holding their hands. I told them there were two options, the one where they tried to live a sober, healthy life and the one where they continued as they have been, using substances, losing relationships, and getting in legal trouble. Sitting there on the floor in front of them I asked, “are you ready to choose?”

Now, let me be clear, I was terrified! In my head I was preparing for what the answer might be. I was considering how I could support them, even if the answer was not the one I was hoping for. Frankly, I don’t know who had more anxiety, me or the patient. I had to ask the question. I had to give my patient some agency. My patient needed to want to be well, me wanting it was not enough.

So, there we sat, together…I asked the question again, “Are you ready to choose?” Then, I held my breath and waited. My patient, looked up at me and said quietly, “yes, I choose being mentally well.” I could not have been more pleased and together we started making a treatment plan. Undoubtedly, there will be setbacks, challenges and relapses but we had a start.

So, why am writing about this? Its because in that moment I knew asking was a risk. They could have chosen something different and in all honesty, I was making decisions about what medicines I would have to stop, how to prevent overdose, how to keep them alive until they were ready to do something different even as I was sitting there. You see, its not up to us as providers to make choices for our patients. It is not up to us to make demands about how they live their lives. Its not up to us tell them if they are right or wrong. All we can do is educate, provide resources, care for them in the best way possible and implement whatever safety protocols we can to keep them alive. The patient has to choose because when we force the change, or treatment or level of care it usually isn’t sustainable, no matter how much we want it for our patients.

Here is the conclusion I have come too-its my job to take the risk. Even when I’m not sure what the answer will be. Even when I’m crossing my fingers and toes. Even when my voice shakes as I ask the question. It won’t always work out the way I hope. Sometimes the answer will be I’m not ready to change, to stop, to grow, to process, to do the work, but every now and then the choice will mean I get the privilage of watching someone begin their journey to change. And guess what-if the answer is they are not ready, I have planted a seed.

So, I will keep askimg, fully realizing I have to be prepared for whatever the answer is because part of my job is to let my patients choose for themselves.

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In the clinic where I am currently working things are done a bit differently. There are really no 15 minute appointments, we see people for same day crisis appointments and sometimes patients come to the clinic to sit in the waiting room and calm themselves. What I am starting to appreciate the most is the way we collaborate within the office.

In recent weeks I have joined forces with another PMHNP to work on several cases. This is not the kind of collaboration where we simply run a case by eachother or debrief after, though that happens all the time as well, these are cases where we cocoon the patient and really try to stabilize quickly and support fully. Cases where we each see the patient separately and sometimes see them together. Cases where one of us manages medication and the other provides an added layer of psychotherapy, or even cases where one provider meets with a child or adolescent and the other meets with the parents. Sometimes these are cases where a recreation therapist or health coach are involved as well. These are the complex cases, where in other models of care the patient would be hospitalized. The cases are intense but the benefits and outcomes are often far better.

Consider the benefits of this approach to care.

-The patient has a back up provider they are familiar with if the primary person is not available. When a patient presents in crisis is not an ideal time to build rapport for the first time so this is a good way to have a safety in place for the most complex cases.

-While only 1 provider is the prescriber both provide input and monitoring so there is less risk of medication error or even polypharmacy.

-The providers have the opportunity to learn from eachother and try out new techniques or practices.

-There is always collateral information available and the provders can compare notes about how the patient presents for each of them or what observations they make.

-There is a larger support system available to the patient.

-At times the patient is more comfortable sharing certain things with one provider so having a second person sometimes sheds light on addional factors.

-We are keeping patients out of the hospital by seeing them more often when necessary, sometimes providing an intensive program similar to an IOP but on an individual basis.

Of course this model of care has its challenges as well.

-The intensity of cases can be exhausting and without good support burnout could be a factor.

-Insurance carriers sometimes do not see the need for this level of care. To this I suggest a hospital stay is not less expensive.

-The frequency of visits can be challenging to the individual and their family.

-Two providers both seeing a patient can take up slots in schedules that are already hectic and in areas of care where wait times to see providers can already be long.

Mostly, I think the challenges are because of the broken system we are all operating in. A system where dollars and cents matter more than patients truly improving. A system where insurance audits make sure that boxes are checked but fail to ask the patient about their experience with the care they are getting. A system where the reimbursement for some of the most vulnerable patients is not enough to keep community clinics open and running smoothly.

What I’m certain of is the way I feel about the job I’m doing and the care I provide is very different than what I would experience in a more traditional setting. The medical model where how many people you see is constantly tracked. The model where appointments are 15 minutes and take place every few months. The model where providers who know their patients are the exception and not the norm. When I arrive home from work I am tired but I know that I did the best I could. I was safe. My patients have a team of providers working on the best plans when conplexity increases. And most of all I am keeping people out of hospitals that are overcrowded, under staffed and not always healing environments when it is safe to do so.

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We then started to talk about what words feel more powerful, strong or solid. She came up with the word believe. She felt that when she said “I believe” she was making an active choice. She was jumping in with both feet and understanding where she is headed.

When i think back on the conversation I think what believe had that hope didn’t is personal responsibility and the power to influence. Hope implies that the universe will provide for you. Believe implies that you can make it happen and you may need to engage in certain behaviors to move towards that future realization. When we hope something is going to happen the power and control are not ours

I’m still considering this perspective. In some ways I feel a little sad about the idea. It feels a bit like takimg the magic of the universe and wonder out of certain things. In other ways it feels empowering and determined and active There is more ponder I guess.

I hope, no I believe today will be amazing!

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I have reached a point in my life where I appreciate quiet more. There was a time when I wanted to be constantly on the go, busy and not still. It was difficult for me to be still because my mind was never quiet and when I was physically still the noise in my own mind was overwhelming. I am not exactly sure when the change happened, I imagine it happened slowly over time, but recently I am able to find internal quiet in the loudest circumstances (SOMETIMES-progress not perfection). It brings me a clarity that I haven’t always been able tofind before.

Part of the transition definitely came when I learned to recognize cues from my nervous system that something is happening and something is needed. What is needed may be time, it may be space, it may be information or guidance from someone else but when I ignore the cues and try to push past that is when the noise in my head intensifies. When I practice taking a pause rather than plowing ahead I am able to bring back the quiet.

What I have learned and what I hope to share with my future clients is that each of us can learn to have quiet and knowing within our own selves. Even in situations where things are loud, chaotic and upsetting each of us can learn to recognize and regulate the internal volume. It may not be possible to turn the volume off but sometimes a slight decrease allows the space for clarity.

Its not easy to learn how to create quiet within yourself. Its challenging and it forces you to look inside for calm and nuturing. It comes once you recognize that you can have control and make choices over how you react to all of the external stimuli coming your way. This takes a lot of practice! But, when you can find quiet within yourself in the loudest places perspective can shift.

When your internal noise is loudest, what do you need? Is there an unmet that that if acknowledged can finally rest?

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I have started learning to pay attention to my own nervous system in the last 6 months. It all started with me recognizing the love/hate relationship I have with my own body. If you have a chronic diseases (MS for those who don’t know) it is easy to see the ways your own body has failed you. This led me to somatic experience therapy with the most AMAZING practitioner, Tammy Limbach. It is now much easier for me to recognize when I am getting off track. It is easier to stop and be present. I am remembering that I have choices. I am also learning to recognize what is happening in my body at a particular moment, to use those cues as tools rather than just being overtaken. I am also remembering to recognize the good and remember to experience the joys along the way.

What is happening in your body during a particular event or situation can provide important data and if practiced consistently it can help you understand what some part of you needs in the moment. What does that knot in your stomach need to relax? Can you enjoy the lightness that comes from laughing? Can you say “no” to the part of you that never slows down to celebrate or linger? Can you lean into the dysregulation you are feeling instead of pushing it away…is it really trying to tell you something it needs. I am learning to listen to myself and more importantly to trust myself.

So today I challenge each of you to stop and pay attention…where are you carrying your tension, are you present in this moment, are you ignoring something that part of you needs, can you use your resources to stay in a moment a little longer than you are comfortable with? I promise you taking that first full breath in the moment and not jumping 10 steps ahead is worth it and self regulation and resourcing yourself is a gift.

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So, this is my reminder to everyone out there…its important to celebrate your journey, your successes, that you worked hard and are proud of yourself. It is important to really absorb all the congratulations, good jobs and your are amazings!! Live it up, because it will energize you and excite you. It will remind you that doing hard things (because they are THAT important! A nod to my good friend D.S. ❤️) is rewarding in the end.

And after you celebrate, GET BACK TO WORK!

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Today you will receive an award for faculty excellence. Our small group wanted to acknowledge you today as not only a faculty member of excellence but a human of excellence!

At some point during our program we established a group called the DOCS, not because we are doctors but based on our first names…Daniella, Omer, Christine and Shari. This group met with Dr. Convoy on a regular basis. We started practicing CBT but quickly progressed to discussing mental health issues, contract negotiating, ethical dilemas and life. Dr. Convoy made time for these sessions, not as part of the curriculum, but because of the person he is. From the beginning he said to trust him and he would be there to support us every step of the way…not only did he support us, but it is safe to say he undoubtedly and indelibly helped shape us into the practitioners we will be. He did this with care, honesty, integrity and compassion but most importantly he did this by getting to know us as individuals and encouraging our unique interests, goals and circumstances.

Congratulations Dr. Sean Convoy from the DOCS. DUKE is lucky to have you…scratch that the WORLD is lucky to have you.

Fondly,

Daniella, Omer, Christine and Shari

When I was a kid, schools, hospitals and police stations were considered places of safety. That is certainly not the case anymore. During my grad school program we talked a lot about the dangers that come with working in psychiatry and we were urged to question potential employers about safety plans. I have been a nurse long enough to know this is necessary but it doesn’t make it less troublesome.

It would be easy to think the dangers are related to mental illness and substance use but the truth is many situations can be dangerous…ER waiting rooms with extended wait times, visiting areas where hospital staff have to limit the number of visitors, exhausted hospital staff who are mandated to work extra shifts losing their patients and patience, stressed family members waiting for medical updates, uninsured patients worrying about the expense of healthcare and so many others. We take people in high stress jobs, mix them with patients who don’t feel well, and then add concerned family members who aren’t eating or sleeping properly. It shouldn’t be surprising when the powder keg erupts.

Its sad. It makes me sad that no place is safe. We are a society that needs instant gratification and has poor impulse control. We act or respond first, and think later. People are so desperate to have a need met or get even that they act or react aggressively.

This morning I read an article saying that 30% of nurses want to leave the profession because of feeling exhausted and overworked (Mandowara & Leo, 2023). More than half of them said that half of them said that their safety was an issue. With nurses continuing to leave the professions the issues discussed above will be further exacerbated.

Like so many things, we are stuck in a vicious cycle and it certainly doesn’t seem likely it will get better any time soon. How do we provide the care that people need and also keep those providing the care safe? Its not an easy task and like most things it probably isn’t inexpensive but something has to give.

I definitely am not writing with any answers but I do know that the only way we get to solutions is if people keep talking about issues. This is one more problem in an already strained and irretrievably broken system. Preliminary reports suggest that the suspect in the Atlanta shooting was frustrated that he wasn’t getting the medication he believed he needed. He was not being listened to or heard. I’m certain those denying the medications also felt unheard, that their assessments and concerns about the medication were bring ignored. Maybe that is the one reminder I can give…really try to listen to those you interact with. REALLY listen instead of just crafting your response.

My thoughts are with the families of those who were injured or lost in Atlanta but I know that is a small and empty gesture. I will however commit to keep talking about the issues in the healthcare system.

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Professionals need to be the example to society. To demonstrate treating those with mental illness and substance use without stigma and judgement. To demonstrate recognition that we are all humans with flaws and wounds and pain. Aren’t we all one or two steps removed from finding ourselves in crisis? Consider what would need to happen for you to find yourself or a loved one in need of mental health care or substance use treatment. The reality is, probably not very much--the loss of one job, the death of a loved one, being victim to or witness to a crime, an unexpected illness, a stressful life event, the end of a relationship. In an instant, it can all change for each one of us. If you believe it would be impossible for you to end up there yourself, you are living in fantasy. You are perpetuating the belief that those with a substance use disorder or mental illness are somehow different than the rest of us.

We have the responsibility to do better, to be better, to get it right. Too often in healthcare we make judgements about people without asking, knowing, or caring about the full story. We decide who deserves our time, our care, and our resources. Those judgements can be made because of fatigue, lack of time, burn out, shortages of resources, or frustration. The challenge is to recognize that when we make those critical judgements, it may only be one moment in time for us, but for the patient or their family the impact could be lasting. The wound can cut deep and can mean the difference between seeking help or not, between starting to heal and continuing in pain, between life and death.

So, how do we get there? That is the real challenge. It isn’t going to happen through law or policy (that is another discussion). It is going happen in a million small moments that change the culture. It is going happen when we recognize we are all humans and none of us have it 100% together or are immune to hurt and harm. It is going to happen when we start asking what each individual needs and empowering them to help steer their own course. It is going to happen when we start challenging our peers to show up and get it right. When we stop standing by silently, allowing those with substance use disorder or mental illness to be perpetrated by the very people they rely on for medical and mental health care. It is going to happen slowly and painfully, because it will mean that we will have start talking honestly and openly about the ways that we have failed, the ways that we have hurt people and the ways that we have wronged people who needed humanity and care. I recently heard Brené Brown say in a podcast, “I am not here to be right. I am here to get it right.” Her words stuck with me, and I believe that this is the attitude that we will need to bring to our profession to bring about a change in stigmatization related to substance use and mental health. When we have done something wrong or hurt someone, we need to put aside the part of us that wants to explain why we did what we did. We need to not justify our actions but really hear how our words, or judgements, or actions, or body language made someone feel. It will mean approaching things differently, not as experts who have the answers but with open hearts and minds ready to explore how to get it right. It will mean eliminating the words I did it because from our vocabulary. It will mean apologizing when we fall into old habits. It will mean asking how we can do better. It will be a journey, but it will begin the process of healing and changing the overall mental health of our country.  It will mean that people can seek treatment for themselves or their families with hope rather than fear and that the process of seeking care won’t add to wounds that have not yet had the chance to heal.

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Treating mental health issues in the United States is a difficult business. The stigma surrounding mental health disorders, the lack of mental health providers and the lack of resources have been an issue for years. Covid-19 has likely not done any favors to the mental health of the country. According to the World Health Organization approximately 16 million people per year attempt suicide (Xiong et al., 2020). Based on this statistic, and the likelihood that the COVID-19 has severely impacted the mental and psychological health in the United States it is imperative that new ways to rapidly address the suffering of those with depression and suicidal thoughts be investigated and implemented (Xiong et al., 2020). When a patient presents for treatment either with treatment resistant depression or with active suicidal ideation they are often considered at imminent risk for self-harm and require hospitalization to keep them safe. This period of imminent risk is a time of significant stress and hopelessness for both the patients and families involved. Standard antidepressants often require 4-6 weeks for optimal effect and hospital bed availability is a problem in many areas of the country (Canuso et al., 2018). The use of intranasal ketamine has shown promise in rapidly improving depressive symptoms, including suicidal ideation among some people who are at imminent risk for suicide (Canuso et al., 2018). Though additional research is needed and continues, intranasal ketamine may offer providers and option to help patients who have not experienced an improvement in depressive symptoms through traditional medications as well as those that are experiencing suicidal thoughts.

Operational Definition & Practice Implications

The discussion here will be limited to the use of intranasal ketamine (commonly sold under the trade name Spravato). The medication can be administered intravenously, intramuscularly, and orally as well.  Spravato is esketamine, one of the 2 isomers of ketamine and is the only NMDA antagonist FDA approved for those with treatment resistant depression or major depressive disorder with suicidal ideation (Titusville, 2020). We will operationally define the patient population of interest as those with treatment resistant depression or major depressive disorder at imminent risk of suicide, presenting to the emergency department or psychiatric provider with active thoughts of suicide and some intent or plan to carry that out. According to Hubers et al., (2018) this presentation is a significant predictor if death by suicide.

If ongoing research continues to provide evidence that intranasal ketamine can provide some substantial relief in a short period of time, this medication could provide a novel approach for providers and patients alike. One could argue that there are 2 distinct areas where intranasal ketamine could be of benefit.

1. This medication could provide quick relief to a patient experiencing hopelessness and active suicidal thoughts. A 2018 study found a significant reduction in scores using the Montgomery-Asberg Depression Scale (MADRS) at 4 hours post administration of intranasal ketamine and continuing at 25 days. (Canuso et al., 2018). Ketamine has a half-life of 7-12 hours, with a more rapid decline noted in plasma concentrations in the initial 2-4 hours. In the Canuso et al. (2018) study used 84mg of intranasal ketamine and dosed it twice weekly for 4 weeks. While intranasal ketamine should not be considered a miracle drug, it could provide a quick and much needed improvement in depressive symptoms including suicidal ideation. This reprieve could have the effect of allowing a patient who has lost hope, to again believe that they can feel better.

2.  This medication could be administered over a short duration to afford providers an opportunity to start an SSRI or SNRI that will take some time to get up to speed and provide symptom relief. Intranasal ketamine can be administered on an emergency basis but also for longer duration giving symptom relief while allowing more traditional treatment medications to get up to speed. It would also afford providers the opportunity to arrange treatment with other members of the treatment team such as therapists, primary care, and family to assure the patient has an integrated approach to care and support from multiple avenues.

Current State of the Science/Evidence

Research and discussion on the use of psychedelic medication in psychiatric medicine and therapy has exploded in recent years, and many would argue that the use of psychedelics will grow in popularity and acceptance in the very near future. There will likely be increasing requests for the use of these medications as the public becomes more aware of the availability and research through media outlets.

Intranasal ketamine has shown promise in several studies in treating depressive symptoms, including suicidality. A systematic review from 2021, reviewed the outcomes of 15 studies or case reports where IV or intranasal ketamine were administered and found support for improvement of depressive symptoms in multiple cases (Siegel et al., 2021). But perhaps the greatest support came from the FDA approval in 2019 of intranasal ketamine for treatment resistant depression, and then in 2020 for major depressive disorder with acute suicidality. The 2020 approval came following 2 phase 3 clinical trials using intranasal ketamine on patients with suicidal thoughts (Popova et al., 2019). Patients experiencing suicidal thoughts had previously been excluded from research. These studies did not specifically demonstrate a reduction in SI but did demonstrate a rapid improvement in depressive symptoms, sometimes in as little as 4 hours (Popova et al., 2019). Research on the use of intranasal ketamine has demonstrated short term safety (Iqbal & Mathew, 2020). The most common side effects included dissociation, dizziness, sedation, increased blood pressure, hypoesthesia, vomiting, euphoric mood, and vertigo (Titusville, 2020). The medication can cause a transient increase in blood pressure for approximately 4 hours following the administration so it must be used with caution in those with hypertension (Titusville, 2020).  It is also contraindicated in patients who are known to have an aneurysm or with a history of a brain bleed (Titusville, 2020). The FDA does continue to collect information about adverse reactions to intranasal ketamine through the Risk Evaluation & Mitigation Strategy (REMS) program which will be discussed below. Providers should continue to monitor research findings as additional data is collected and reported to be aware of the most recent information available. Because of the explosion of research related to psychedelic medicine it is likely that indications, research findings and best practices will continue to evolve in the coming years.

S.W.O.T Analysis

Strengths

The strength of intranasal ketamine has already been mentioned. This is the ability to offer an alternative therapy to those with treatment resistant depression and immediate treatment to those at imminent risk for suicide. This combined with the safety profile discussed above support the use of intranasal in specific subset of patients under the guidance of professionals specifically certified in the administration and follow up necessary. Until now psychiatric providers have offered medications that take weeks to work to patients who are in crisis. The patient may see medication side effects before seeing a relief and they may not have the patience and fortitude to wait out the process. Offering a faster improvement in symptomatology could shorten (but not eliminate) inpatient hospital stays and lower the risk of suicide in a more immediate timeframe. Pompili (2018) states, “Clinical environments will encounter unprecedented opportunities to assess and manage suicide risk.”

Weaknesses

The use of intranasal ketamine is not, however, without its barriers or weaknesses. The most troubling weakness being that intranasal ketamine has not yet completely demonstrated its effectiveness in preventing suicide or reducing suicidal ideation despite its approval by the FDA. While the available research does support a reduction in depressive symptoms as discussed above, additional research and investigation is clearly necessary to further make the case for the use of this medication. However, it does seem reasonable that a quick improvement in depressive symptoms may also allow some relief of suicidal ideation or at the very least some additional time for other treatment modalities to take effect, whether that be a medication, working with a therapist or even considering another method such as ECT or TMS. One of the reasons that reduction of SI has not fully been demonstrated is that investigators often exclude participants with suicidal ideation from their study because of ethical concerns (Siegel et al., 2021). Providers using intranasal ketamine must be aware that the medication does not mean a patient with suicidal ideation should not be hospitalized and should be certain to use clinical judgement and consider patient safety the utmost priority.

An additional barrier or hurdle to using this medication in practice is that only a certified center or provider can offer intranasal ketamine. To administer intranasal ketamine a provider must be certified with the Risk Evaluation & Mitigation Strategy (REMS) program for intranasal ketamine. The purpose of the REMS program is to ensure that the medication is only administered by qualified professionals, to ensure that patients are educated about the risk of sedation and dissociation and to collect data to further support the safe use of the medication (Titusville, 2020). This means that when a provider identifies a patient who may benefit from intranasal ketamine there may be a delay while a certified provider is identified, and the requirements are completed. If additional research supports, the use of intranasal ketamine it is possible that more emergency rooms and providers will become certified resulting in the treatment becoming more readily available. In addition, to being a certified provider the patient must be observed for 2 hours following the administration of the medication and is unable to drive following the appointment leading to time and transportation constraints for some patients. Going to a certified center could also be a barrier for someone whose depression or anxiety are so severe they have trouble leaving their home.

Opportunities

The barrier or weakness above does however provide an opportunity for providers working in the mental health arena and with an interest in psychedelic medicine, to become a certified as intranasal ketamine providers or clinics offering this novel treatment to patients in their area. A brief search reveals information about the use of ketamine for depression in The New York Times, USA today, Fox News and CBS. As media coverage about ketamine continues the public demand for information and providers will increase. Patients will start to ask their providers about ketamine and providers will be looking for trusted colleagues as referrals. While some could see this as a moneymaking opportunity, quality providers can grow their practice while providing education to both patients and other providers.

Threats

Perhaps the biggest threat to intranasal ketamine becoming more widely used is the abuse potential of ketamine. Ketamine can be abused as a street drug, causing relaxation at low doses and a dream like state at higher doses (Gautam et. al, 2020). The medication needs to be carefully regulated with regard to dispensation and used very selectively in patients with a known history of a substance use disorder.  Some providers view the use of ketamine in a negative light because of the use of ketamine as a street drug. With additional research this threat may eventually be decreased. It should be noted that some research supports the use of ketamine in the treatment of substance use disorders with ketamine showing promising treatment results by decreasing relapse events, increasing abstinence, and diminishing cravings (Sepulveda et al., 2022).

Safety in the PMHNP Practice

Providers who are interested in suggesting treatment with intranasal ketamine should carefully screen and pre-select patients, develop relationships with providers they refer to so they can trust patients are being cared for safely and appropriately and actively engage in keeping up on ongoing research.

Psychiatric Mental Health Nurse Practitioners (PMHNP) who are interested in offering selective patients, ketamine as a treatment option, either in their own practice or through referral to another provider should exercise caution in patient selection and carefully screen candidates prior to proceeding with the therapy. As a prescriber it important to screen perspective ketamine patients for any previous substance use, including alcohol, opiates, or prescription drugs (Titusville, 2020). In addition, to screening prior to administration the PMHNP should also monitor for any signs of physical or psychological dependence during treatment. One argument for why the administration of intranasal ketamine requires provider or clinic certification is that it helps to limit the risk of abuse or misuse because the medication can only be administered in limited settings (Pompili, 2020). If the PMHNP is referring to another provider for intranasal ketamine screening should still be conducted prior to the referral and the PMHNP should refer to a trusted provider who is willing to collaborate during the treatment process. Prior to referring to another provider it should also be confirmed that the administering provider is using FDA approved intranasal ketamine. In 2022 the FDA issued a warning to providers and patients indicating that intranasal ketamine compounded or dispensed from a compounding pharmacy is not FDA approved and has been associated with increased risk of adverse events (Food & Drug Administration 2022).

In addition, to screening patients for prior or current substance use disorders all patients being considered for intranasal ketamine should have a complete medical history taken. The medication is contraindicated in patients with history aneurysm, AV malformation, or history of bleeding on the brain. It should be used with caution in those with hypertension, cardiac problems, history of stroke or heart attack and those with liver disease (Titusville, 2020). As an additional safety it may be prudent to check in with the patient’s primary care provider or specialist if there are any concerns or uncertainties about co-morbid medical conditions. This collaborative relationship can benefit the patient and allows all members of the care team an opportunity to weigh on how intranasal ketamine can impact other medical conditions.

Perhaps the most important safety mechanism to have in place before either administering intranasal ketamine (if certified) or referring a patient for intranasal ketamine is constant and thorough following of the most current research. The research is quickly unfolding as evidenced by the FDA approving intranasal ketamine in 2019 for treatment resistant depression and then introducing a new indication in 2020 (Titusville, 2020). Having a new treatment for patients that have previously not found relief from current regimens and for those at risk for suicide is offers mental health providers a new era of treatment, but it will require constant updates and continuous education (Pompili, 2020).

Conclusion

Psychiatric providers have many tools available to them and intranasal ketamine is beginning to be added as another available option. Research and FDA indications support the use of intranasal ketamine for patients with treatment  resistant depression and major depressive disorder with suicidal ideation (Titusville, 2020).  Intranasal ketamine may be an option to address the needs of patients either with treatment resistant depression or who are suicidal. This treatment has the benefit of being fast acting, offering patients relief that has been previously unavailable. It seems to be well tolerated and though there are some restrictions on who can prescribe and administer the medication and it does require a time commitment on the part of the patient the relief it offers may be well worth the hurdles in this subset of patients. Additional research is underway and as more longitudinal studies take place intranasal ketamine has the potential to become more of a mainstay of treatment.

References

Canuso, C. M., Singh, J. B., Fedgchin, M., Alphs, L., Lane, R., Lim, P., Pinter, C., Hough, D., Sanacora, G., Manji, H. & Drevets, W.C. (2018). Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double Blind Randomized, Placebo-Controlled Study. The Journal of Psychiatry, 175(7), 620-630. https://doi.org/10.1176/appi.ajp.2018.170-60720.

Food & Drug Administration (2022) FDA alerts health care professionals of potential risks associated with compounded ketamine nasal spray. https://www.fda.gov/drugs/human-drug compounding/fda-alerts-health-care-professionals-potential-risks-associated-compounded-ketamine-nasal-spray. Gautam, C. S., Mahajan, S. S., Sharma, J., Singh, H., & Singh, J. (2020). Repurposing Potential of Ketamine: Opportunities and Challenges. Indian journal of psychological medicine, 42(1), 22–29 https://doi.org/10.4103/IJPSYM.IJPSYM_228_1

Hubers, A., Moaddine, S., Peersmann, S., Stijnen, T., van Duijn, E., van der Mast, R. C., Dekkers, O. M., & Giltay, E. J. (2018). Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis. Epidemiology and psychiatric sciences, 27(2), 186–198. https://doi.org/10.1017/S2045796016001049

Pompili M. (2020). Intranasal Esketamine and Current Suicidal Ideation With Intent in Major Depression Disorder: Beat the Clock, Save a Life, Start a Strategy. Frontiers in psychiatry, 11, 325 https://doi.org/10.3389/fpsyt.2020.00325

Popova, V., Daly, E. J., Trivedi, M., Cooper, K., Lane, R., Lim, P., Mazzucco, C., Hough, D., Thase, M.E.,Shelton, R. C., Molero, P., Vieta, E., Bajbouj, M., Manji, H., Drevets, W. C., & Singh, J. B. (2019). Efficacy and Safety of Flexibly Dosed Esketamine Nasal Spray Combined With a Newly Initiated Oral Antidepressant in Treatment-Resistant Depression: A Randomized Double-Blind Active-Controlled Study. The American journal of psychiatry, 176(6), 428–438. https://doi.org/10.1176/appi.ajp.2019.19020172

Sepulveda Ramos C, Thornburg M, Long K, et al. (March 30, 2022) The Therapeutic Effects of Ketamine in Mental Health Disorders: A Narrative Review. Cureus 14(3): e23647. doi:10.7759/cureus.23647

Siegel, A. N., Di Vincenzo, J. D., Brietzke, E., Gill, H., Rodrigues, N. B., Lui, L., Teopiz, K. M., Ng, J., Ho, R., McIntyre, R. S., & Rosenblat, J. D. (2021). Antisuicidal and antidepressant effects of ketamine and esketamine in patients with baseline suicidality: A systematic review. Journal of psychiatric research, 137, 426–436. https://doi.org/10.1016/j.jpsychires.2021.03.009

SPRAVATO® [Prescribing Information]. Titusville, N.J., Janssen Pharmaceuticals, Inc. July 2020.

Xiong, J., Lipsitz, O., Chen-Li, D., Rosenblat, J. D., Rodrigues, N. B., Carvalho, I., Lui, L., Gill, H., Narsi, F., Mansur, R. B., Lee, Y., & McIntyre, R. S. (2021). The acute antisuicidal effects of single-dose intravenous ketamine and intranasal esketamine in individuals with major depression and bipolar disorders: A systematic review and meta-analysis. Journal of psychiatric research, 134,57–68. https://doi.org/10.1016/j.jpsychires.2020.12.038

I will never be sorry I stretched myself and took this journey. It changed me and helped me learn so much. There is no doubt that Alaska holds a piece of my heart. From moose to bear spray, anxiety to schizophrenia, mountains to mud flats and northen lights to shooting stars. I took it all in!

Stay tuned!!

Last photo in Alaska 😢

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The chance to go to Alaska was presented to me as I started my program at Duke and my immediate reaction was “NOPE! NOT ME”. As time went on, it kept coming up, over and over again. Something told me it was an opportunity I needed to consider. I spent endless time considering the option and eventually decided (with a lot of pushing from others) to look into it. A million times I changed my mind, but eventually I boarded the plane. I was stressed, my anxiety at an all-time high, I was unemployed, I was overworked and exhausted, I was afraid of being away from home and not knowing anyone and I questioned if I actually knew enough to help people in a safe way. But the answer always seemed to be that the experience I could get doing clinicals in Alaska was too good of an opportunity to pass up. Everyone around me thought this would be good for me. I thought it would make me a better nurse practitioner.

I made up my mind, that if I was going to take this leap, I was going to get absolutely everything out it that I possibly could.

So, an introverted girl from Wisconsin made a promise to herself that she would explore, that she would drive in a strange state, that she would get to know people, ask questions and not just go to clinicals and back to the apartment.

Well, I kept that promise and I will definitely be a better nurse practitioner because of the things I learned in Alaska, but I have gotten so much more from the experience! I found out I could manage a full schedule of patients, that I could navigate taking care of patients with serious mental illness and I found my voice as a provider. But, more importantly I found a peace in my surroundings and with myself that I have not had in a long while. My anxiety is decreased (unless I think too much about unemployment lol). I walk and walk outside taking in all the scenery. I hike in the mountains. I stay out way too late hoping to see the Northern Lights! I have and they are MAGNIFICENT! And I drive—singing to myself with the radio turned way, way up just enjoying the sights and appreciating that the view is nothing short of breathtaking a lot of the time. I feel calm and clear, and I am starting to have a confidence that I lost somewhere along the way. I know who I am and what impact I can have on people.

Don’t get me wrong, I miss my person, our home and our dogs! I have tried suggesting they should come here instead of me coming home, but that idea is being met with a little cold weather resistance (LOL). There is still nervousness about being unemployed and the stress of taking boards, but it all seems less daunting now. It’s all going to work out just the way it is supposed to.

Any who…once upon a time a girl went on an adventure to Alaska, and it reminded her of all she is.

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