This June, White Mountain Community Health Center welcomed a new psychiatric nurse practitioner, Julie Everett Hill, MSN, APRN, PMHNP-BC. Julie isn’t new to the health center, however – she’s served as the director of operations for over a decade, after starting there as a nurse. Director of Communications and Development Siena Kaplan-Thompson recently sat down with Julie to learn about her new role and what led her to make this transition.
Congratulations on your certification! I know you’ve been working towards this for a few years. To start, what is a psychiatric nurse practitioner?
A psychiatric nurse practitioner (PMHNP) is a nurse with an advanced degree, who has specialty training in psychiatry. We diagnose and treat mental health conditions, prescribe medications, and provide therapy.
You provide therapy too, not just prescribe medications?
Yes, that’s one thing I love about this role – for patients who have both talk therapy and medication as part of their treatment plan, they don’t need to see two different people.
If someone wants psychiatric treatment, what should they do?
A good place to start is by seeing your primary care provider (PCP). That’s often where a need is identified. A patient might mention incidentally at a visit that they’ve really been struggling with mental health. Their PCP can refer them to me, and I’m able to really sit with that person and dig into what’s going on, which is something that’s difficult to do during a 20-minute primary care visit.
Are there people who should seek out psychiatric treatment and might not realize it?
If someone is having difficulty performing their daily functions, or they have observed changes in a loved one- sometimes people aren’t aware that they’re not functioning at the capacity that they were. When I say “functioning,” what I mean is, are you able to perform basic needs you have typically been able to do for yourself – are you showering and feeding yourself? Are you able to do your job, or has something changed there? Has something socially changed? Those are functional changes that are worth exploring.
When we’re thinking about whether something might be a mental health disorder, we’re really looking at whether somebody’s functional capacity is impaired. It’s really tricky with social media nowadays, everyone can Dr. Google themselves. We all see ourselves in lots of traits and characteristics that may or may not be part of any diagnosis, and it’s important to realize that human behavior and experience is on a spectrum. It’s only when it’s to the level of functional impairment that we’re really concerned about it being a disorder.
How does psychiatric care fit in with other behavioral health treatment?
When assessing a patient, we’re looking at their potential mental health problems through multiple lenses. We’re looking at what underlying medical conditions may be contributing to their mental health condition. If someone says they feel anxious, it’s really important to determine the root cause of that anxiety. Is it a thyroid disorder? Is it related to substance use? Or is it related to something happening in their brain that’s best addressed with psychiatric treatment?
So part of your role is identifying root causes and making referrals to other providers based on that. But you would provide psychiatric treatment if it is about – is ‘brain chemistry’ still the right way to talk about it?
The language around that has evolved somewhat. With mental health conditions, it used to be reduced to – “oh, it’s a chemical imbalance in your brain.” Now we talk about neural pathways and have more nuance in our understanding. Yes, there are neurotransmitters and chemicals involved in brain function, but you also have to look at the roads those chemicals are traveling on. There are times when you may have formed ruts and go down a road without thinking, but it’s not the most efficient path and leads to bad judgment or difficulty making a decision. Talk therapy helps you stop and ask the question, is this the right road to turn down in this circumstance?
What’s the difference between what a psychiatric provider might do, and a mental health counselor? We now have both at the health center, what distinguishes those roles?
A counselor is looking through a psychological lens, whereas I am also looking at it through a medical lens. There are different approaches to therapy, each provider has strengths in some therapies versus others, so it depends on the person’s needs. But a key difference is that a psychiatric provider can prescribe medication.
Why might someone see a psychiatric nurse practitioner, rather than a psychiatrist?
The availability of psychiatric nurse practitioners is much better, and we can do many of the same things. It’s like choosing between an MD and a nurse practitioner – both can provide excellent primary care. Because they’re so hard to come by, psychiatrists tend to practice in large institutions, heading up departments of psychiatry. When I did my practicum, I did it through Dartmouth psychiatry, and I had the privilege to work with psychiatrists and psychiatrist nurse practitioners. In the hospital setting, both led teams and had the same responsibilities in some cases.
Why did you decide to become a psychiatric nurse practitioner after so many years as a nurse and then an administrator?
Over the course of my nursing career, I learned that I’m not afraid to sit with someone in their discomfort. I considered going back to school to become a nurse practitioner years ago, and my career started taking a different path, of being an administrative leader, which I also really enjoy. When the pandemic happened, I was called to split part of my time into clinical practice out of necessity, and I realized how much I missed that patient interaction, and decided that’s where my heart really was.
Why did you choose psychiatry instead of focusing on primary care?
Everyone has a story, and in this role, I’m able to look at a person’s experiences and piece together how they intersect with their symptoms. I find that really fascinating and it’s something I’m excited to continually learn about. It’s a career field that engages me like no other. I also have lived experience that gives me perspective and allows me to sit with someone in their discomfort and not be afraid of it. When I did my clinical through Dartmouth psychiatry, on my first day there, I had this sense of – “oh my goodness, I’ve found my people!” Their commitment to advancing the field and the dignity shown to patients was exactly what I would expect when seeking care for anyone I love.
What’s your approach to practicing psychiatry? What distinguishes you as a provider?
I don’t know if this makes me different, but I don’t want to jump to conclusions when I’m evaluating someone. That’s easy to do, especially when you start seeing patterns – that’s part of how our brains work – but we also have to be cautious about that. Everybody has a different story.
I have an interest in metabolic and nutritional psychiatry. I’m doing a year-long fellowship for continuing education in that area, because I think it’s important to understand the intersection between the environment and our metabolism and mental health. The brain is 2% of your body weight, but takes 20% of your energy to keep it operational at rest. When we dismiss what’s happening metabolically with the rest of our body and don’t link it to what’s happening in our brain, we’re dismissing a huge piece of our functionality. I’m really excited to learn more about that, and make sure I’m observing my patients in a way that includes assessing nutrition and physical activity. Not just on a cursory level, but really digging into movement as medicine.
I did an article a while back on Debbie Cross’s suggestion [our other psychiatric nurse practitioners] about exercise and mental health. It was so interesting reading the studies that show you can see things changing physically in the brain in response to exercise in the same way you would if you took medicine.
Yes, absolutely. I think what’s challenging for folks is, it’s not a lack of knowledge, everyone knows they need to eat more fruits and vegetables and get more exercise. But we have a lot of barriers that get in the way of implementing those recommendations.
How do you address that in psychiatric practice?
Every patient is unique, so it starts with helping people identify what’s important to them. Once we know what that is, I present the tools in the toolbox – medication, behavioral changes, nutritional changes, or therapy – that will help them get closer to that goal. It’s often a combination of tools that helps someone feel better. For some folks, the most helpful option may be starting with medicine to get through an acute stage of illness, then when they have improved functioning, we reach for other tools. With behavior changes, we work together to identify attainable goals, using what is already available and accessible to the patient, and build from there. I tell patients it’s a marathon, not a sprint. Either way, we get there one step at a time.
What is it like to see a psychiatric nurse practitioner? If someone is thinking about starting treatment, what could they expect?
The first visit is the longest visit. It’s usually about 75 minutes, and it involves finding out what’s going on with you now, recent symptoms that are bringing you in, and a complete history of symptoms that you may have had in the past, your medical history, your family’s medical and psychiatric history, and your developmental history. It ends up being a long visit because there are a lot of pieces to get through.
It’s important for people to know they might come in with an idea about what’s going on with them, and sometimes it’s evident at the end of the visit, but we might not have a diagnosis yet. Based on all the information we gather in that visit, we come up with a hypothesis, and possible approaches to treatment. Then we follow up and learn more about what’s happening in future visits. It’s a discovery that happens between the psychiatric NP and the patient together.
What’s the progression like after that? Do you see someone every week?
It depends on what the person’s needs are. There have been times when I’ve met with someone and they didn’t have a mental health disorder, but definitely had some needs that could be really helped by therapy, and I referred them to a counselor at the health center. If someone has a chronic illness like schizophrenia or bipolar, some illnesses need management for the long term. Whereas, if someone has a first episode of major depressive disorder, we would want to follow that person to remission, then see them as needed after remission. Every situation is different.
If someone wants to see you for treatment, what should they do?
They would see their PCP first and be referred. We haven’t started taking referrals from outside providers yet, but I anticipate that will change after we meet the needs of our existing patients and assess my caseload.
Is there anything we haven’t covered that people should know?
I love the integrated model we have, where we have psychiatric nurse practitioners and mental health counselors on staff along with primary care providers. Patients get to stay under one roof, we get to do warm handoffs, and the collaboration that can happen in real time is helpful for patients and clinicians.
Julie Everett Hill, PMHNP, is taking new psychiatric patients ages 18 and older, by referral from White Mountain Community Health Center’s primary care providers. White Mountain Community Health Center is taking new primary care patients for family nurse practitioners Deborah Cross, APRN PMHNP, Josie Lamb, APRN, and Marcelo Maiorano, APRN. To learn more or become a patient, visit whitemountainhealth.org or call (603) 447-8900.