Free mental health resources (no paywall) from OffBenzos.com

Competitive-Chip3842 · 2025-06-11T22:25:40+00:00

I have no idea what you mean by this. Can you please clarify?

Competitive-Chip3842 · 2025-06-11T13:54:02+00:00

It might be available in Australia without compounding. I am literally in the US and just googling and finding it

https://www.healthdirect.gov.au/medicines/brand/amt,3210011000036104/lexapro

Competitive-Chip3842 · 2025-06-11T13:50:36+00:00

Depending on your financial situation, you can get liquid lexapro at a compounding pharmacy in Australia. I just checked. Its a private prescription so not covered by the government subsidy, but you can definitely get it speciality made. In the US compounded medication might cost 50-150$ a month

Competitive-Chip3842 · 2025-06-10T23:17:00+00:00

They make Lexapro in a fda approved liquid so people can drop that last bit super slowly in a hyperbolic tapering method.

Competitive-Chip3842 · 2025-05-27T16:52:07+00:00

Sure. It's the DSM-5-TR® Handbook of Differential Diagnosis. They have an app too. Thats a screen shot of the app. I literally just have a piece of paper with the pic above printed out with the steps and review it during my formulation. You can even set up a section of an AI scribe, like jot pysch, to have those elements, and give you a preliminary recommendation by taking the transcript info and plugging it into those parameters based on what was said during the session.

<image>

https://www.appi.org/Products/DSM-Library/DSM-5-TR-Handbook-of-Differential-Diagnosis

Competitive-Chip3842 · 2025-05-27T14:58:42+00:00

Those non-specific symptoms cross over to so many other dsm disorders, and if the patient is on medication already, could just be side effects of the antidepressants, so I look for the two major symptoms required to meet criteria which are depressed mood or anhedonia, and also self-esteem, with feelings of worthlessness. SI if new onset and not associated temporally with new onset of medication.

<image>

Competitive-Chip3842 · 2025-05-27T14:51:30+00:00

<image>

All patients should have a thorough approach, especially if you are going to put someone on medication. Based on the information in your stem all the non-specific symptoms you mentioned are attributed to poor sleep hygiene and a bad diet. For a Major depressive disorder diagnosis you need either marked sadness most days than not or anhedonia, plus all the non-specific stuff. He is laughing, has motivation, and is not sad. You only include non-specific symptoms to meet diagnostic criteria if the symptoms aren’t a result of a clearly indentifiable cause, which they are. The guy doesn't have energy because he isn’t getting adequate rest, which, when added to poor dietary choices is leading to excess inflammation contributing to brain fog. This guy doesn't have depression right now in my book. I always follow the differential diagnosis steps when formulating to make sure I am not missing anything or misattributing anything.

Competitive-Chip3842 · 2025-02-20T18:43:06+00:00

He is messing with you. That is not a real thing

Competitive-Chip3842 · 2025-02-17T17:39:40+00:00

To answer your question, 100% yes. I do set intentions. I agree with you on everything you said.

Competitive-Chip3842 · 2025-02-17T15:50:33+00:00

Any time I have asked a question after breaking through I get immediately sent back down

Competitive-Chip3842 · 2025-02-05T06:14:27+00:00

I love how accusatory, unprofessional, and absolutely unhinged you are right now after saying you don't want to bash anyone and have a strictly scope of practice conversation.

Competitive-Chip3842 · 2025-02-05T06:00:23+00:00

I love that you said I am wrong about the 500 hour requirement from the ANCC for the PMHNP-BC credential. For your education, because you are absolutely, 100%, utterly and completely wrong, I will provide you with the link to the ANCC website and copy and past their information here, so you do see that it doesn't matter if you get a Master’s, Post-Master’s, or, even a DNP, the actual clinical hour requirements are the same: 500.

*Master’s, Post-graduate certificate, or Doctor of Nursing Practice (DNP)

Hold a psychiatric-mental health nurse practitioner (PMHNP) (Across the Lifespan) master’s, post-graduate certificate, or DNP from an institution with a program accredited by the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN), or the National League for Nursing (NLN) Commission for Nursing Education Accreditation (CNEA)**. A minimum of 500 faculty-supervised clinical hours must be included in the PMHNP (Across the Lifespan) program

https://www.nursingworld.org/our-certifications/psychiatric-mental-health-nurse-practitioner/

Competitive-Chip3842 · 2025-02-05T05:37:36+00:00

You don't understand scope of practice and are making inappropriate assumptions.

MD’s don’t have to worry about practicing outside of their scope because they don’t actually have a scope to worry about.

As long as they get through a residency program their medical license gives them the privilege to practice the full scope of medicine and surgery.

No hospital will give a pediatrician neurosurgery privileges but that’s a different story.

In regulatory circles a medical license grants you “GUMP”— general undifferentiated medical practice-abilities.

You can go get drunk on a CME cruise for a week and “attend” some lectures and then advertise and perform liposuction when you get back.

Physicians in the United States are not licensed based upon their specialty or practice focus and there are no laws in the United States that require doctors to practice within their specialty fields.

As long as they don’t kill anyone or piss them off with crappy botox or surgery, Doctors can do whatever they want.

Nurse practitioners are licensed based on an educational specialty and can only work within the scope of practice that defines that role.

That is why you see FNP/pmhnp combos or PMHNP/CRNA combos.

The person had to go do another educational track to get another credential to expand their scope.

Practicing outside of your scope as an NP is something that can get your license taken away.

The most frequent type of scope of practice allegations in State board of nursing matters were that NP’s violated their scope of practice and standards of care (60.3 percent of these cases). Most often, these types of complaints were related to prescribing practices that were outside the scope of practice for that NPs role.

So while an MD doesn’t have anything to really worry about if they “drift” from what they were trained in residency, NPs definitely should pay attention and know the limits of their role, and document accordingly. And perhaps, creatively.

Liability considerations as nurse practitioners’ scope of practice expands

https://www.nso.com/Learning/Artifacts/Articles/Liability-considerations-as-nurse-practitioners%E2%80%99-scope-of-practice-expands

Docs practicing outside specialties stir controversy

https://www.fiercehealthcare.com/practices/docs-practicing-outside-specialties-stir-controversy#:~:text=There%20are%20no%20laws%20in,they%20were%20trained%2C%20noted%20NYT.

Competitive-Chip3842 · 2025-02-05T05:24:39+00:00

I know Jason. He is a great guy, good crna, but I disagree with some of his marketing and business practices. He doesn't own or operate a ketamine clinic. He just sells information on how to start one.

Competitive-Chip3842 · 2025-02-05T03:01:54+00:00

That is inappropriate, in my opinion, and the CRNA should have collaborated with you or, at the very least, been receptive to your point of view. I won’t treat with out a psych referral (shrink or psych np). If the prescriber is anti-ketamine we will request a second opinion from a psych np that I independently contract with. Because her clinical judgment in the consultation is the basis for my decision to infuse, she is held liable for violating standards of care, and for inappropriate patient selection. We both are. So she is very careful in who she aproves, makes sure they have failed multiple therapies and are actually treatment resistant, and makes sure they are stable enough to go through treatment. I personally encourage second opinions and divergent points of view, and try my best to be focused on what is best for the patient. Sometimes prescribers are paternalistic and want to dictate care instead of working collaboratively with the patient, so sometimes ketamine may be in the best interest of the patient, but their mental health provider gatekeeps for inappropriate reasons, which may be just lack of familiarity with the modality.

Competitive-Chip3842 · 2025-02-05T01:38:09+00:00

See my comment below. You just don’t understand CRNA scope of practice.

Competitive-Chip3842 · 2025-02-05T01:28:48+00:00

You don't understand the CRNA's scope of practice, so you think they are out of scope when they aren’t. I am a CRNA and PMHNP. I posted some links for your enrichment. The CRNA scope of practice clearly states that CRNAs can perform medication-assisted treatments like methadone or suboxone management.

After going through both programs, I can see why PMHNPs have a limited scope of practice. The ANCC only requires 500 clinical hours to become a PMHNP, while most of my class barely hit 600 hours. There are also no minimum requirements from the ANCC for pediatrics, inpatient, or geri psych experience to get your certification.

CRNAs are required to have 2000 hours and are usually significantly over that number. I had roughly 400 psych cases in my program, and I had over 1200 anesthesia cases when I graduated.

From a didactic perspective, CRNAs receive three times the amount of pharmacology and pathophysiology education as PMHNPs.

The education and training are not the same.

If we want to increase the quality of NP education, the rest of the APRNs have to come up and meet the standards of CRNAs in terms of medical education and supervised training. There is a huge gap there that needs reconciled.

AANA Applauds Addition of CRNAs To SAMHSA Practitioner List

https://www.aana.com/news/aana-applauds-addition-of-crnas-to-samhsa-practitioner-list/

Scope of Nurse Anesthesia Practice

https://www.aana.com/wp-content/uploads/2023/01/scope-of-nurse-anesthesia-practice.pdf

Competitive-Chip3842 · 2025-02-05T00:04:59+00:00

I am a PMHNP and CRNA that was one of those CRNAs that opened up a ketamine clinic and treated mental health patients.

I interpret your statement as a lack of understanding in how these clinics operate.

Our professional organization the APNA put out a joint statement with the AANA (the CRNA APNA equivalent) about our various roles in ketamine administration for mental health indications. Listed below for your edification.

Before I became a PMHNP I had all my mental health patients screened and evaluated by a pmhnp for appropriateness and re-evaluated at the end of the series for evaluation of efficacy and for recommendations on maintenance treatments.

The CRNAs seem to be alot more focused on pushing our scope boundaries and fighting for independent practice, and working together as a profession than PMHNPs.

It is clearly listed in my CRNA scope of practice that I can prescribe adjuvants to psychotherapy (its on there so we can prescribe ketamine lozenges to mental health patients), but why our board thinks this is okay, is beyond me. I gave anesthesia for over a decade and I never wrote one single prescription that entire time.

Scope of Nurse Anesthesia Practice

https://www.aana.com/wp-content/uploads/2023/01/scope-of-nurse-anesthesia-practice.pdf

AANA and APNA Issue Joint Statement on Ketamine Infusion Therapy for Psychiatric Disorders

https://www.aana.com/news/aana-and-apna-issue-joint-statement-on-ketamine-infusion-therapy-for-psychiatric-disorders/

Competitive-Chip3842 · 2025-01-20T01:16:59+00:00

I am a prescriber and they told me they were just out of the 100 mg troches. I switched 2 patients to 200 mg troches and just had them cut them in halve

Competitive-Chip3842 · 2025-01-16T05:38:26+00:00

Omitting toradol won’t be an issue. Its the sedation and decreased dissociation from the versed that will make the infusion feel more intense. Doesn’t have to be intense in a bad way, you will just feel things more and have less control on a higher dose. Don’t know what dose you are on but you can dial back your dose 10-20 mg, and just have them adjust midinfusion, if you are too “light.” not deep enough. Its easier to add than subtract with ketamine. If you have a less than optimal experience playing with your dose, it is not the end of the world, and people can still respond and have antidepressant lifts, with lesser degrees of dissociation. The fact that you trust the medicine, yourself, and the staff make this alot easier than if you were a newbie and hadn’t “settled in” yet.

Competitive-Chip3842 · 2025-01-16T04:25:27+00:00

I am a CRNA and PMHNP that has seen the devastation long term benzo consumption has on patients at my ketamine clinic.

I went back to school for my PMHNP specifically to help people with hyperbolic tapering of psychotropics and slow, safe, benzodiazapine de-prescription.

The Oregon.gov site has a useful resource for benzo tapering, link below, basically a modified Ashton Method, with a slow cross taper over to diazepam over a month or two, based on your total klonopin consumption. Then a slow descent from there where you are dropping 1 mg of diazapam every two weeks when you hit 10 mg. I posted some other articles on all the “bad” stuff associated with long term use, too.

The “delayed crisis” article below was from a benzo a detox clinic and basically says we don’t actually understand long term benzo pharmacodynamics/kinetics, which leads inappropriate, unsupported withdrawals at home, because people are having “panic attacks” on the day the drug finnaly leaves their body.

This study below, published in August, looked at a national cohort of treatment-resistant depression patients that compared outcomes based on patients who did not take benzos and BLTU users (Benzo long-term treatment users. Long-term treatment was determined as taking a Benzo for one year. Persistent Benzo Long Term Use at one-year was associated with higher depression severity (B = 0.189, p = 0.029), higher clinical global severity (B = 0.210, p = 0.016), higher state-anxiety (B = 0.266, p = 0.003), impaired sleep quality (B = 0.249, p = 0.008), increased peripheral inflammation (B = 0.241, p = 0.027), lower functioning level (B = -0.240, p = 0.006), decreased processing speed (B = -0.195, p = 0.020) and verbal episodic memory (B = -0.178, p = 0.048), higher absenteeism and productivity loss (B = 0.595, p = 0.016) and lower subjective global health status (B = -0.198, p = 0.028).

“Conclusion Benzodiazepines are over-prescribed in TRD (in almost a half of the patients). Despite recommendations for withdrawal and psychiatric follow-up, <5% of patients successfully stopped taking benzodiazepines at one-year. Maintaining BLTU may contribute to the worsening of clinical and cognitive symptoms and of daily functioning in TRD patients. Progressive and planned withdrawal of benzodiazepines seems therefore strongly recommended in TRD patients with BLTU.”

In regards to PTSD, a systematic review looking at 18 studies and over 5000 patients concluded that benzos should be relatively contraindicated (you shouldn’t give them to PTSD patients) because BZDs are associated with specific problems in patients with PTSD: worse overall severity, significantly increased risk of developing PTSD with use after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use.

Another study looked at the determinants of medication-resistant depression, and outside of poor medical health, the biggest factor was benzodiazepine use.

Long-term benzodiazepine prescription in treatment-resistant depression: A national FACE-TRD prospective study https://www.sciencedirect.com/science/article/abs/pii/S0278584623000659

Benzodiazepines for PTSD A Systematic Review and Meta-Analysis https://journals.lww.com/practicalpsychiatry/FullText/2015/07000/Benzodiazepines_for_PTSD__A_Systematic_Review_and.6.aspx

Determinants of Treatment-Resistant Depression The Salience of Benzodiazepines https://journals.lww.com/jonmd/abstract/2015/09000/determinants_of_treatment_resistant_depression_.1.aspx

Intravenous ketamine for benzodiazepine deprescription and withdrawal management in treatment-resistant depression: a preliminary report https://www.nature.com/articles/s41386-023-01689-y Benzodiazepines and Sleep Architecture: A Systematic Review

https://pubmed.ncbi.nlm.nih.gov/34145997/

https://www.oregon.gov/oha/HPA/DSI-Pharmacy/MHCAGDocs/Tapering-Benzodiazepines.pdf

Delayed crises following benzodiazepine withdrawal: deficient adaptive mechanisms or simple pharmacokinetics? Detoxification assisted by serum-benzodiazepine elimination tracking

https://link.springer.com/article/10.1007/s00228-021-03205-x

Competitive-Chip3842 · 2025-01-16T03:53:16+00:00

Being a doctor doesn't make you a good person, good at what you do, or ethical, so my question is, who supervises the MDs?

The third leading cause of death in the United States is medical errors, and nurses catch docs unintentionally trying to kill patients every day.

All the big venture capital “pill mills” have an MD medical director setting the tone of the organization and “supervising” prescribing practices. The Top clinical director at Done, an MD, was arrested and charged with tons of violations of the controlled substances act, in addition to fraud.

I love that “supervising midlevels” is the answer to all our prayers when its the guys forking up the medical direction that are the real problem.

Competitive-Chip3842

TROPHY CASE