From pamme at sbcglobal.net  Fri Mar 26 13:37:27 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Fri, 26 Mar 2004 16:37:27 -0500
Subject: [PrvPracNP] Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's
References: <PKEDIBHEGKJAPEHFEPMOMEEACJAA.prispunnyfnp@metrocast.net>
Message-ID: <002d01c4137a$897aa2b0$209cfea9@VAIO>

Dear Priscilla,
I commiserate with your frustration.  When I was in CT, working as a psychiatric consultant, I was livid that our firm used Cigna.  Cigna does not recognize, nor will accept billing statements from NPs in CT.   Needless to say, I raised the rooftops.  We dropped them as our carrier and told them why.  I see at least now, they accept billing but will not list us in the providers listing.
As to Mailhandler's, get on the net and go to the .gov site and start emailing the heck out of your congressionals.  I implore all reading this to please do this and have your family and friends do this as well.   Our recognition came from grassroots movements.  In the 80's and 90's, it was thwarted by the old guard RN's.  However, we persevered.  We can't stop until we are separate, but equal to all payor sources.
In addition, if you don't belong to the AANP (American Academy of Nurse Practitioners) and their Political Action Committee, I urge you to investigate and join.  Their website is http://www.aanp.org
They are located in D.C. and have a growing powerful lobby with seasoned lobbyists.  Believe me, the AMA has their lobbyists, bumping into our lobbyists.  Once they realize that we have stopped squabbling amongst ourselves, have consolidated and are behind the national promotion, recognition and reimbursement of NPs, the AMA will do a jump back jack and realize that by banding together with us, instead of against us, we can stop healthcare from continuing down the road to ruin that it has become in the US.

Peace,
Pamme

GOD BLESS US ALL 
Life may not be the party we hoped for, but while we are here, we may as well dance 

----- Original Message ----- 
From: "Priscilla Merrill" <prispunnyfnp at metrocast.net>
To: "NP Info" <npinfo at nurse.net>; "Lisah K. Carpenter" <lkcarpenter at fcgnetworks.net>; "Prvpracnp" <prvpracnp at nurse.net>
Sent: Friday, March 26, 2004 5:42 AM
Subject: [Prv Prac NP] CIGNA WEBSITE excludes NP's


> Call to action for brave souls.
> Have you visited Cigna.com and looked for yourself in the provider
> directory?  Have you noticed we are totally excluded and is physician only
> provider directory?  I spent much time on phone and no one could explain
> why.  I am in their system but am not visible to patients or to anyone else
> looking for a provider.  PCP is designated primary care physician, not
> provider.  
> After speaking to 4 people and getting nowhere, I decided to put this out
> there and flood them with complaint calls about their verbiage of exclusion.
> Please first check for yourself by looking yourself up (maybe this is unique
> to New Hampshire?) and then if you're upset, call them (see provider
> relations under customer service for your state).
> While I'm on a rampage, I must ask if any of you have had luck with
> Mailhandlers covering NP services?  They are now under First Health and
> after spending an hour on the phone with no one who had heard of a nurse
> practitioner, I sent the patient elsewhere.  They were very condescending
> and kept telling me I was working outside of my expertise!  They will cover
> us as specialists but not PCP's.  It was sad to me to hear that not one
> person on their provider relations staff had heard of nurse practitioners.
> They are government sponsored so the red tape to change it must be a huge
> process. They only consider pcp's primary care physicians regardless of our
> independent practice status.
> 
> Yours in frustration,
> 
> Priscilla Merrill ARNP
> 
> ---
> Outgoing mail is certified Virus Free.
> Checked by AVG anti-virus system (http://www.grisoft.com).
> Version: 6.0.637 / Virus Database: 408 - Release Date: 3/20/2004
>  
> 
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From pamme at sbcglobal.net  Fri Mar 26 13:42:40 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Fri, 26 Mar 2004 16:42:40 -0500
Subject: [PrvPracNP] Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's
References: <PKEDIBHEGKJAPEHFEPMOMEEACJAA.prispunnyfnp@metrocast.net>
	<40644BD8.3A328717@eiu.edu>
Message-ID: <004a01c4137b$444defc0$209cfea9@VAIO>

My friend and colleague is an independent contractor NP in Illinois.
I haven't asked her if she takes Cigna or not.
I do know that a lot of PCP's were dropping them in CT.
I also know they are horrible to as a patient to get anything covered.
While I had the misfortune of having them for insurance coverage, I had to
contact them every time we went to a provider.  They questioned everything.
I even had to go through the appeals process to get them to pay for my
daughter's cancer surgery.
Cigna is not just bad for NPs; they are rotten to patients as well.
Ciao,
Pamme
~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Daphne Piercy" <csdlp at eiu.edu>
To: <prvpracnp at nurse.net>
Sent: Friday, March 26, 2004 10:27 AM
Subject: Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's


> I have noticed that there are no providers listed in Illinois.  If you see
a
> significant number of CIGNA patients you might get a better response from
the
> company if the patients complain.  If there are local providers that
patients
> are not utilizing because they are not being informed of the available
service,
> many paying customers will be upset.  You may also benefit from an article
in
> the local paper.
>
> Daphne Piercy CFNP, Illinois
>
> Priscilla Merrill wrote:
>
> > Call to action for brave souls.
> > Have you visited Cigna.com and looked for yourself in the provider
> > directory?  Have you noticed we are totally excluded and is physician
only
> > provider directory?  I spent much time on phone and no one could explain
> > why.  I am in their system but am not visible to patients or to anyone
else
> > looking for a provider.  PCP is designated primary care physician, not
> > provider.
> > After speaking to 4 people and getting nowhere, I decided to put this
out
> > there and flood them with complaint calls about their verbiage of
exclusion.
> > Please first check for yourself by looking yourself up (maybe this is
unique
> > to New Hampshire?) and then if you're upset, call them (see provider
> > relations under customer service for your state).
> > While I'm on a rampage, I must ask if any of you have had luck with
> > Mailhandlers covering NP services?  They are now under First Health and
> > after spending an hour on the phone with no one who had heard of a nurse
> > practitioner, I sent the patient elsewhere.  They were very
condescending
> > and kept telling me I was working outside of my expertise!  They will
cover
> > us as specialists but not PCP's.  It was sad to me to hear that not one
> > person on their provider relations staff had heard of nurse
practitioners.
> > They are government sponsored so the red tape to change it must be a
huge
> > process. They only consider pcp's primary care physicians regardless of
our
> > independent practice status.
> >
> > Yours in frustration,
> >
> > Priscilla Merrill ARNP
> >
> > ---
> > Outgoing mail is certified Virus Free.
> > Checked by AVG anti-virus system (http://www.grisoft.com).
> > Version: 6.0.637 / Virus Database: 408 - Release Date: 3/20/2004
> >
> >
>
  ------------------------------------------------------------------------
> >                   Name: winmail.dat
> >    winmail.dat    Type: application/ms-tnef
> >               Encoding: base64



From LauraHoemanARNP at aol.com  Fri Mar 26 19:35:15 2004
From: LauraHoemanARNP at aol.com (LauraHoemanARNP at aol.com)
Date: Fri, 26 Mar 2004 22:35:15 EST
Subject: [PrvPracNP] Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's
Message-ID: <97.45cdbb90.2d965073@aol.com>

Exactly.  Amen to that!  --Laura
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From shirguy at mindspring.com  Sat Mar 27 21:39:34 2004
From: shirguy at mindspring.com (Guy Graves)
Date: Sun, 28 Mar 2004 00:39:34 -0500
Subject: [PrvPracNP] Re: [Prv Prac NP] Need advice-all please help!!!
References: <20040323173116.63812.qmail@web40909.mail.yahoo.com>
	<014f01c4126b$79949dc0$829a4b0c@AKV62XY>
	<001d01c412b7$1bd6e5c0$209cfea9@VAIO>
Message-ID: <00ee01c41487$0d718360$76d31d43@0018479713>

Pam, what part of Indiana?  And how are things going for you?

Shirley

----- Original Message -----
From: "Pr. Pamela A. Provost N.P." <pamme at sbcglobal.net>
To: <prvpracnp at nurse.net>
Sent: Thursday, March 25, 2004 5:18 PM
Subject: Re: [Prv Prac NP] Need advice-all please help!!!


> LOL.   Isn't that the truth!!
> I just moved a year ago to Indiana from CT.  Talk about having to jump
> through hoops to achieve what is needed.  Such a game they play out here.
> But, everyone is so nice about it.
> Good luck to you both,
> Pamme
> ~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while
we
> are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
> Climb to End Breast Cancer! Join Care2.com's Race for Children in Need!
Join
> Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
> Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
> Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
> ----- Original Message -----
> From: "Pat Camillo" <looking-glass at worldnet.att.net>
> To: <prvpracnp at nurse.net>
> Sent: Thursday, March 25, 2004 8:17 AM
> Subject: Re: [Prv Prac NP] Need advice-all please help!!!
>
>
> > Amy, where are you in NYC....I'm in Manhattan....live on 72 st and 3rd
and
> > was involved as an independent contractor for an internal medicine group
> on
> > 65th street.
> > Where are you looking to practice?? I'm exploring other options now
> .....the
> > culture of health care in NYC is so different from anything I had seen
in
> > the midwest over the past 15 years.....still trying to understand it!
> >
> > Pat Camillo PhD,RNC,ARNP-BC
> > Associate Professor and Director
> > Women's Health Program
> > Seton Hall University
> > South Orange, New Jersey
> > Complete Online Programs!!!
> > Menopause Consultations by Phone
> > http://www.allwise.com
> >
> > ----- Original Message -----
> > From: "amy ma" <maxiaochen at yahoo.com>
> > To: <prvpracnp at nurse.net>
> > Sent: Tuesday, March 23, 2004 12:31 PM
> > Subject: Re: [Prv Prac NP] Need advice-all please help!!!
> >
> >
> > > Hi, Pat;
> > > Thank you for asking!  We are just thinking about this
> > > matter but no action yet.  we are gathering
> > > information.  I am in New York City.
> > >
> > > Amy
> > >
> > >
> > > --- Pat Camillo <looking-glass at worldnet.att.net>
> > > wrote:
> > > > Amy,
> > > >
> > > > How are you doing opening a practice in NY .....is
> > > > it upstate?
> > > >
> > > > Pat Camillo PhD,RNC,ARNP-BC
> > > > Associate Professor and Director
> > > > Women's Health Program
> > > > Seton Hall University
> > > > South Orange, New Jersey
> > > > Complete Online Programs!!!
> > > > Menopause Consultations by Phone
> > > > http://www.allwise.com
> > > >
> > > > ----- Original Message -----
> > > > From: "amy ma" <maxiaochen at yahoo.com>
> > > > To: <prvpracnp at nurse.net>
> > > > Sent: Tuesday, January 13, 2004 3:10 PM
> > > > Subject: RE: [Prv Prac NP] Need advice-all please
> > > > help!!!
> > > >
> > > >
> > > > > Hello;
> > > > > Is anybody in private practice in New York state?
> > > > I
> > > > > need advice on openning a private practice here in
> > > > New
> > > > > York!  Thank you!!
> > > > >
> > > > > Amy FNP
> > > > >
> > > > > __________________________________
> > > > > Do you Yahoo!?
> > > > > Yahoo! Hotjobs: Enter the "Signing Bonus"
> > > > Sweepstakes
> > > > > http://hotjobs.sweepstakes.yahoo.com/signingbonus
> > >
> > >
> > > =====
> > > Amy Ma, Nurse Practitioner
> > > Tel: (212)780-4459
> > > AHRC Healthcare
> > > New York, NY
> > >
> > > __________________________________
> > > Do you Yahoo!?
> > > Yahoo! Finance Tax Center - File online. File on time.
> > > http://taxes.yahoo.com/filing.html
>



From pamme at sbcglobal.net  Fri Mar 26 13:38:59 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Fri, 26 Mar 2004 16:38:59 -0500
Subject: [PrvPracNP] Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's
References: <128.3db6b0a7.2d9580d5@aol.com>
Message-ID: <003e01c4137a$c02032d0$209cfea9@VAIO>

LOL.  There we go again Marla.  Thinking alike.
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Friday, March 26, 2004 7:49 AM
  Subject: Re: [Prv Prac NP] CIGNA WEBSITE excludes NP's


  Dear PRicilla,
  Now that you are nicely fired up is the time to contact your legislators and newspapers and write letters to the editors etc.  I was working for a huge PCP group and was not listed either and questioned it and wasn't listed with Trigon blue cross blue sheild even though I had to go through this huge long process of credentialing. When I called them, they said only doctors could be listed. I knew this was not true.  It was so frustrating. I ultimately left but feel bad that I can't seem to effect change in this area.  Listen to this!  I now have my own (albiet not too successful) business now, teaching patients about wellness, stop smoking etc, helping them with stress of chronic illness, but because I don't have a "supervising" physician in the state of VA, I have to do this as a NURSE, under my RN, not my NP.  I'm protected under my RN but cannot say I'm practicing as an NP.  We must band together and change the laws and become the bargening force that the AMA is.  Sincerely,

  Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From bsmithing at nurse.net  Sun Mar 28 21:43:48 2004
From: bsmithing at nurse.net (Bob Smithing)
Date: Sun, 28 Mar 2004 21:43:48 -0800
Subject: [PrvPracNP] Re: [Prv Prac NP] Fw: Majordomo results
In-Reply-To: <01fa01c412f5$ea4b2fe0$6501a8c0@rochester.rr.com>
References: <01fa01c412f5$ea4b2fe0$6501a8c0@rochester.rr.com>
Message-ID: <6.0.3.0.2.20040328214249.02777ec0@207.173.190.1>

Hi Catherine,

I believe my sysadm got the list moved over to our new list management 
software. I'll check with here.

Bob

At 09:48 PM 3/25/2004, you wrote:
>Dear Bob,
>
>
>   I followed the instructions to get the info from the listserv on how to
>accesss the archives (said to be in the welcome message one receives upon
>joining).  Below is what I received when I just followed the instructions.
>
>Regards,
>Catherine
>
>
>----- Original Message -----
>From: <majordomo at merlin.wizards.net>
>To: <ccreel at rochester.rr.com>
>Sent: Friday, March 26, 2004 12:28 AM
>Subject: Majordomo results
>
>
>| --
>|
>| >>>> info prvpracnp
>| Congratulations! You are now subscribed to the NPs in Private
>| Practice list at NP Central!
>|
>|
>| The NPs in Private Practice is a majordomo-based list serve.
>| This is a technological way of communicating with others on
>| the list. The NPs in Private Practice list is an automated
>| E-mail service that allows you to send and receive electronic
>| messages. The service is available to all NPs who are in
>| private practice or who are considering entering private
>| practice. There are a lot of complex issues unique to being
>| in private practice, and this is the place to discuss them!
>| If you've been in practice for 2 months or 20 years, we'd love
>| to have your comments, suggestions, questions, and advice
>| on the list.
>|
>|
>| If you would like, you can introduce yourself to the "NPs
>| in Private Practice" group, by stating where you are practicing,
>| how long you've been in practice, and any other questions
>| or comments you'd like to share.
>|
>|
>| Simply send your message with any comment,
>| question, etc. to the address of: prvpracnp at nurse.net.
>|
>|
>| If you ever have a question, e-mail us at: info at nurse.net.
>|
>|
>| If you ever want to remove yourself from this mailing list,
>| send mail to "majordomo at nurse.net" with the following
>| command in the body of your e-mail message:
>|
>|
>| unsubscribe prvpracnp your_e-mail_address
>| >>>> --
>| END OF COMMANDS

--
=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
Robert T. Smithing, MSN, FNP              bsmithing at nurse.net
Nurse Practitioner Central                       253.852.9042
10024 SE 240th St, #102, Kent, WA 98031        F 253.852.7725
www.npcentral.net                           www.npclinics.com
=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
   NP Central is a non-profit organization dedicated to the
practice development, advancement and educational support of
    Nurse Practitioners and to the promotion of accessible,
            quality, health care to the consumer. 



From ccreel at rochester.rr.com  Tue Mar 30 10:13:25 2004
From: ccreel at rochester.rr.com (C Creel)
Date: Tue, 30 Mar 2004 13:13:25 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in Cord and Maternal
	Serum Show Significant Neonate Exposure
Message-ID: <00c501c41682$b33e9880$6601a8c0@rochester.rr.com>

Greetings Everyone,


   Most of you are not going to be surprised by this results of this study.
I'll refrain from commenting further.

    I've pasted the PubMed abstract below the article.--Catherine



Title: Antidepressant Concentrations in Cord and Maternal Serum Show
Significant Neonate Exposure

Int J Neuropsychopharmacol 2004 Sep;1-6.[Epub ahead of print]. "A pilot
study of newer antidepressant concentrations in cord and maternal serum and
possible effects in the neonate"

03/30/2004
By Jill Taylor

>From Doctor's Guide
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256E6200267D
65?OpenDocument&c=Depression&count=10


Neonatal in utero exposure to antidepressants taken for maternal anxiety and
depression is significant, and may precipitate short-term adverse effects in
neonates after birth. Neonatal serotonin toxicity, the term used for
short-term adverse effects of fluoxetine and paroxetine taken during the
antenatal period on neonates, has been described in previous studies.
Investigating a potential relationship between the extent of neonatal in
utero antidepressant exposure and well-being after birth, Dr. Jonathan
Rampono of the Department of Psychological Medicine, King Edward Memorial
Hospital, Subiaco, Western Australia, and colleagues studied a cohort of 11
women in the last trimester of pregnancy who were taking antidepressant
medications. Four women were taking fluoxetine, 4 sertraline, 2 paroxetine,
and 1 venlafaxine. All had clinically established steady-state
antidepressant concentrations prior to delivery. Antidepressant assays were
performed using venous blood serum collected from the mother in the first
stage of labour, the umbilical cord soon after delivery, and infant heel on
day 5 after birth. Neonatal well-being was determined by gestation age,
birth weight, Apgar score at birth, and Neonatal Abstinence Scores (NAS) on
each of the first 3 days postpartum. A significant in utero exposure was
observed for all drugs tested, with cord:maternal serum ratios being a mean
of 0.52 for paroxetine, and a median of 0.67 for sertraline, 0.63 for
N-desmethylsertraline (metabolite), 0.67 for fluoxetine, 0.72 for
norfluoxetine (metabolite), 1.1 for venlafaxine (single case), and 1 for
O-desmethylvenlafaxine (metabolite, single case). At birth, children were on
average 38 weeks of gestational age and weighed 2.88 kg, with generally good
to excellent Apgar scores. NAS scores were mildly increased for half of the
neonates exposed to fluoxetine, and in 1 twin exposed to paroxetine. Only
fluoxetine and norfluoxetine were measurable in day 5 infant serum samples.
Based on their results, Dr. Rampono and colleagues hypothesise that low
clearance of antidepressants may predispose neonates to 'neonatal serotonin
toxicity,' and recommend further study in a larger population.
==========================================

Int J Neuropsychopharmacol. 2004 Sep;:1-6. [Epub ahead of print]


A pilot study of newer antidepressant concentrations in cord and maternal
serum and possible effects in the neonate.

Rampono J, Proud S, Hackett LP, Kristensen JH, Ilett KF.

Department of Psychological Medicine, Womens and Childrens Health Service
Subiaco, WA, Australia.

Antidepressants are often used antenatally, and placental transfer may lead
to adverse effects (toxicity) in the neonate. Pregnant women taking
fluoxetine (n=4), sertraline (n=4), paroxetine (n=2) or venlafaxine (n=1) in
the last trimester were studied. Maternal and cord sera were collected at
delivery and infant serum on day 5 after birth for measurement of
antidepressant concentrations. Neonatal Abstinence Scores (NAS) were
measured in the infants on days 13 after birth. In maternal serum, median
drug concentrations were: fluoxetine (96 gl), norfluoxetine (110 gl),
sertraline (11 gl), desmethylsertraline (38 gl), paroxetine (mean 12 gl),
venlafaxine (220 gl), and O-desmethylvenlafaxine (392 gl). Corresponding
median values in cord serum were: fluoxetine (65 gl), norfluoxetine (81 gl),
sertraline (10 gl), desmethylsertraline (27 gl), paroxetine (mean 6 gl),
venlafaxine (232 gl), and O-desmethylvenlafaxine (406 gl). Corresponding
median cordmaternal concentration ratios were 0.67 for fluoxetine and 0.72
for norfluoxetine, 0.67 for sertraline and 0.63 for demethylsertraline, 0.52
(mean) for paroxetine, and 1.1 and 1.0 for venlafaxine and
O-desmethylvenlafaxine respectively. The neonates of two patients taking
fluoxetine had high NAS. Only fluoxetine and norfluoxetine were detected in
infant serum. Our data show substantial placental transfer of
antidepressants, but only fluoxetine persisted in the infants serum.
Neonatal toxicity may be associated with serotonin uptake blockade, and also
be influenced by neonatal clearance.

PMID: 15035694 [PubMed - as supplied by publisher]

----------------------------------------------------------------------------
----








From harriet_james at usa.net  Mon Mar 29 12:41:12 2004
From: harriet_james at usa.net (Harriet James)
Date: Mon, 29 Mar 2004 13:41:12 -0700
Subject: [PrvPracNP] RE: [NPinfo] CIGNA WEBSITE excludes NP's
In-Reply-To: <PKEDIBHEGKJAPEHFEPMOMEEACJAA.prispunnyfnp@metrocast.net>
Message-ID: <200403292038.i2TKc0Q30891@merlin.wizards.net>

I am listed with Cigna on their website. Use link below.


http://cigna.benefitnation.net/cigna/(a4cxhgrjlbz32wrgbujdppqb)/searchresult
.aspx?txtAddress=&zip=87144&radius=5&searchType=phys&searchName=James&city=&
state=&productplan=H&netid=NM802&role=P&Pspec=&Sspec=&hospaff=&sex=F&lang=
Harriet James, CNP
Enchanted Hills Family Healthcare
4351 Jager Dr NE, Suite C
Rio Rancho, NM 87144
505-771-1180  Fax: 505-771-2688 



> _____________________________________________ 
> From: 	owner-npinfo at nurse.net [mailto:owner-npinfo at nurse.net]  On
> Behalf Of Priscilla Merrill
> Sent:	Friday, March 26, 2004 3:42 AM
> To:	NP Info; Lisah K. Carpenter; Prvpracnp
> Subject:	[NPinfo] CIGNA WEBSITE excludes NP's
> 
> Call to action for brave souls.
> Have you visited Cigna.com and looked for yourself in the provider
> directory?  Have you noticed we are totally excluded and is physician only
> provider directory?  I spent much time on phone and no one could explain
> why.  I am in their system but am not visible to patients or to anyone
> else looking for a provider.  PCP is designated primary care physician,
> not provider.  
> After speaking to 4 people and getting nowhere, I decided to put this out
> there and flood them with complaint calls about their verbiage of
> exclusion.  Please first check for yourself by looking yourself up (maybe
> this is unique to New Hampshire?) and then if you're upset, call them (see
> provider relations under customer service for your state).
> While I'm on a rampage, I must ask if any of you have had luck with
> Mailhandlers covering NP services?  They are now under First Health and
> after spending an hour on the phone with no one who had heard of a nurse
> practitioner, I sent the patient elsewhere.  They were very condescending
> and kept telling me I was working outside of my expertise!  They will
> cover us as specialists but not PCP's.  It was sad to me to hear that not
> one person on their provider relations staff had heard of nurse
> practitioners.  They are government sponsored so the red tape to change it
> must be a huge process. They only consider pcp's primary care physicians
> regardless of our independent practice status.
> 
> Yours in frustration,
> 
> Priscilla Merrill ARNP
> 
> ---
> Outgoing mail is certified Virus Free.
> Checked by AVG anti-virus system (http://www.grisoft.com).
> Version: 6.0.637 / Virus Database: 408 - Release Date: 3/20/2004
>  
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From harriet_james at usa.net  Mon Mar 29 14:12:23 2004
From: harriet_james at usa.net (Harriet James)
Date: Mon, 29 Mar 2004 15:12:23 -0700
Subject: [PrvPracNP] RE: [NPinfo] CIGNA WEBSITE excludes NP's
In-Reply-To: <PKEDIBHEGKJAPEHFEPMOMEEACJAA.prispunnyfnp@metrocast.net>
Message-ID: <200403292209.i2TM9CQ01958@merlin.wizards.net>

Priscilla, click on physician, put in your zip code, distance, continue,
select health plan, click on Primary Care Physician, do NOT select type,
select gender, continue. See if you come up that way.

Harriet James, CNP
Enchanted Hills Family Healthcare
4351 Jager Dr NE, Suite C
Rio Rancho, NM 87144
505-771-1180  Fax: 505-771-2688 



> _____________________________________________ 
> From: 	owner-npinfo at nurse.net [mailto:owner-npinfo at nurse.net]  On
> Behalf Of Priscilla Merrill
> Sent:	Friday, March 26, 2004 3:42 AM
> To:	NP Info; Lisah K. Carpenter; Prvpracnp
> Subject:	[NPinfo] CIGNA WEBSITE excludes NP's
> 
> Call to action for brave souls.
> Have you visited Cigna.com and looked for yourself in the provider
> directory?  Have you noticed we are totally excluded and is physician only
> provider directory?  I spent much time on phone and no one could explain
> why.  I am in their system but am not visible to patients or to anyone
> else looking for a provider.  PCP is designated primary care physician,
> not provider.  
> After speaking to 4 people and getting nowhere, I decided to put this out
> there and flood them with complaint calls about their verbiage of
> exclusion.  Please first check for yourself by looking yourself up (maybe
> this is unique to New Hampshire?) and then if you're upset, call them (see
> provider relations under customer service for your state).
> While I'm on a rampage, I must ask if any of you have had luck with
> Mailhandlers covering NP services?  They are now under First Health and
> after spending an hour on the phone with no one who had heard of a nurse
> practitioner, I sent the patient elsewhere.  They were very condescending
> and kept telling me I was working outside of my expertise!  They will
> cover us as specialists but not PCP's.  It was sad to me to hear that not
> one person on their provider relations staff had heard of nurse
> practitioners.  They are government sponsored so the red tape to change it
> must be a huge process. They only consider pcp's primary care physicians
> regardless of our independent practice status.
> 
> Yours in frustration,
> 
> Priscilla Merrill ARNP
> 
> ---
> Outgoing mail is certified Virus Free.
> Checked by AVG anti-virus system (http://www.grisoft.com).
> Version: 6.0.637 / Virus Database: 408 - Release Date: 3/20/2004
>  
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From pamme at sbcglobal.net  Tue Mar 30 16:09:22 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Tue, 30 Mar 2004 19:09:22 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in Cord and
	MaternalSerum Show Significant Neonate Exposure
References: <00c501c41682$b33e9880$6601a8c0@rochester.rr.com>
Message-ID: <002701c416b4$6c478f90$209cfea9@VAIO>

Although this study has a significantly low population, SSRI's have never
been recommended in pregnant woman.  We, in the mental health field, never
prescribe these medications to any pregnant woman, unless failure to do so
may result in the suicide of the mother.  At that point, we defer to the OB,
who usually recommends a TCA in the first trimester only.
Regards,
Pamme
~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "C Creel" <ccreel at rochester.rr.com>
To: "C Creel" <ccreel at rochester.rr.com>
Sent: Tuesday, March 30, 2004 1:13 PM
Subject: [PrvPracNP] Antidepressant Concentrations in Cord and MaternalSerum
Show Significant Neonate Exposure


> Greetings Everyone,
>
>
>    Most of you are not going to be surprised by this results of this
study.
> I'll refrain from commenting further.
>
>     I've pasted the PubMed abstract below the article.--Catherine
>
>
>
> Title: Antidepressant Concentrations in Cord and Maternal Serum Show
> Significant Neonate Exposure
>
> Int J Neuropsychopharmacol 2004 Sep;1-6.[Epub ahead of print]. "A pilot
> study of newer antidepressant concentrations in cord and maternal serum
and
> possible effects in the neonate"
>
> 03/30/2004
> By Jill Taylor
>
> >From Doctor's Guide
>
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256E6200267D
> 65?OpenDocument&c=Depression&count=10
>
>
> Neonatal in utero exposure to antidepressants taken for maternal anxiety
and
> depression is significant, and may precipitate short-term adverse effects
in
> neonates after birth. Neonatal serotonin toxicity, the term used for
> short-term adverse effects of fluoxetine and paroxetine taken during the
> antenatal period on neonates, has been described in previous studies.
> Investigating a potential relationship between the extent of neonatal in
> utero antidepressant exposure and well-being after birth, Dr. Jonathan
> Rampono of the Department of Psychological Medicine, King Edward Memorial
> Hospital, Subiaco, Western Australia, and colleagues studied a cohort of
11
> women in the last trimester of pregnancy who were taking antidepressant
> medications. Four women were taking fluoxetine, 4 sertraline, 2
paroxetine,
> and 1 venlafaxine. All had clinically established steady-state
> antidepressant concentrations prior to delivery. Antidepressant assays
were
> performed using venous blood serum collected from the mother in the first
> stage of labour, the umbilical cord soon after delivery, and infant heel
on
> day 5 after birth. Neonatal well-being was determined by gestation age,
> birth weight, Apgar score at birth, and Neonatal Abstinence Scores (NAS)
on
> each of the first 3 days postpartum. A significant in utero exposure was
> observed for all drugs tested, with cord:maternal serum ratios being a
mean
> of 0.52 for paroxetine, and a median of 0.67 for sertraline, 0.63 for
> N-desmethylsertraline (metabolite), 0.67 for fluoxetine, 0.72 for
> norfluoxetine (metabolite), 1.1 for venlafaxine (single case), and 1 for
> O-desmethylvenlafaxine (metabolite, single case). At birth, children were
on
> average 38 weeks of gestational age and weighed 2.88 kg, with generally
good
> to excellent Apgar scores. NAS scores were mildly increased for half of
the
> neonates exposed to fluoxetine, and in 1 twin exposed to paroxetine. Only
> fluoxetine and norfluoxetine were measurable in day 5 infant serum
samples.
> Based on their results, Dr. Rampono and colleagues hypothesise that low
> clearance of antidepressants may predispose neonates to 'neonatal
serotonin
> toxicity,' and recommend further study in a larger population.
> ==========================================
>
> Int J Neuropsychopharmacol. 2004 Sep;:1-6. [Epub ahead of print]
>
>
> A pilot study of newer antidepressant concentrations in cord and maternal
> serum and possible effects in the neonate.
>
> Rampono J, Proud S, Hackett LP, Kristensen JH, Ilett KF.
>
> Department of Psychological Medicine, Womens and Childrens Health Service
> Subiaco, WA, Australia.
>
> Antidepressants are often used antenatally, and placental transfer may
lead
> to adverse effects (toxicity) in the neonate. Pregnant women taking
> fluoxetine (n=4), sertraline (n=4), paroxetine (n=2) or venlafaxine (n=1)
in
> the last trimester were studied. Maternal and cord sera were collected at
> delivery and infant serum on day 5 after birth for measurement of
> antidepressant concentrations. Neonatal Abstinence Scores (NAS) were
> measured in the infants on days 13 after birth. In maternal serum, median
> drug concentrations were: fluoxetine (96 gl), norfluoxetine (110 gl),
> sertraline (11 gl), desmethylsertraline (38 gl), paroxetine (mean 12 gl),
> venlafaxine (220 gl), and O-desmethylvenlafaxine (392 gl). Corresponding
> median values in cord serum were: fluoxetine (65 gl), norfluoxetine (81
gl),
> sertraline (10 gl), desmethylsertraline (27 gl), paroxetine (mean 6 gl),
> venlafaxine (232 gl), and O-desmethylvenlafaxine (406 gl). Corresponding
> median cordmaternal concentration ratios were 0.67 for fluoxetine and 0.72
> for norfluoxetine, 0.67 for sertraline and 0.63 for demethylsertraline,
0.52
> (mean) for paroxetine, and 1.1 and 1.0 for venlafaxine and
> O-desmethylvenlafaxine respectively. The neonates of two patients taking
> fluoxetine had high NAS. Only fluoxetine and norfluoxetine were detected
in
> infant serum. Our data show substantial placental transfer of
> antidepressants, but only fluoxetine persisted in the infants serum.
> Neonatal toxicity may be associated with serotonin uptake blockade, and
also
> be influenced by neonatal clearance.
>
> PMID: 15035694 [PubMed - as supplied by publisher]
>
> --------------------------------------------------------------------------
--
> ----
>
>
>
>
>
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From ccreel at rochester.rr.com  Tue Mar 30 16:28:31 2004
From: ccreel at rochester.rr.com (C Creel)
Date: Tue, 30 Mar 2004 19:28:31 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in Cord
	andMaternalSerum Show Significant Neonate Exposure
References: <00c501c41682$b33e9880$6601a8c0@rochester.rr.com>
	<002701c416b4$6c478f90$209cfea9@VAIO>
Message-ID: <014c01c416b7$18d11b80$6601a8c0@rochester.rr.com>

Dear Pamme,


   You said:

<<Although this study has a significantly low population, SSRI's have never
been recommended in pregnant woman.  We, in the mental health field, never
prescribe these medications to any pregnant woman, unless failure to do so
may result in the suicide of the mother.  At that point, we defer to the OB,
who usually recommends a TCA in the first trimester only.>>


  **  WEll, bless the docs you're hanging around! ;-)  I tend to get women
in a panic because they were told it was fine to continue on their SSRI or
'atypical' AD and then they read something that concerns them.


    There is currently a database kept by GlaxoSmithKline on pregnancy
outcomes for women taking Wellbutrin.  I believe they've been keeping this
for 2 years now.  The last report I saw (issued quarterly) showed some
significant increases in miscarriages and birth defects compared to a
control group not taking an antidepressant.  I will try to come up with the
report and send it if anyone is interested.

Regards,
Catherine



From pamme at sbcglobal.net  Tue Mar 30 18:24:08 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Tue, 30 Mar 2004 21:24:08 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in CordandMaternalSerum
	Show Significant Neonate Exposure
References: <00c501c41682$b33e9880$6601a8c0@rochester.rr.com><002701c416b4$6c478f90$209cfea9@VAIO>
	<014c01c416b7$18d11b80$6601a8c0@rochester.rr.com>
Message-ID: <00be01c416c7$3f511d40$209cfea9@VAIO>

Doc's smocks.  LOL.
I keep current in the literature.
The docs ask me for advice on special populations LOL.
Peace,
Pamme
~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "C Creel" <ccreel at rochester.rr.com>
To: "Private Practice NPs" <prvpracnp at nurse.net>
Sent: Tuesday, March 30, 2004 7:28 PM
Subject: Re: [PrvPracNP] Antidepressant Concentrations in
CordandMaternalSerum Show Significant Neonate Exposure


> Dear Pamme,
>
>
>    You said:
>
> <<Although this study has a significantly low population, SSRI's have
never
> been recommended in pregnant woman.  We, in the mental health field, never
> prescribe these medications to any pregnant woman, unless failure to do so
> may result in the suicide of the mother.  At that point, we defer to the
OB,
> who usually recommends a TCA in the first trimester only.>>
>
>
>   **  WEll, bless the docs you're hanging around! ;-)  I tend to get women
> in a panic because they were told it was fine to continue on their SSRI or
> 'atypical' AD and then they read something that concerns them.
>
>
>     There is currently a database kept by GlaxoSmithKline on pregnancy
> outcomes for women taking Wellbutrin.  I believe they've been keeping this
> for 2 years now.  The last report I saw (issued quarterly) showed some
> significant increases in miscarriages and birth defects compared to a
> control group not taking an antidepressant.  I will try to come up with
the
> report and send it if anyone is interested.
>
> Regards,
> Catherine
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From SamaraFNP at aol.com  Tue Mar 30 19:21:16 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Tue, 30 Mar 2004 22:21:16 EST
Subject: [PrvPracNP] Antidepressant Concentrations in Cord
	andMaternalSerum Show S...
Message-ID: <68.3d03080a.2d9b932c@aol.com>

I've had physicians tell me it was perfectly fine for a pregnant woman to 
continue at least in the first trimester on their antidepressants, always an 
SSRI.  I called the obstetrician 2 years ago when a patient of mine her early 30's 
on zoloft for 2 years found out she was 2 months pregnant and he said to have 
her continue and to wean off slowly if she wanted to.  She stayed on it for 4 
months and had a healthy baby about a year ago.

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From SamaraFNP at aol.com  Tue Mar 30 19:23:14 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Tue, 30 Mar 2004 22:23:14 EST
Subject: [PrvPracNP] Antidepressant Concentrations in Cord and Maternal
	Serum Show...
Message-ID: <22.44d0fed8.2d9b93a2@aol.com>

Yes, I heard of this study.  Keep in mind, it is the antenatal period, the 
3rd trimester. it is not about women in the first or 2nd trimester.  There are 
many drugs that cannot be taken in the first trimester that can be taken in the 
last and visa versa.  Always, the benifits have to outweigh the risks.

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From ccreel at rochester.rr.com  Tue Mar 30 22:24:42 2004
From: ccreel at rochester.rr.com (C Creel)
Date: Wed, 31 Mar 2004 01:24:42 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in
	Cord	andMaternalSerumShow S...
References: <68.3d03080a.2d9b932c@aol.com>
Message-ID: <004501c416e8$dab475e0$6601a8c0@rochester.rr.com>

Dear Marla,



  You said:


<<I've had physicians tell me it was perfectly fine for a pregnant woman to
continue at least in the first trimester on their antidepressants, always an
SSRI.  I called the obstetrician 2 years ago when a patient of mine her
early 30's on zoloft for 2 years found out she was 2 months pregnant and he
said to have her continue and to wean off slowly if she wanted to.  She
stayed on it for 4 months and had a healthy baby about a year ago.>>



   **  How "healthy" the child is remains to be seen as the child is only a
year old.

Regards,
Catherine



From SamaraFNP at aol.com  Wed Mar 31 04:08:07 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 07:08:07 EST
Subject: [PrvPracNP] Antidepressant Concentrations in Cord
	andMaternalSerumShow S...
Message-ID: <157.31757d07.2d9c0ea7@aol.com>

To all,
As for how healthy the baby is now, I do know at it was perfect at 1 as this 
person was my nurse.  She would have let me know if there were a problem.  
What we need to keep in mind, is there are many women who get pregnant while on 
SSRI (antidepressants) and they do not find out sometimes until they are nearly 
2 months in some cases.  NO OBGYN will tell someone to abruptly go off SSRI.  
I have had at least 6 patients as an NP in family practice to whom this 
happened.  You see I did counseling with a group in NY of couples who had been 
infertile.  MANY of the women were on SSRI due to depression related to not 
conceiving.  Most stayed on their meds when they conceived, some to the end, most 
stopped gradually by a month after finding out they were successful in 
conceiving.  I think being on NO meds is always the best in pregnancy but I assure 
women.  I was on proventil and theophylline and prednisone for my ENTIRE pregnancy 
and had adjusted to the fact my child might have a cleft palate.  He was fine 
and enters med school in JUly at UVA!  Sincerely,

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From pamme at sbcglobal.net  Wed Mar 31 04:30:09 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 07:30:09 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in
	CordandMaternalSerumShow S...
References: <157.31757d07.2d9c0ea7@aol.com>
Message-ID: <014d01c4171b$e8c77c80$209cfea9@VAIO>

You were truly blessed Marla.
Unfortunately, not all cases turn out that way.  Better safe than sorry.
Depending on the dosage of SSRI, and the specific SSRI, it may need to be weaned but can often be abruptly stopped as very few are on dosages high enough to require weaning.  The only exception is Paxil, as it can cause seizures and terrific neuropathy.
This is my field.   The only clinical trials of significant population were done on non-pregnant women.  The drug companies resist the liability involved in testing medications during pregnancy.  Most research is based on pregnant rats.
The research that Catherine presented, was on a very limited population that would not transpose through validity.  It is something to always consider.  I believe it was presented to enlighten and give pause when prescribing.
As we all know, there is risk involved in any drug that crosses the placental barrier.
You were very fortunate, as was your nurse.  But, would you want to risk the same on a patient and her unborn child?
I counsel my patients to let me know when they are thinking about pregnancy.  My patients are all on psychotropics.  They are strongly encouraged and I document it, that I counseled them to use birth control with any psychotropic.   IF they are considering pregnancy, we review how their emotional status will change and what behavioral options they have to get through the pregnancy.  
It is not so bad for those with Major Depression as we step up their therapy sessions and remain in close contact.  The ones with Schizophrenia and Bipolar Disorder are another story.  All must consider IF, since all three of the diseases are genetically predisposed, do they want to bring a child into the world that may carry the disease?
I urge all providers to discuss birth control options with their patients on any long term medications.
There is nothing sadder than a still birth or deformed baby after nine months of expectation of bringing a wonderful healthy life into this world.
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 7:08 AM
  Subject: Re: [PrvPracNP] Antidepressant Concentrations in CordandMaternalSerumShow S...


  To all,
  As for how healthy the baby is now, I do know at it was perfect at 1 as this person was my nurse.  She would have let me know if there were a problem.  What we need to keep in mind, is there are many women who get pregnant while on SSRI (antidepressants) and they do not find out sometimes until they are nearly 2 months in some cases.  NO OBGYN will tell someone to abruptly go off SSRI.  I have had at least 6 patients as an NP in family practice to whom this happened.  You see I did counseling with a group in NY of couples who had been infertile.  MANY of the women were on SSRI due to depression related to not conceiving.  Most stayed on their meds when they conceived, some to the end, most stopped gradually by a month after finding out they were successful in conceiving.  I think being on NO meds is always the best in pregnancy but I assure women.  I was on proventil and theophylline and prednisone for my ENTIRE pregnancy and had adjusted to the fact my child might have a cleft palate.  He was fine and enters med school in JUly at UVA!  Sincerely,

  Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)


------------------------------------------------------------------------------


  _______________________________________________
  PrvPracNP mailing list
  PrvPracNP at nurse.net
  http://lists.nurse.net/mailman/listinfo/prvpracnp



--------------------------------------------------------------------------------


You were truly blessed Marla.
Unfortunately, not all cases turn out that way.  Better safe than sorry.
Depending on the dosage of SSRI, and the specific SSRI, it may need to be weaned but can often be abruptly stopped as very few are on dosages high enough to require weaning.  The only exception is Paxil, as it can cause seizures and terrific neuropathy.
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 7:08 AM
  Subject: Re: [PrvPracNP] Antidepressant Concentrations in CordandMaternalSerumShow S...


  To all,
  As for how healthy the baby is now, I do know at it was perfect at 1 as this person was my nurse.  She would have let me know if there were a problem.  What we need to keep in mind, is there are many women who get pregnant while on SSRI (antidepressants) and they do not find out sometimes until they are nearly 2 months in some cases.  NO OBGYN will tell someone to abruptly go off SSRI.  I have had at least 6 patients as an NP in family practice to whom this happened.  You see I did counseling with a group in NY of couples who had been infertile.  MANY of the women were on SSRI due to depression related to not conceiving.  Most stayed on their meds when they conceived, some to the end, most stopped gradually by a month after finding out they were successful in conceiving.  I think being on NO meds is always the best in pregnancy but I assure women.  I was on proventil and theophylline and prednisone for my ENTIRE pregnancy and had adjusted to the fact my child might have a cleft palate.  He was fine and enters med school in JUly at UVA!  Sincerely,

  Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)


------------------------------------------------------------------------------


  _______________________________________________
  PrvPracNP mailing list
  PrvPracNP at nurse.net
  http://lists.nurse.net/mailman/listinfo/prvpracnp
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From SamaraFNP at aol.com  Wed Mar 31 15:11:26 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 18:11:26 -0500
Subject: [PrvPracNP] Antidepressant Concentrations in
	CordandMaternalSerumShow S...
Message-ID: <7187B9D1.402F4DE7.02824545@aol.com>

You are very knowledgeable.  I also wean Serzone, which is still prescribed.  I happen to like it for my anxious patients who can't sleep and are depressed. Some studies have shown that if you abuptly stop zoloft or celexa or lexapro, in about 3 weeks one can have a terrible "fall" in mood.  So I err on the side of caution and wean all SSRIs.  Yes, no drugs are better than any drug. but, as I said, my population was dealing with not being able to conceive and this was a support group for couples having problems due to this.  Most of the women were on ssri's and were wanting to get pregnant. This was a unique population.  Marla

Sincerely,
Marla Spring, RN MSN FNP-C MLC (Medical Legal Consultant)


From pamme at sbcglobal.net  Wed Mar 31 16:03:40 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 19:03:40 -0500
Subject: [PrvPracNP] Antidepressant Concentrations
	inCordandMaternalSerumShow S...
References: <7187B9D1.402F4DE7.02824545@aol.com>
Message-ID: <016301c4177c$ca6f6ca0$209cfea9@VAIO>

Very much so.
Do you refer them to therapists for their depression?
I avoid Serzone at all costs r/t the black box warning.
Seroquel is a much safer drug and is excellent in low doses for mood
stabilization and sleep disturbance.  But again, it is a Category C.
Best Wishes Marla!!  Sounds like you have it under control and I wouldn't
think anything less as I have come to appreciate your practice philosophy.
You Rock!!
Pamme

~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: <SamaraFNP at aol.com>
To: "Private Practice NPs" <prvpracnp at nurse.net>
Sent: Wednesday, March 31, 2004 6:11 PM
Subject: Re: [PrvPracNP] Antidepressant Concentrations
inCordandMaternalSerumShow S...


> You are very knowledgeable.  I also wean Serzone, which is still
prescribed.  I happen to like it for my anxious patients who can't sleep and
are depressed. Some studies have shown that if you abuptly stop zoloft or
celexa or lexapro, in about 3 weeks one can have a terrible "fall" in mood.
So I err on the side of caution and wean all SSRIs.  Yes, no drugs are
better than any drug. but, as I said, my population was dealing with not
being able to conceive and this was a support group for couples having
problems due to this.  Most of the women were on ssri's and were wanting to
get pregnant. This was a unique population.  Marla
>
> Sincerely,
> Marla Spring, RN MSN FNP-C MLC (Medical Legal Consultant)
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From SamaraFNP at aol.com  Wed Mar 31 16:52:26 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 19:52:26 EST
Subject: [PrvPracNP] Antidepressant Concentrations
	inCordandMaternalSerumShow S...
Message-ID: <12f.3e388b7a.2d9cc1ca@aol.com>

You are so positive my friend.  No, i rarely refer to psychiatrists.  I 
consult on the phone with them.  If they are truly anxious or depressed, they need 
what I have to offer and I do great with med management.  We in primary care 
are often given cmes in psychiatry in primary care or treating depression and 
anxiety in primary care.  There are too few psychiatrists nowadays and to get 
an appt for 15 min med managemtn may take up to 2 months or more.  I have many 
who I call if I need assistance.  I do not even attempt to manage 
schizophrenia or bipoloar unless psychiatrist has formally diagnosed and prescribed and 
gotten them stablized.  I used seraquill in the nursing homes a lot but it 
really drugged people (elderly).  I do like it in some cases of aggressive behavior 
in the elderly.  In your average anxious middle aged person  with clearly 
defined issues, serzone doesn't sedate by day but can really help them cope. It 
works great with situational depression, such as grief reactions.  See my web 
site at www.letstalkcounseling.com/sites/bodymindconnection   I value 
psychiatrists and psychologists input for many patients but we in primary care need to 
know how to handle it all.  We refer kids with unusual presentations to 
pediatricians who like it this way, and difficult psych patients but we handle the 
rest.  Again, thanks for your kind words and positive energy.

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From SamaraFNP at aol.com  Wed Mar 31 17:07:53 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 20:07:53 EST
Subject: [PrvPracNP] Antidepressant Concentrations
	inCordandMaternalSerumShow S...
Message-ID: <167.2d7a880c.2d9cc569@aol.com>

Oh, sorry for coming back again.  Serzone was out a long time before this 
warning came out with it.  I had no problems with about 60 people on it.  The 
ones who went off it out of fear were about 10.  The others are happy on it.  As 
for Seroquil, it may yet get some kind of study that shows some long term 
effects.  What doesn't have side effects.  But, like I tell my patients, the side 
effects of depression are suicide, unhappiness, inability to work, to carry on 
relationships etc.  You know I had so many patients call me who took 
themselves off lipitor when they heard about the rare side effects of liver disease 
and rhabdomyolysis,  When I told them the side effect of being OFF lipitor was 
heart attack, stroke etc, they went back on.  You know now they say lipitor and 
other statins like zocor can actually predispose people to heart disease.  
WHo knows.  I know seroquil can depress bone marrow, but this is rare and if it 
is the drug your patient needs, again the risk/benifit ratio must be 
considered.  I always inform my patients that all drugs have side effects and that it 
cannot just "fix your arthritis in your knee and not go to any other part of 
your body>"  
Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From pamme at sbcglobal.net  Wed Mar 31 17:31:03 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 20:31:03 -0500
Subject: [PrvPracNP] Psychotropics et al/risk vs benefits
References: <167.2d7a880c.2d9cc569@aol.com>
Message-ID: <022001c41788$ffa12b00$209cfea9@VAIO>

I used to put my patients on Serzone.  Then, I started taking EKGs routinely.  I was working in the VA system at the time.  I discovered the prolongation of the QTc without symptoms, long before the black box warning came out.
I love Seroquel and have prescribed it and taken it.  I don't like giving something to my patients without knowing what the effects might be.  It is the safest of the neuroleptics.  It's best use is as a sleeping and anti anxiety aid.   But it is strong stuff.  25mg knocked me out for 12 hours and I was fuzzy for another 12.  It biggest side effect is that it creates a tremendous hunger in some people and that yields weight gain.
I took Lipitor for hyperlipidemia.  Was on it for 6 months without incident.  Then, the provider I was seeing ran out of samples.  I was switched to Baycol before the warning.  I developed Rhabdomylosis and subsequent long term effects, i.e., FMS.  Thank goodness my kidneys are ok and they took the drug off the market.
You are very smart to give your patients the risks and benefits of controversial drugs.  Do you have them sign a paper stating that you have educated and that they understand the risk and benefits of the medication.  That they freely, with informed consent agree to the treatment?  
Remember the two caveats:  Do No Harm and Cover Thy Butt.
Love,
      ~:~~:~aka  
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 8:07 PM
  Subject: Re: [PrvPracNP] Antidepressant ConcentrationsinCordandMaternalSerumShow S...


  Oh, sorry for coming back again.  Serzone was out a long time before this warning came out with it.  I had no problems with about 60 people on it.  The ones who went off it out of fear were about 10.  The others are happy on it.  As for Seroquil, it may yet get some kind of study that shows some long term effects.  What doesn't have side effects.  But, like I tell my patients, the side effects of depression are suicide, unhappiness, inability to work, to carry on relationships etc.  You know I had so many patients call me who took themselves off lipitor when they heard about the rare side effects of liver disease and rhabdomyolysis,  When I told them the side effect of being OFF lipitor was heart attack, stroke etc, they went back on.  You know now they say lipitor and other statins like zocor can actually predispose people to heart disease.  WHo knows.  I know seroquil can depress bone marrow, but this is rare and if it is the drug your patient needs, again the risk/benifit ratio must be considered.  I always inform my patients that all drugs have side effects 
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From pamme at sbcglobal.net  Wed Mar 31 17:40:17 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 20:40:17 -0500
Subject: [PrvPracNP] Board Certification
References: <12f.3e388b7a.2d9cc1ca@aol.com>
Message-ID: <025001c4178a$4a2745f0$209cfea9@VAIO>

My board certification is in Family Practice.  I have practiced primary care, and didn't care for it.  I prefer to specialize and that is why I went into psychiatry.  Now with the lack of psychiatrists nationwide, it is a big business for NPs.
Have you ever taken Serzone?
Give it a try sometime.  Talk about anticholinergic effects.  Whoa!!  LOL.
Yep, it relaxes, but the SE's are not risk the worth in my practice.  
And God bless you for taking those fertility patients.  Your malpractice insurance must cost a mint.  
I was bummed as in this state, I had to pay double because Indiana has a Patient Compensation Fund that most third party payers insist one is enrolled in.  Course that limits the amount a patient can sue for but in just starting up a private practice, it was a 
, aka Psychiatric Provider
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 7:52 PM
  Subject: Re: [PrvPracNP] Antidepressant ConcentrationsinCordandMaternalSerumShow S...


  You are so positive my friend.  No, i rarely refer to psychiatrists.  I consult on the phone with them.  If they are truly anxious or depressed, they need what I have to offer and I do great with med management.  We in primary care are often given cmes in psychiatry in primary care or treating depression and anxiety in primary care.  There are too few psychiatrists nowadays and to get an appt for 15 min med managemtn may take up to 2 months or more.  I have many who I call if I need assistance.  I do not even attempt to manage schizophrenia or bipoloar unless psychiatrist has formally diagnosed and prescribed and gotten them stablized.  I used seraquill in the nursing homes a lot but it really drugged people (elderly).  I do like it in some cases of aggressive behavior in the elderly.  In your average anxious middle aged person  with clearly defined issues, serzone doesn't sedate by day but can really help them cope. It works great with situational depression, such as grief reactions.  See my web site at www.letstalkcounseling.com/sites/bodymindconnection   I value psychiatrists and psychologists input for many patients but we in primary care need to know how to handle it all.  We refer kids with unusual presentations to pediatricians who like it this way, and difficult psych patients but we handle the rest.  Again, thanks for your kind words and positive energy.
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From buckwheat at cybernet1.com  Wed Mar 31 18:00:02 2004
From: buckwheat at cybernet1.com (Alex Wagner)
Date: Wed, 31 Mar 2004 19:00:02 -0700
Subject: [PrvPracNP] bipolar
Message-ID: <6.0.3.0.0.20040331185852.01f115e8@mail.cybernet1.com>

I need some suggestion for a teenage diagnoses by psychiatrist for bipolar 
is very dizzy on Lithium.  What else are you guys using for this in this 
age group with less side effects.


---
[This E-mail scanned for viruses]



From pamme at sbcglobal.net  Wed Mar 31 17:59:29 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 20:59:29 -0500
Subject: [PrvPracNP] bipolar
References: <6.0.3.0.0.20040331185852.01f115e8@mail.cybernet1.com>
Message-ID: <029f01c4178c$f857f230$209cfea9@VAIO>

Topamax.  Works well, they don't need blood draws and they don't gain a
bunch of weight.
Regards,
Pamme
~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Alex Wagner" <buckwheat at cybernet1.com>
To: <prvpracnp at nurse.net>
Sent: Wednesday, March 31, 2004 9:00 PM
Subject: [PrvPracNP] bipolar


> I need some suggestion for a teenage diagnoses by psychiatrist for bipolar
> is very dizzy on Lithium.  What else are you guys using for this in this
> age group with less side effects.
>
>
> ---
> [This E-mail scanned for viruses]
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From SamaraFNP at aol.com  Wed Mar 31 18:30:52 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 21:30:52 EST
Subject: [PrvPracNP] bipolar
Message-ID: <144.25be0f25.2d9cd8dc@aol.com>

Valproic Acid (depakote), 

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From SamaraFNP at aol.com  Wed Mar 31 18:31:21 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 21:31:21 EST
Subject: [PrvPracNP] bipolar
Message-ID: <8d.722d2d2.2d9cd8f9@aol.com>

yes, topamax is good.

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From pamme at sbcglobal.net  Wed Mar 31 18:36:12 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 21:36:12 -0500
Subject: [PrvPracNP] bipolar
References: <8d.722d2d2.2d9cd8f9@aol.com>
Message-ID: <030b01c41792$1943e300$209cfea9@VAIO>

tx for the agreement Marla.  Okay if we can get one more person to agree, then not only is it a truism, it is almost an impossible feat.  
It's like 5 cardiologists reading the same EKG and all 5 have different diagnoses. 
LMAO.  I am in a very humorous state today.
Love ya,
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 9:31 PM
  Subject: Re: [PrvPracNP] bipolar


  yes, topamax is good.

  Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)


------------------------------------------------------------------------------


  _______________________________________________
  PrvPracNP mailing list
  PrvPracNP at nurse.net
  http://lists.nurse.net/mailman/listinfo/prvpracnp
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From SamaraFNP at aol.com  Wed Mar 31 18:37:37 2004
From: SamaraFNP at aol.com (SamaraFNP at aol.com)
Date: Wed, 31 Mar 2004 21:37:37 EST
Subject: [PrvPracNP] Psychotropics et al/risk vs benefits
Message-ID: <15c.30f1a29c.2d9cda71@aol.com>

I have a pat statement in my notes in the computer that says, pat has been 
informed etc etc.  Some patients, I have actualy sign my statement in thier note 
if hand written.  I don't give all the side effects as patients will have 
them.  Well, yes, I did take serzone.  I put myself on it 5 months before my 
mother died from ovarian cancer.  I was the only child taking care of her with her 
fear, my fear etc and sleep became impossible.  I took 150mg bid for those 
months and then for 6 months after she died and then slowly weaned myself off 
it.  outside of dry mouth which did not impact me as a singer (I sing with the 
roanoke symphony), I had no side effects.  It enabled me to sleep, to feel like 
I could cope and help my early alzheimers' dad cope and make all the 
arrangements that I had to and still work full time etc.  I only needed meds for under 
a year but I'm greatful to serzone for helping me get thru.  That was in 1999 
before all the controversy.  

Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)
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From pamme at sbcglobal.net  Wed Mar 31 18:41:49 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 21:41:49 -0500
Subject: [PrvPracNP] Psychotropics et al/risk vs benefits
References: <15c.30f1a29c.2d9cda71@aol.com>
Message-ID: <032c01c41792$e2d6f9a0$209cfea9@VAIO>

Dang woman you had a rough go of it.  You are one strong lady!!
Hey GF, I'm a singer also: Church choir and repetoire theatre.
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: SamaraFNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 9:37 PM
  Subject: Re: [PrvPracNP] Psychotropics et al/risk vs benefits


  I have a pat statement in my notes in the computer that says, pat has been informed etc etc.  Some patients, I have actualy sign my statement in thier note if hand written.  I don't give all the side effects as patients will have them.  Well, yes, I did take serzone.  I put myself on it 5 months before my mother died from ovarian cancer.  I was the only child taking care of her with her fear, my fear etc and sleep became impossible.  I took 150mg bid for those months and then for 6 months after she died and then slowly weaned myself off it.  outside of dry mouth which did not impact me as a singer (I sing with the roanoke symphony), I had no side effects.  It enabled me to sleep, to feel like I could cope and help my early alzheimers' dad cope and make all the arrangements that I had to and still work full time etc.  I only needed meds for under a year but I'm greatful to serzone for helping me get thru.  That was in 1999 before all the controversy.  

  Marla Spring, RN, FNP-C, MSN, MLC (medical legal consultant)


------------------------------------------------------------------------------


  _______________________________________________
  PrvPracNP mailing list
  PrvPracNP at nurse.net
  http://lists.nurse.net/mailman/listinfo/prvpracnp
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From nravey at bellsouth.net  Wed Mar 31 19:58:08 2004
From: nravey at bellsouth.net (Nina Ravey)
Date: Wed, 31 Mar 2004 21:58:08 -0600
Subject: [PrvPracNP] bipolar
In-Reply-To: <6.0.3.0.0.20040331185852.01f115e8@mail.cybernet1.com>
Message-ID: <20040401035829.SEBS1775.imf19aec.mail.bellsouth.net@nina>

Just went to a seminar where psychiatrist talked about anti-psychotics and
Seroquel was suggested as one of the safest with out black box warning, not
tounted to cause diabetes.  Works well if you start with 100mg bid and
titrate up every day by 100 until you reach the 800 dose range.
I've used it and it works well on bipolar.  Depakote also works well.
He also explained that the drugs may be used in children and adolescents.
Nina

Nina Ravey, RN, MSN, CNS, C-FNP
Family Nurse Practitioner
Shirley Medical Clinic
711 N. Main St.
Jennings, LA 70546
337-824-2002
Fax:337-824-2004
www.shirleymedical.com
Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
Management, Physical Medicine and Rehabilitation, Diabetic Education
Classes, Walk-ins, Appointments


"It never ceases to amaze me how being a good nurse is often in direct
opposition to being a "good employee."

 

-----Original Message-----
From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
Behalf Of Alex Wagner
Sent: Wednesday, March 31, 2004 8:00 PM
To: prvpracnp at nurse.net
Subject: [PrvPracNP] bipolar

I need some suggestion for a teenage diagnoses by psychiatrist for bipolar 
is very dizzy on Lithium.  What else are you guys using for this in this 
age group with less side effects.


---
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PrvPracNP at nurse.net
http://lists.nurse.net/mailman/listinfo/prvpracnp



From nravey at bellsouth.net  Wed Mar 31 20:01:28 2004
From: nravey at bellsouth.net (Nina Ravey)
Date: Wed, 31 Mar 2004 22:01:28 -0600
Subject: [PrvPracNP] bipolar
In-Reply-To: <6.0.3.0.0.20040331185852.01f115e8@mail.cybernet1.com>
Message-ID: <20040401040133.NGRC1746.imf17aec.mail.bellsouth.net@nina>

Just went to a seminar where psychiatrist talked about anti-psychotics and
Seroquel was suggested as one of the safest with out black box warning, not
tounted to cause diabetes.  Works well if you start with 100mg bid and
titrate up every day by 100 until you reach the 800 dose range.
I've used it and it works well on bipolar.  Depakote also works well.
He also explained that the drugs may be used in children and adolescents.
Nina

Nina Ravey, RN, MSN, CNS, C-FNP
Family Nurse Practitioner
Shirley Medical Clinic
711 N. Main St.
Jennings, LA 70546
337-824-2002
Fax:337-824-2004
www.shirleymedical.com
Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
Management, Physical Medicine and Rehabilitation, Diabetic Education
Classes, Walk-ins, Appointments


"It never ceases to amaze me how being a good nurse is often in direct
opposition to being a "good employee."

 

-----Original Message-----
From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
Behalf Of Alex Wagner
Sent: Wednesday, March 31, 2004 8:00 PM
To: prvpracnp at nurse.net
Subject: [PrvPracNP] bipolar

I need some suggestion for a teenage diagnoses by psychiatrist for bipolar 
is very dizzy on Lithium.  What else are you guys using for this in this 
age group with less side effects.


---
[This E-mail scanned for viruses]

_______________________________________________
PrvPracNP mailing list
PrvPracNP at nurse.net
http://lists.nurse.net/mailman/listinfo/prvpracnp



From pamme at sbcglobal.net  Wed Mar 31 20:50:47 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 23:50:47 -0500
Subject: [PrvPracNP] bipolar
References: <20040401035829.SEBS1775.imf19aec.mail.bellsouth.net@nina>
Message-ID: <033e01c417a4$e6b60360$209cfea9@VAIO>

Having used Seroquel with hundreds of patients, I advise against starting at
100mg bid.  The patients experience significant somnolence and tremendous
hunger.  Compliance is definitely at risk.  If you choose to use Seroquel,
which works well with a manic or hypomanic presentation in Bipolar I, I
suggest that you start at 25mg Q 1300 and qhs.  Titrating up every 3-5 days
avoids side effects and makes compliance more expected.  The 100mg bid to
start in a teenager is not advised, particularly if manic or hypomanic, as
the teenage psyche is geared towards the enjoyment of that state of mind.
Kill that intrinsic feeling and you may sacrifice the benefit of the drug
from slow titration.
Topamax, on the other hand, does not cause somnolence and the patient does
not feel drugged.  Based on experience and research, I recommend the use of
Topamax first and do agree that Seroquel is a viable second alternative.
Other research recommends Geodon at 80mg bid for bipolar.  However, it is
not as safe as Topamax nor Seroquel and often lacks efficacy.
In addition, Topamax has a direct action on the temporal and prefrontal
lobes.  It dampens impulsivity and mania.
Pamela A. Provost N.P.
Psychiatric Provider
~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Nina Ravey" <nravey at bellsouth.net>
To: "'Private Practice NPs'" <prvpracnp at nurse.net>
Sent: Wednesday, March 31, 2004 10:58 PM
Subject: RE: [PrvPracNP] bipolar


> Just went to a seminar where psychiatrist talked about anti-psychotics and
> Seroquel was suggested as one of the safest with out black box warning,
not
> tounted to cause diabetes.  Works well if you start with 100mg bid and
> titrate up every day by 100 until you reach the 800 dose range.
> I've used it and it works well on bipolar.  Depakote also works well.
> He also explained that the drugs may be used in children and adolescents.
> Nina
>
> Nina Ravey, RN, MSN, CNS, C-FNP
> Family Nurse Practitioner
> Shirley Medical Clinic
> 711 N. Main St.
> Jennings, LA 70546
> 337-824-2002
> Fax:337-824-2004
> www.shirleymedical.com
> Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
> Management, Physical Medicine and Rehabilitation, Diabetic Education
> Classes, Walk-ins, Appointments
>
>
> "It never ceases to amaze me how being a good nurse is often in direct
> opposition to being a "good employee."
>
>
>
> -----Original Message-----
> From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
> Behalf Of Alex Wagner
> Sent: Wednesday, March 31, 2004 8:00 PM
> To: prvpracnp at nurse.net
> Subject: [PrvPracNP] bipolar
>
> I need some suggestion for a teenage diagnoses by psychiatrist for bipolar
> is very dizzy on Lithium.  What else are you guys using for this in this
> age group with less side effects.
>
>
> ---
> [This E-mail scanned for viruses]
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From LauraHoemanARNP at aol.com  Wed Mar 31 20:53:46 2004
From: LauraHoemanARNP at aol.com (LauraHoemanARNP at aol.com)
Date: Wed, 31 Mar 2004 23:53:46 EST
Subject: [PrvPracNP] bipolar
Message-ID: <bd.3e58cc9e.2d9cfa5a@aol.com>

Is it a teenage boy or girl?  And how old?  I've had good results with 
adolescent males--over age 17--with neurontin, but it's a controversial medication, 
unfortunately. The "new neurontin":--which will be called pregabalin--is 
coming out soon and will have an FDA indication for mental health, which neurontin 
does not. Pregabalin is the new incarnation of neurontin.  The only reason I'm 
not using much neurontin right now is that there was so much controversy over 
Pfizer's marketing of it for mental health that some people got gun-shy. But 
I've seen it work very well.  I plan to use pregabalin extensively.   Seroquel 
works well for bipolar, but of course it can have side effects and most 
people don't need anywhere near 800 MG. (Some do, however.)   If this young person 
is dizzy on lithium, several issues come to mind--is he really bipolar , and 
is the dosage right?  Maybe he's got ADHD instead. They're hard to 
differentiate sometimes.  I don't use lithium much because it's so toxic, easy to use for 
suicide, hard to get dosage right, etc.  Topamax, like neurontin, is used off 
label, which I used to think was fine but some people think you're setting 
yourself up for an undeserved lawsuit (as with neurontin).  I still use meds off 
label but I've gotten gun-shy myself, so you might include something on your 
consent that "patient is aware this medication is used off label."   One mood 
stabilizer I've had no luck with is gabitril. It doesn't work for my patients.  
Some of my colleagues say lamictal works well, but due to the risk for 
Stevens Johnson I've never tried it. Good luck with your patient.  --Laura Hoeman, 
Psych. NP
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From pamme at sbcglobal.net  Wed Mar 31 20:55:05 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Wed, 31 Mar 2004 23:55:05 -0500
Subject: [PrvPracNP] bipolar
References: <20040401040133.NGRC1746.imf17aec.mail.bellsouth.net@nina>
Message-ID: <034401c417a5$80a73160$209cfea9@VAIO>

Depakote requires blood draws and teenagers as well as children, balk
greatly at this necessary intervention.  In addition, the added weight gain,
a significant side effect in Depakote, effects the ego status of the child
and teenager as well as the health status.
It is definitely a good mood stabilizer, but Topamax is far superior in
effect, compliance, no need for blood level monitoring and lack the side
effects that impact weight gain .
Sincerely,
Pamela A. Provost N.P.
Psychiatric Provider
Neuroscience Consultant

~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Nina Ravey" <nravey at bellsouth.net>
To: "'Private Practice NPs'" <prvpracnp at nurse.net>
Sent: Wednesday, March 31, 2004 11:01 PM
Subject: RE: [PrvPracNP] bipolar


> Just went to a seminar where psychiatrist talked about anti-psychotics and
> Seroquel was suggested as one of the safest with out black box warning,
not
> tounted to cause diabetes.  Works well if you start with 100mg bid and
> titrate up every day by 100 until you reach the 800 dose range.
> I've used it and it works well on bipolar.  Depakote also works well.
> He also explained that the drugs may be used in children and adolescents.
> Nina
>
> Nina Ravey, RN, MSN, CNS, C-FNP
> Family Nurse Practitioner
> Shirley Medical Clinic
> 711 N. Main St.
> Jennings, LA 70546
> 337-824-2002
> Fax:337-824-2004
> www.shirleymedical.com
> Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
> Management, Physical Medicine and Rehabilitation, Diabetic Education
> Classes, Walk-ins, Appointments
>
>
> "It never ceases to amaze me how being a good nurse is often in direct
> opposition to being a "good employee."
>
>
>
> -----Original Message-----
> From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
> Behalf Of Alex Wagner
> Sent: Wednesday, March 31, 2004 8:00 PM
> To: prvpracnp at nurse.net
> Subject: [PrvPracNP] bipolar
>
> I need some suggestion for a teenage diagnoses by psychiatrist for bipolar
> is very dizzy on Lithium.  What else are you guys using for this in this
> age group with less side effects.
>
>
> ---
> [This E-mail scanned for viruses]
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp



From nravey at bellsouth.net  Wed Mar 31 21:24:08 2004
From: nravey at bellsouth.net (Nina Ravey)
Date: Wed, 31 Mar 2004 23:24:08 -0600
Subject: [PrvPracNP] bipolar
In-Reply-To: <034401c417a5$80a73160$209cfea9@VAIO>
Message-ID: <20040401052408.RHP1797.imf22aec.mail.bellsouth.net@nina>

Thanks to ya'll for clarifying information for one who is not a psych nurse,
but quickly learning in the school of hard knocks how to care for bipolar
and schizophrenia patients.
Nina

Nina Ravey, RN, MSN, CNS, C-FNP
Family Nurse Practitioner
Shirley Medical Clinic
711 N. Main St.
Jennings, LA 70546
337-824-2002
Fax:337-824-2004
www.shirleymedical.com
Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
Management, Physical Medicine and Rehabilitation, Diabetic Education
Classes, Walk-ins, Appointments


"It never ceases to amaze me how being a good nurse is often in direct
opposition to being a "good employee."

 


-----Original Message-----
From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
Behalf Of Pr. Pamela A. Provost N.P.
Sent: Wednesday, March 31, 2004 10:55 PM
To: Private Practice NPs
Subject: Re: [PrvPracNP] bipolar

Depakote requires blood draws and teenagers as well as children, balk
greatly at this necessary intervention.  In addition, the added weight gain,
a significant side effect in Depakote, effects the ego status of the child
and teenager as well as the health status.
It is definitely a good mood stabilizer, but Topamax is far superior in
effect, compliance, no need for blood level monitoring and lack the side
effects that impact weight gain .
Sincerely,
Pamela A. Provost N.P.
Psychiatric Provider
Neuroscience Consultant

~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Nina Ravey" <nravey at bellsouth.net>
To: "'Private Practice NPs'" <prvpracnp at nurse.net>
Sent: Wednesday, March 31, 2004 11:01 PM
Subject: RE: [PrvPracNP] bipolar


> Just went to a seminar where psychiatrist talked about anti-psychotics and
> Seroquel was suggested as one of the safest with out black box warning,
not
> tounted to cause diabetes.  Works well if you start with 100mg bid and
> titrate up every day by 100 until you reach the 800 dose range.
> I've used it and it works well on bipolar.  Depakote also works well.
> He also explained that the drugs may be used in children and adolescents.
> Nina
>
> Nina Ravey, RN, MSN, CNS, C-FNP
> Family Nurse Practitioner
> Shirley Medical Clinic
> 711 N. Main St.
> Jennings, LA 70546
> 337-824-2002
> Fax:337-824-2004
> www.shirleymedical.com
> Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
> Management, Physical Medicine and Rehabilitation, Diabetic Education
> Classes, Walk-ins, Appointments
>
>
> "It never ceases to amaze me how being a good nurse is often in direct
> opposition to being a "good employee."
>
>
>
> -----Original Message-----
> From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
> Behalf Of Alex Wagner
> Sent: Wednesday, March 31, 2004 8:00 PM
> To: prvpracnp at nurse.net
> Subject: [PrvPracNP] bipolar
>
> I need some suggestion for a teenage diagnoses by psychiatrist for bipolar
> is very dizzy on Lithium.  What else are you guys using for this in this
> age group with less side effects.
>
>
> ---
> [This E-mail scanned for viruses]
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp
>
> _______________________________________________
> PrvPracNP mailing list
> PrvPracNP at nurse.net
> http://lists.nurse.net/mailman/listinfo/prvpracnp

_______________________________________________
PrvPracNP mailing list
PrvPracNP at nurse.net
http://lists.nurse.net/mailman/listinfo/prvpracnp



From pamme at sbcglobal.net  Wed Mar 31 21:25:26 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Thu, 1 Apr 2004 00:25:26 -0500
Subject: [PrvPracNP] bipolar
References: <bd.3e58cc9e.2d9cfa5a@aol.com>
Message-ID: <036c01c417a9$bdde2260$209cfea9@VAIO>

I have tried all the medications that you have mentioned.  This is the response from my adolescent patients:
Neurotin:  "makes me feel dopey all day," or "it doesn't do nothing."
Lamictal:  "it gave me the shakes," or "it makes me feel too nervous."
I don't use lithium for all the reasons you stated and 2ndly because no one likes blood draws.  It is too easy to go toxic on Lithium.
My first choice remains Topamax for ease of use, lack of side effects and good efficacy.
I agree with you Laura.  Often times, Bipolar is diagnosed when it is really ADHD and vice versa.  Even the very best of psychiatric providers have difficulty distinguishing in this patient population.  Of course, if you suspect ADHD and give them Adderall and the mania worsens or the patient develops severe anxiety, you can almost bet it's Bipolar.  I follow strictly the DSM-IV TR items when doing my psyche eval.  I take each criteria and pose it as a question that my patient's can understand.  This has been quite successful in differentiating between Bipolar and ADHD.
As to off label use, it is a standard of practice in the psychiatric field.  The FDA is very cautious regarding approving psychotropics for specific needs.
Thanks for sharing.  I really appreciated your comments and experience with the various meds.
Regards,
Pamela A. Provost N.P.
Psychiatric Provider
Neuroscience Consultant
      ~:~~:~ 
      GOD BLESS US ALL

      Life may not be the party we hoped for, but while we are here, we may as well dance

      Join Care2.com and The Breast Cancer Fund's Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things  
----- Original Message ----- 
  From: LauraHoemanARNP at aol.com 
  To: prvpracnp at nurse.net 
  Sent: Wednesday, March 31, 2004 11:53 PM
  Subject: Re: [PrvPracNP] bipolar


  Is it a teenage boy or girl?  And how old?  I've had good results with adolescent males--over age 17--with neurontin, but it's a controversial medication, unfortunately. The "new neurontin":--which will be called pregabalin--is coming out soon and will have an FDA indication for mental health, which neurontin does not. Pregabalin is the new incarnation of neurontin.  The only reason I'm not using much neurontin right now is that there was so much controversy over Pfizer's marketing of it for mental health that some people got gun-shy. But I've seen it work very well.  I plan to use pregabalin extensively.   Seroquel works well for bipolar, but of course it can have side effects and most people don't need anywhere near 800 MG. (Some do, however.)   If this young person is dizzy on lithium, several issues come to mind--is he really bipolar , and is the dosage right?  Maybe he's got ADHD instead. They're hard to differentiate sometimes.  I don't use lithium much because it's so toxic, easy to use for suicide, hard to get dosage right, etc.  Topamax, like neurontin, is used off label, which I used to think was fine but some people think you're setting yourself up for an undeserved lawsuit (as with neurontin).  I still use meds off label but I've gotten gun-shy myself, so you might include something on your consent that "patient is aware this medication is used off label."   One mood stabilizer I've had no luck with is gabitril. It doesn't work for my patients.  Some of my colleagues say lamictal works well, but due to the risk for Stevens Johnson I've never tried it. Good luck with your patient.  --Laura Hoeman, Psych. NP 


------------------------------------------------------------------------------


  _______________________________________________
  PrvPracNP mailing list
  PrvPracNP at nurse.net
  http://lists.nurse.net/mailman/listinfo/prvpracnp
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From pamme at sbcglobal.net  Wed Mar 31 21:30:08 2004
From: pamme at sbcglobal.net (Pr. Pamela A. Provost N.P.)
Date: Thu, 1 Apr 2004 00:30:08 -0500
Subject: [PrvPracNP] bipolar
References: <20040401052408.RHP1797.imf22aec.mail.bellsouth.net@nina>
Message-ID: <037601c417aa$65d93770$209cfea9@VAIO>

Bless your heart for even attempting to care for Bipolar, Schizoaffective
and Schizophrenic patients.  These patients belong to the scope of the
psychiatric provider, but we all know that one is not always available.  It
is heartwarming to know that FNP's, such as yourself continue to keep
current on these very difficult disease processes. Thanks for the kind
words, Nina.  You are a wonderful provider yourself.
Sincerely,
Pamme
Pamela A. Provost N.P.
Psychiatric Provider
Neuroscience Consultant

~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while we
are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
Climb to End Breast Cancer! Join Care2.com's Race for Children in Need! Join
Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
----- Original Message ----- 
From: "Nina Ravey" <nravey at bellsouth.net>
To: "'Private Practice NPs'" <prvpracnp at nurse.net>
Sent: Thursday, April 01, 2004 12:24 AM
Subject: RE: [PrvPracNP] bipolar


> Thanks to ya'll for clarifying information for one who is not a psych
nurse,
> but quickly learning in the school of hard knocks how to care for bipolar
> and schizophrenia patients.
> Nina
>
> Nina Ravey, RN, MSN, CNS, C-FNP
> Family Nurse Practitioner
> Shirley Medical Clinic
> 711 N. Main St.
> Jennings, LA 70546
> 337-824-2002
> Fax:337-824-2004
> www.shirleymedical.com
> Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
> Management, Physical Medicine and Rehabilitation, Diabetic Education
> Classes, Walk-ins, Appointments
>
>
> "It never ceases to amaze me how being a good nurse is often in direct
> opposition to being a "good employee."
>
>
>
>
> -----Original Message-----
> From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net] On
> Behalf Of Pr. Pamela A. Provost N.P.
> Sent: Wednesday, March 31, 2004 10:55 PM
> To: Private Practice NPs
> Subject: Re: [PrvPracNP] bipolar
>
> Depakote requires blood draws and teenagers as well as children, balk
> greatly at this necessary intervention.  In addition, the added weight
gain,
> a significant side effect in Depakote, effects the ego status of the child
> and teenager as well as the health status.
> It is definitely a good mood stabilizer, but Topamax is far superior in
> effect, compliance, no need for blood level monitoring and lack the side
> effects that impact weight gain .
> Sincerely,
> Pamela A. Provost N.P.
> Psychiatric Provider
> Neuroscience Consultant
>
> ~:~~:~ GOD BLESS US ALL Life may not be the party we hoped for, but while
we
> are here, we may as well dance Join Care2.com and The Breast Cancer Fund's
> Climb to End Breast Cancer! Join Care2.com's Race for Children in Need!
Join
> Care2.com's Race for the Rain Forest! Join Care2.com's Race for the Big
> Cats! Join Care2.com's Race for the Oceans! Join Care2.com's Race for the
> Primates! Join Care2.com's Race for Pets in Need! Holidays 'N Things
> ----- Original Message ----- 
> From: "Nina Ravey" <nravey at bellsouth.net>
> To: "'Private Practice NPs'" <prvpracnp at nurse.net>
> Sent: Wednesday, March 31, 2004 11:01 PM
> Subject: RE: [PrvPracNP] bipolar
>
>
> > Just went to a seminar where psychiatrist talked about anti-psychotics
and
> > Seroquel was suggested as one of the safest with out black box warning,
> not
> > tounted to cause diabetes.  Works well if you start with 100mg bid and
> > titrate up every day by 100 until you reach the 800 dose range.
> > I've used it and it works well on bipolar.  Depakote also works well.
> > He also explained that the drugs may be used in children and
adolescents.
> > Nina
> >
> > Nina Ravey, RN, MSN, CNS, C-FNP
> > Family Nurse Practitioner
> > Shirley Medical Clinic
> > 711 N. Main St.
> > Jennings, LA 70546
> > 337-824-2002
> > Fax:337-824-2004
> > www.shirleymedical.com
> > Programs we offer: Pharmacy Assist, Kid-Med, LEAP Testing, Weight
> > Management, Physical Medicine and Rehabilitation, Diabetic Education
> > Classes, Walk-ins, Appointments
> >
> >
> > "It never ceases to amaze me how being a good nurse is often in direct
> > opposition to being a "good employee."
> >
> >
> >
> > -----Original Message-----
> > From: prvpracnp-bounces at nurse.net [mailto:prvpracnp-bounces at nurse.net]
On
> > Behalf Of Alex Wagner
> > Sent: Wednesday, March 31, 2004 8:00 PM
> > To: prvpracnp at nurse.net
> > Subject: [PrvPracNP] bipolar
> >
> > I need some suggestion for a teenage diagnoses by psychiatrist for
bipolar
> > is very dizzy on Lithium.  What else are you guys using for this in this
> > age group with less side effects.
> >
> >
> > ---
> > [This E-mail scanned for viruses]
> >
> > _______________________________________________
> > PrvPracNP mailing list
> > PrvPracNP at nurse.net
> > http://lists.nurse.net/mailman/listinfo/prvpracnp
> >
> > _______________________________________________
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