Think across systems
Plan for conditions that cross specialty boundaries
Chronic illness, polypharmacy, disability, pregnancy, immunocompromise, aging, fragmented care, and limited access to specialty services can change the probability of competing diagnoses and the feasibility of follow-up.
- Practice context
- Outpatient, consultation-liaison, emergency, inpatient, primary care, neurology, and collaborative-care settings
- Typical pace
- Ranges from immediate escalation for acute red flags to longitudinal diagnostic clarification and coordinated management
- Who's involved
- People with new, atypical, fluctuating, treatment-resistant, or functionally significant psychiatric symptoms alongside medical, neurologic, medication, or substance concerns
Common presentations
- Psychiatric illness alongside diabetes, cardiovascular, renal, hepatic, endocrine, infectious, autoimmune, or pain conditions
- Pregnancy, postpartum changes, aging, disability, or other physiologic contexts that alter presentation and treatment
- Polypharmacy and treatment plans shared across several specialties
- Functional symptoms or persistent complaints spanning psychiatric and medical systems
- Diagnostic overshadowing in people with serious mental illness or developmental disability
- Fragmented care, limited collateral, or unequal access to diagnostic and specialty services
PMHNP priorities
- Adjust the differential for age, reproductive status, comorbidity, medications, exposures, disability, and care setting
- Prevent diagnostic overshadowing by treating new physical or cognitive concerns as findings that deserve evaluation
- Clarify which clinician owns each medication, test result, referral, and follow-up decision
- Balance psychiatric benefit with organ function, interaction risk, treatment burden, and patient goals
- Use collateral and cross-specialty records to reconstruct longitudinal patterns
- Plan around access, transportation, health literacy, cost, caregiver capacity, and continuity
- Revisit the formulation when the clinical course does not fit the expected pattern
Care team
PMHNPs, psychiatrists, primary care clinicians, neurologists, emergency and hospital medicine teams, pharmacists, nurses, laboratory and diagnostic services, infectious disease and other medical specialists, rehabilitation clinicians, social workers, and patient-identified supports.