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PA vs. NP for psych?

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I know there are tons of places online to read about the PA vs. NP issue (and I've read many of them), but my question is specific to working in psychiatry/mental health. This isn't a popular specialization for PAs or NPs and I haven't found much (at all) discussion of it.

 

I'm an RN who went into nursing with the intention of working as a psych/mental health NP down the line. I'm about 6 months into my first job as an RN, in a rural hospital where I work with medical inpatients, ED patients, and (to a lesser extent) post-surgical patients.

 

My goal is still to work as a clinician in psych/mental health, but lately I'm not so sure that NP would be the best path for me to do this. In all honesty although that's the area I'm interested in, I really like the flexibility that PAs seem to have as far as working in different areas of medicine. As a PMHNP I'd be much more limited (as far as I can tell). I suspect that burnout could be a concern for anyone working in mental health and I'd like the ability to work in more than that area if that becomes an issue for me later in my career as a provider.

 

I also get the sense that with a PA education I'd have a more solid foundation for treating patients no matter what area I choose to work in. I'm especially wary of being underprepared to treat psych patients; I don't want to be a clinician who overlooks physical aspects of health and treats them as completely separate from mental ones. I don't want to focus on mental health to the exclusion of physical health simply because I don't feel competent to deal with the latter.

 

I've been accepted to a DNP program in psych/mental health, but am seriously considering turning down the offer and focusing on preparing to apply to PA programs instead. I hate to turn down a sure thing for an unknown one (I don't know if my application will be competitive enough for PA programs), but the combination of greater flexibility and the medical approach to patient care are making the PA path look like the better choice for me.

 

Any insights would be much appreciated.

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Hmmm. It depends. If you want psychiatry, then PMHNP, no questions asked. You will get better training (yes, I know some PAs will howl at this, but there is no denying that a psych NP gets way more psych training than a PA). I have met multiple PAs who state they do not feel comfortable practicing in psych because of the abbreviated training. For example, this quarter I am taking psychopharm, geriatric psychiatry, adult therapy, family therapy, and etiology and treatment of trauma. We are taught by some of the same faculty who teach the psychiatry residents. I'm also taking the general NP classes and doing my psych practicum. This is just one quarter of my psych NP training. I take multiple psych specific classes each quarter, plus the regular NP classes (advanced pharm, patho, physical health assessment + skills lab, chronic disease management, differential diagnosis, etc.) on top of it. I have looked at PA curriculum and it just pales in comparison to the depth of training in my program for psychiatry. Just go to a reputable PMHNP program. Don't go to some crappy Walden/Phoenix, BS. Go to a university based NP program attached to a medical center and your training will be solid.

 

HOWEVER, if you are not certain you want to do psych, then PA is a great option. But if you have a strong interest in psych, then I wouldn't go that route. PAs also do not learn psychotherapy. I initially thought PMHNP training wasn't strong in psychotherapy, and now I've realized that this depends on the program. My program, actually has a ton of psychotherapy content. My advisor is a psychologist and he stated that our program has the same amount of therapy training as his clinical psychology PhD program. My point is that for psychiatry, PMHNP is the way to go. I understand you are worried about missing physical problems with NP education, but honestly, I'd be more worried about not being equipped to handle psych with the average PA curriculum. Especially without a residency. Recognizing (and learning to manage) physical issues that occur w/psychiatric problems is a cornerstone of PMHNP training. Just go to a PMHNP program that's heavy on the physical health training as well (mine is that way). I am planning on probably going back for my FNP several years into practicing as a psych NP, since I too worry about burnout. Psych is my primary passion, though, and I wanted to learn a lot about my field, so that's why I went with NP instead of PA. If you are more interested in general medicine, then PA might make more sense for you. I just want to warn you that if you think you want to practice psych at all, PMHNP is the better option, especially because you are already an RN. Also, the money is pretty great as well. ;)

 

This is coming from someone who has a hell of a lot of respect for PAs and thinks that their training is really great for most specialties. There are exceptions though, and psych is one where the NP model (specialize upfront and receive in depth training from the get go) works very well. It's probably because psych is very much a niche.

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if you don't want to do a residency I agree with above.

I think someone who does a general pa program + a 1 yr psych residency would be equivalent to a psych np in psych and superior in general medicine.

the other issue is independent practice. in some states the psych np can do this and nowhere can a pa do this.

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I agree with Lexapro and EMEDPA.  My psych training in PA school was one module and very little exposure during rotations.  If I was ever to practice true psychiatry as a PA I would first apply to a residency program.  There are a few of those offered.  One in Iowa and one in Minnesota.  I don't know where the others are. Getting OTJ training would be difficult because  psychiatrists are scarce where I live. 

 

I agree that NPs get better training than PAs in psych practice because it is the focus of your training.  A very good friend of mine finished her PMHNP in May, passed her boards and was immediately snapped up by the VA.  In WI NPs have collaborative practices with independent prescribing rights.  PMHNP will be in demand.  

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Thank-you, Lexapro, for your in depth and enthusiastic reply.  This is an issue I am struggling with, as well.

 

I have been wondering to what extent psych PA's and PMHNP's have limitations on the medical care they can provide.  I work in a psych hospital and the psych docs are largely forbidden from medical management, so I am sure the same would be true for midlevels.  However, I am not sure how that differs institution to institution.

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Thank-you, Lexapro, for your in depth and enthusiastic reply.  This is an issue I am struggling with, as well.

 

I have been wondering to what extent psych PA's and PMHNP's have limitations on the medical care they can provide.  I work in a psych hospital and the psych docs are largely forbidden from medical management, so I am sure the same would be true for midlevels.  However, I am not sure how that differs institution to institution.

The e.d. PAs where I work do the medical management of the pts in the inpt psych ward. it's a strange arrangement , but they pay us well to do it. general med issues only, no psych stuff. takes about an hr/day and we do it during a part of our shift that has double coverage.

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Lexapro: (I LOVE your name BTW ;-)  ) I am curious where did you go to school? Thank you for your insight. 

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Thank you for your insights, everyone!

 

Lexapro, your response was exactly the kind of informed thinking I was looking for. I realized that PAs don't get the preparation for working in psych that psych NPs do, but I was minimizing that because I have concerns about not being comfortable on the physical health side of things. Although I have some very limited, short-term experience working in mental health, I haven't worked in that area as an RN and thus definitely need as much preparation as I can get prior to beginning work as a psych/mental health provider. I think you're absolutely right that that should be my focus, given that psych/mental health is my passion. I need to focus on that and take the path that will help me be best prepared for a career in that area. Although there is the PA + psych residency option EMEDPA mentioned, given that psych is the area I want to be in I think it makes a bit more sense to get as much of that training up front as I can.

 

After looking again at the curriculum of the program I've been accepted to, I feel confident that it will give me solid preparation in both psych as well as physical health. And like you said, there's always the option to add the FNP certification later on. Do you know if there are programs specifically geared toward that for people who are already NPs in other areas, or would it require an additional MSN?

 

I think I'm going to stick with the PMHNP option since that's the reason I went into nursing in the first place, and do as much as I can to build my all-around knowledge/skills as well.

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prescribing psychiatric medication without an indepth medical backround is dangerous and borders malpractice. many psychiatric medications interact with common medications and can have a detrimental effect on certain diseases. i can only speak from my schooling experience but as a PA we were required to do psy rotations and had significant training with inpatient psychiatry. general medical training is crucial for psychiatry and prevails early specialization.

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Lexapro: (I LOVE your name BTW ;-)  ) I am curious where did you go to school? Thank you for your insight. 

 

Eh. I'm gonna edit this reply because I'm paranoid. I go to a very well known, prestigious university/medical center in a big city. PM me for if you'd like to know more. PAs do not have much of a presence here, which is a bummer, because the few encounters I have had w/PAs have been really positive. Oh and thanks!

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Thank-you, Lexapro, for your in depth and enthusiastic reply.  This is an issue I am struggling with, as well.

 

I have been wondering to what extent psych PA's and PMHNP's have limitations on the medical care they can provide.  I work in a psych hospital and the psych docs are largely forbidden from medical management, so I am sure the same would be true for midlevels.  However, I am not sure how that differs institution to institution.

 

I agree with emed. It's really, really site specific. In outpatient psych, the PMHNPs seem to practice like psychiatrists and basically refer out anything physical, they might do a quick neuro exam, etc. However, in psych urgent care settings I have seen PMHNPs doing full H+Ps and prescribing Albuterol, Metformin, and other meds to help get pts stabilized as they transition out to primary care/outpatient. I also know of a PMHNP who works inpatient at a large hospital system on the neuro team. So, yes, it seems to vary by institution.

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Thank you for your insights, everyone!

 

Lexapro, your response was exactly the kind of informed thinking I was looking for. I realized that PAs don't get the preparation for working in psych that psych NPs do, but I was minimizing that because I have concerns about not being comfortable on the physical health side of things. Although I have some very limited, short-term experience working in mental health, I haven't worked in that area as an RN and thus definitely need as much preparation as I can get prior to beginning work as a psych/mental health provider. I think you're absolutely right that that should be my focus, given that psych/mental health is my passion. I need to focus on that and take the path that will help me be best prepared for a career in that area. Although there is the PA + psych residency option EMEDPA mentioned, given that psych is the area I want to be in I think it makes a bit more sense to get as much of that training up front as I can.

 

After looking again at the curriculum of the program I've been accepted to, I feel confident that it will give me solid preparation in both psych as well as physical health. And like you said, there's always the option to add the FNP certification later on. Do you know if there are programs specifically geared toward that for people who are already NPs in other areas, or would it require an additional MSN?

 

I think I'm going to stick with the PMHNP option since that's the reason I went into nursing in the first place, and do as much as I can to build my all-around knowledge/skills as well.

 

You do not need to get another MSN. There are many NP programs that offer what is called a "post-masters certificate". It takes about one year and you take all the specialty coursework + clinicals in the new field (FNP, PNP, AGNP, whatever) that you're transitioning into. I want to say I really understand why you are torn, splendid. I am a very linear, analytical thinker and fan of hard sciences, so I think I would have very much enjoyed PA training. Nursing is so circular sometimes, it can drive you nuts. Just go in knowing who you are and feeling free to supplement your training. Nothing is stopping you from studying Goljan for your patho knoweldge, for example. Or you can advocate for yourself to get more training in H+Ps and general med. We use Stahl for psychopharm just like the psychiatry students. Our differential diagnosis class uses a Family Medicine textbook.

 

Anyway, at the end of the day, as much as I might whine about the BS that nursing seems so full of sometimes, I know I made the right decision. I wanted coursework in geripsych and child psych. I want to feel confident that I can treat PTSD both pharmacologically and therapeutically. I might roll my eyes through my nursing theory class, but my family therapy class has been challenging, enlightening, and has altered the way I approach any child psych case... or really all psych patients, since we all are products of our families. Anyway, I hope that helps!

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To the OP: I think you've gotten very good guidance from the informed comments on this thread.  However, I am quite skeptical about the comment that any PMHNP program has "the same amount of training in psychotherapy as (a) clinical PhD program."  This simply cannot be the case, based on the average amount of allotted time to complete each program.  A doctoral program in clinical psychology is between 4 and 6 years long, with the vast majority of coursework required in the areas of mental health and very, very little of that time relegated to the basic sciences or to general medicine.  Additionally, psychotherapy skills are then refined through careful supervision of students' work in mental health specific practica and internship assignments.  How could a two to three year PMHNP program accomplish the equivalent of at least 4 years of psychotherapy training, while simultaneously carving out time for basic medicine coursework?

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To the OP: I think you've gotten very good guidance from the informed comments on this thread.  However, I am quite skeptical about the comment that any PMHNP program has "the same amount of training in psychotherapy as (a) clinical PhD program."  This simply cannot be the case, based on the average amount of allotted time to complete each program.  A doctoral program in clinical psychology is between 4 and 6 years long, with the vast majority of coursework required in the areas of mental health and very, very little of that time relegated to the basic sciences or to general medicine.  Additionally, psychotherapy skills are then refined through careful supervision of students' work in mental health specific practica and internship assignments.  How could a two to three year PMHNP program accomplish the equivalent of at least 4 years of psychotherapy training, while simultaneously carving out time for basic medicine coursework?

 

Hi there, this is what my advisor (a clinical psychology PhD from a traditional, university program) told me, as we were commenting on the significant amount of therapy coursework in my program. He was referring to didactics, although we also get therapy hours in our clinical training. Actually, therapy is not really the mainstay of the coursework of many PhD programs, but rather theory, research methods, stats, assessment, and psych testing are huge portions of the coursework. We do not get as many therapy hours as a clinical psych PhD, though, you are correct there! Sorry if there seemed to be confusion.

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Sigh...

A  observation:

 

The average PMHNP program is around 6 semesters, 32 didactic hrs/12 clinical hrs/~600 direct patient care hrs.

How much "Psychotherapy" can be taught 42 hrs...??

 

Also... after looking at the curriculum outline of a dozen or so programs AND talking to the multiple PMHNPs that I work with daily... I didn't see anywhere where they were subjected to intensive Psychotherapy training. The curriculum here is quite typical for BSN's/MSN's who do not attend full time, on campus programs (majority of them): http://www.uab.edu/nursing/home/images/stories/info_sa/MSN_Flyer_NP_Psych.pdf

 

Lastly... After doing this for YRS... I find that my PMHNP colleagues are GREAT at Psych Med management just like the other prescribers (MD/DO) are even as New Graduates.

 

They DO have a advantage with billing over PAs in some instances and maybe a slight advantage with psych meds over A NEW GRAD/NEW TO PSYCH PA-C.

 

As was stated above... they are typically dangerous/clueless when it comes to the integration of general medicine with mental health.

Any PMHNP managing DM/GI/Cardio/Respiratory issues that are non-emergent ... without having been a ACNP or FNP prior to attending their PMHNP course (or after) is dangerous and does border on malpractice.

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I see that there has been great conversation around this topic. I am a clinical psychology ABD student. I have learned that I should have gone to medical school instead of getting my PhD. Sad to say but I am feeling the burnout already with doing psychotherapy. I was thinking about going to get my PMHNP but I thought about possibly working as a psychiatric PA. I am torn because of the autonomy. I am still going to get licensed as a psychologist (another year of doing therapy) but I forsee me wanting to be more involved in the medicine aspect. I've seen patients who come out of a psychiatric ward or hospital and are not receiving appropriate psychiatric care because of the shortage of practitioners who can prescribe. I did my clinical internship in San Antonio and it happened there as well (as some people say it only happens in rural areas). I think it is a shame that more people are not invested in other's mental well-being. Look at all the violence and shooting across the nation lately! (Let me get off my soap box).

 

What are your thoughts on if I should get a PA or a PMHNP degree? I have a dual undergrad degree (Bio and Psych) both of which I obtained in 2002 so the courses are very much outdated. I know I would have to become a RN before I could apply to NP schools (or do a direct entry program which I probably can't afford unless health education loans have a higher maxout rate).

 

I am 35 with no kids and I am not getting married and 2 dogs. I basically only have me and money that will be a hinderance.

 

So what do you think? I am anxiously waiting your response.

 

Thanks,

 

CB

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