New PMHNPs: Resist the Urge to Make Medication Changes If…

Knowing what medication to prescribe is one of the hardest skills to develop as a new PMHNP.

Bit knowing when not to change anything at all is another.

When a patient is still experiencing symptoms, it can be tempting to immediately make a medication adjustment. Maybe the dose should be increased. Maybe another medication should be added. Maybe the current medication should be discontinued and replaced with something else.

But sometimes, the best clinical decision is to hold steady, monitor, and give the current treatment plan more time.

As a new grad Psych NP, over time I learned that there are a few situations when resisting the urge to make a medication change is the best option.

1. The side effects are mild and continuing to improve

Not every side effect requires an immediate medication change.

Some side effects are transient and may improve as the patient adjusts to the medication. If the side effects are mild, tolerable, and already improving, it may make sense to continue the medication and monitor rather than immediately switching medications or adding something else to treat the side effect.

Of course, this depends on the medication, the specific side effect, its severity, and the patient's individual circumstances and preferences.

The important question is:

Are the side effects actually getting better, or are we assuming they will?

That distinction matters.

2. The medication hasn't had enough time to work

It can be frustrating when a patient is still experiencing symptoms after starting a medication.

But depending on the medication and the condition being treated, therapeutic effects may take time to become apparent.

Before concluding that a medication isn't working, consider:

• How long has the patient been taking it?

• Has the patient been taking it consistently?

• Is the current dose therapeutic?

• Has the medication had a reasonable trial at the current dose?

• Are there other factors affecting the patient's symptoms or response?

Sometimes the medication doesn't need to be changed.

It just needs more time.

3. A major life stressor is making it difficult to tell what's driving the symptoms

Sometimes, new PMHNPs tend to forget that patients don't experience psychiatric symptoms in a vacuum.

A breakup, job loss, financial stress, family conflict, grief, moving, relationship problems, or another major life event can significantly affect mood, anxiety, sleep, concentration, and functioning.

If a patient's symptoms have suddenly worsened during a major stressor, it may be difficult to determine how much of the change is related to the underlying psychiatric condition versus the circumstances surrounding the patient.

That doesn't mean symptoms should be dismissed as "just stress."

It means we should be thoughtful before assuming that a medication change is necessarily the answer.

Sometimes monitoring the patient's symptoms while addressing the stressor and providing appropriate support can give you much more useful information than immediately changing multiple medications.

4. You'd have to make multiple medication changes at the same time

This is one of the lessons I wish more new psychiatric nurse practitioners were taught early on:

Whenever possible, make one medication change at a time.

If you increase one medication, discontinue another, and add a third medication all at once, it becomes much harder to determine what's actually happening.

What helped?

What didn't help?

What caused the new side effect?

What caused the improvement?

When several variables change simultaneously, it can become difficult to answer those questions.

There will absolutely be situations where multiple medication changes are clinically appropriate. Patient safety and clinical circumstances should always come first.

But when you have the flexibility to do so, making one change at a time can make your treatment decisions much easier to evaluate.

Watchful waiting is still a treatment decision

"Watchful waiting" can sometimes feel uncomfortable or like you are doing nothing, especially early in your career as a PMHNP.

Try to remember that watchful waiting can be an active treatment decision.

You're monitoring symptoms. You're reassessing the patient's functioning. You're evaluating side effects. You're considering changes in the patient's circumstances. You're determining whether the current treatment is actually working over time.

And you're giving the current plan a fair chance before introducing another variable.

Of course, none of this means you should ignore worsening symptoms, significant side effects, safety concerns, or a treatment plan that clearly isn't working.

And perhaps most importantly, the patient needs to understand the reasoning behind the plan and agree with it.

A patient who is uncomfortable with continuing the current medication or feels their symptoms aren't manageable shouldn't simply be told to "wait."

The goal isn't to avoid medication changes.

The goal is to make intentional medication changes when they're clinically indicated rather than making changes simply because we're uncomfortable with waiting.

As a new Psych NP, learning when to intervene is important. But learning when not to intervene yet is a skill, too.

Explore our resources for more tips for the new PMHNP starting out in practice.