As a PMHNP, how should I manage a patient who is too complex for my scope and requires referral to a psychiatrist?

Managing Complex Patients Beyond PMHNP Scope

When a patient presents with severe psychiatric symptoms, active safety concerns, or treatment-resistant illness that exceeds your scope as a PMHNP, immediately refer to a psychiatrist while ensuring patient safety during the transition.

Immediate Psychiatry Referral Criteria

You must refer immediately—not schedule for later—when any of these conditions are present:

• Active suicidal ideation with specific plan or intent requires emergency psychiatric evaluation 1, 2
• Risk of harm to others, including homicidal ideation or violent impulses 1, 2
• Psychotic symptoms such as hallucinations, delusions, or disorganized thinking 1, 2
• Severe agitation or confusion (delirium) that may indicate medical emergency 1
• Severe depression with marked functional impairment (PHQ-9 ≥15) combined with poor social support 1, 2

For these emergencies, facilitate safe transport, ensure one-to-one observation if needed, and do not leave the patient alone until psychiatric evaluation is secured 1.

Prompt (Non-Emergency) Psychiatry Referral Indications

Refer within days to weeks for:

• Treatment-resistant depression: Two failed adequate antidepressant trials at therapeutic doses and durations 2
• Severe psychiatric illness requiring complex medication management beyond your training 1
• Comorbid substance use disorder with psychiatric symptoms 1, 2
• Moderate-to-severe symptoms (PHQ-9 15-19) with complicating factors like prior suicide attempts 1, 2
• Concern about medication misuse, particularly benzodiazepines or opiates 1
• Eating disorders comorbid with psychiatric illness 1
• Poor response or nonadherence to your current treatment plan 3

Structured Referral Process

Before Referral

1. Document severity using validated tools: Complete PHQ-9 for depression (score ≥15 indicates severe) or GAD-7 for anxiety 1, 4
2. Assess immediate safety: Directly ask about suicidal/homicidal thoughts, plans, means, and intent 1, 2, 5
3. Identify complicating factors: Substance use, prior attempts, psychosis, medical comorbidities, social isolation 1, 2
4. Stabilize medical issues: Rule out medical causes of psychiatric symptoms (thyroid, B12, substance intoxication/withdrawal) 1

During Referral

• Communicate directly with the receiving psychiatrist by phone or secure message, not just fax 1
• Provide comprehensive summary: Include symptom severity scores, safety assessment, medication trials (doses, durations, responses), substance use history, and social support 1
• Ensure continuity: Do not discharge the patient from your care until psychiatric appointment is confirmed 1
• Activate support networks: Involve family, remove means of self-harm, provide crisis hotline numbers 5, 6

After Referral

• Bridge care: Continue current medications and supportive management until psychiatrist assumes care 1
• Maintain communication: Request updates from psychiatrist and coordinate ongoing shared care when appropriate 1
• Document thoroughly: Record your clinical reasoning for referral and all safety measures implemented 5, 6

Common Pitfalls to Avoid

Do not delay referral hoping symptoms will improve with more time—severe symptoms and safety concerns require immediate specialist involvement 1, 2.

Do not assume absence of current suicidal ideation means low risk if the patient has prior attempts and unchanged risk factors 4.

Do not manage complex polypharmacy (multiple psychotropics, treatment-resistant cases) without psychiatric consultation, as this exceeds typical PMHNP scope 1, 2.

Do not screen for suicidality without having a clear protocol for managing positive screens—screening alone without intervention pathways does not improve outcomes 4.

When Collaborative Care Is Appropriate

For moderate complexity that does not meet urgent referral criteria, consider shared care with psychiatry consultation rather than full transfer:

• Stable patients on established regimens needing periodic psychiatrist oversight 1
• Mild-to-moderate symptoms (PHQ-9 8-14) with good social support and no safety concerns 1
• Patients responding well to initial treatment who need long-term maintenance 1

In these cases, maintain primary responsibility while obtaining psychiatric input for medication adjustments or diagnostic clarification 1.