I am inspired by a post on another blog having to do with
the dangers of “premature psychiatric diagnosis”. The author uses an anecdote to make a point
about how a diagnosis of a psychotic disorder and then mismanagement of the
treatment leads to a situation where there is no hope for the person affected.
From my perspective there are very few people with even
severe psychiatric disorders who are hopeless.
In fact, people with some of the most severe cases of catatonia that I
have treated became fully functional and were restored to their roles in their
families and society. That frequently
occurred after months of inpatient treatment by a psychiatrist and staff who
were interested and skilled in treating severe psychiatric disorders. Much of what I did in 22 years of inpatient
work was restoring hope and maintaining a hopeful atmosphere on my treatment
team.
Diagnostic uncertainty is frequently cited as an area where
mistakes are made. Many studies document
the medical comorbidity in patients with psychiatric disorders. Despite anecdotal cases true medical causes
of psychiatric disorders are rare. I
should qualify that by saying a brain disease, neurological or endocrine
condition that is a direct cause for the psychiatric disorder is rare and I
base that on screening patients and reviewing thousands of negative
studies. That said any acute care
psychiatrist should know more about medicine and neurology than psychiatrists
in outpatient settings because unlike their outpatient colleagues – they are
responsible for making that determination.
On the psychiatric side, the potential list of causes of various
syndromes is long and the actual diagnosis may not be evident until something
happens on a long term basis. A good example would be a drug induced
psychosis. In the ideal case, the
patient is able to remain sober and any medical treatment for the associated
syndrome can be tapered and discontinued.
In the real world, the chances of sobriety or even referral to a
functional addiction treatment are low.
There are numerous limitations on psychiatrists. The obvious one that practically all
commentators leave out is managed care.
Is it reasonable to think that the diagnosis and treatment of any severe
psychiatric problem like a psychotic disorder can be accomplished in 3 – 5
days? That is the time frame that most
managed care case managers are using to get people out of the hospital. They often refer to purely proprietary
guidelines on hospital lengths of stay that were clearly written by business
people rather than clinicians. I have
been in the position of having a patient discharged by an administrator against
my wishes so I know that it happens.
Managed care coercion is more subtle.
A managed care reviewer sitting at a desk in another state – reads chart
notes and presumes to make a remote diagnosis and suggest that the person
should leave the hospital. They have no
responsibility to the patient or their family.
Their only job is to get the patient out of the hospital to save the insurance
company money. Another constraint is at
the level of public assistance. Almost
incredibly, many states link the availability of case management services to
psychiatric diagnoses and they will clearly say in the statute that the person
must have schizophrenia, major depression, bipolar disorder, schizoaffective
disorder, or borderline personality disorder in order to qualify. Having one of those diagnoses at discharge
can be crucial to get housing and funded medical rather than be homeless. That is a strong incentive to get the correct
diagnosis sooner rather than later.
The work flow on inpatient units and in clinics is generally
not considered. If you have a psychiatrist
seeing 12-15 inpatients and some outpatients and they are seeing 3 – 5 new
patients a day that is not a lot of breathing room. They will be (depending on other members of the
team) able to collect collateral information from the family and outside sources,
make direct behavioral observations, and relay treatment decisions and
recommendations to the family. In my
experience occupational therapists, nurses, and social workers are all
indispensable team members and often function in dual roles as a liaison with family
members. They can act as consultants to the
family on legal and social issues as well as keeping them apprised of any changes
in medical treatment on a day to day basis.
One of the key areas where care becomes fragmented both from
a diagnostic and treatment standpoint is anytime there is a transition. In terms of hospitals that occurs with any
admission or discharge. It also occurs between
different outpatient clinics and between psychiatrists and primary care
physicians. I have been in situations
where it took me two hours and calls to different physicians, pharmacies and
relatives to reconcile a list of 10 medications. At the end of that two hours I was still not
absolutely certain of the patient’s correct medication list.
The bottom line here is that good psychiatric diagnosis is a
process. It is not like taking your car in to a mechanic and the mechanic
plugging it in to an analyzer. The best
results occur when the patient and the family can communicate openly with the
psychiatrist and any identified treatment team.
The diagnosis needs to take into account all of the available
information and by definition it will only be as good as that information. The critics of psychiatry always seem to
think that this is a situation that is unique to psychiatric treatment. As I have previously discussed it happens in
all of medicine. The basic difference
being that many nonpsychiatric conditions lend themselves to analysis by a
single observer. There is something readily
visible, audible or palpable that suggests an abnormality. In psychiatry we are focused on
communication, self report, and the observations of others. We are also generally dealing with more information
to make a diagnosis, especially if the patient’s capacity for self report is
limited. Psychiatrists more than anyone
else need to be comfortable with diagnostic uncertainty and explaining these nuances
to the patient and their family.
When the diagnosis is made it should be fully explainable to
the patient and family. Any stigma or
negative reaction to the diagnosis should be discussed. It should be evident that nobody is reducible
to a psychiatric diagnosis given the fact that no two people are alike and each
person is a unique individual with unique attributes. This is true for any medical diagnosis and
psychiatric diagnoses do not differ in that regard. Nobody should leave the encounter with the
idea that they are “hopeless”,
particularly in the case of a pure psychiatric diagnosis in the absence
of a neurodegenerative disease.
I realize that most of us in one way or another are held
hostage by a certain health plan, but if your psychiatrist or more probably
your health plan does not follow that basic process – find a new one. Getting stuck on whether or not a
misdiagnosis has occurred without a plausible explanation for what has happened
or continues to happen is generally not productive. If you can’t get out of your health plan talk
to the medical director and explain the deficiencies. If that doesn’t work and you are concerned
about the diagnostic and treatment process being rationed, contact your state
insurance commissioner and file a complaint against the health plan.
Quality psychiatric care is possible, but it has been
demonstrated that in many cases you have to fight for it.
George Dawson, MD. DFAPA
