I do psychiatric interviews all week long. At this point
I’ve been doing it for over three decades. I am always interested in improving
the process. I came up with this idea recently and wish I had thought about it
many years ago. My standard initial interviews are anywhere from 45 minutes to
60 minutes long and that includes a lot of information transfer. The actual
amount of information transferred and whether it can be used come up with
formulation and diagnosis is always an unknown variable. There are people who
can come in and succinctly produce that information in 30 minutes or less.
Other people will take several hours. At the end of every interview, I have to
dictate a report that contains fairly standardized sections including a
diagnosis and treatment plan.
When physicians are trained there is an implicit
understanding that they will be able to adhere to a specific protocol and come
up with a diagnosis and treatment plan. In the real-world things are never that
linear. In inpatient psychiatry, the patient may not be able to produce a
coherent history or any history at all if they are severely ill and the
diagnosis needs to be pieced together by collateral information and the medical
and behavioral presentation. In outpatient clinics, the format is much
different. It is still possible to interview a patient who communicates low
information content but it is much more likely that patients describe what is
necessary for diagnosis and treatment. One of the main problems is the
discussion at the end of the assessment. It is typically truncated by time
constraints. Many patients leave the assessment and realize they should have
mentioned specific concerns or asked more questions. I often have people tell me that they are
drawing a blank in the interview and want to know if they can call me if they
have additional questions. I reassure them that they can.
These brief observations highlight the need for adequate
time and structure following the diagnostic interview to facilitate the
discussion and make sure that the patient can send and receive the
communication that is both necessary and what they want beyond that. I came up
with the structure over the past two weeks and I think is a good starting point.
I also refer interested readers to the only post on this blog that was not made
by me. It was written by Cedric Skillon, MD one of my psychiatric colleagues
because I observed his superior treatment planning in all of his notes that I
encountered.
This exercise assumes that any psychiatrist reading this as
adequate time to do their work. I don’t think psychiatry can be reduced to a
checklist and I don’t think it can be done in a short period of time. I realize
that there are psychiatrists reading this who may have evaluations
scheduled back to back in the morning and 15-minute appointments scheduled back
to back all afternoon. We all know how that schedule gets accommodated and the
outcomes are not good. What typically happens is there is very little emphasis
on getting to know and understand patients and little emphasis on communicating
with them about their problem. I also understand that the people who really
control all psychiatrist practice these days don’t really care about quality
treatment. The emphasis here is always on quality and the obvious fact that
quality work is not easy and it takes time.
What follows is my proposed outline for the patient
discussion. I think that in even moderately complex cases at least 25% of the
allotted time should be for this discussion. I have not done it yet but I hope
to hand an outline to the patient in order to facilitate discussion. I’m very
interested in whether their psychiatrist have used this technique and also
speculation on why it may or may not be a good idea.
1. A discussion of
the diagnosis and/or formulation
Of the people I talk with very few seem interested in the
specific diagnosis. It does happen, and when it does, I think it is important
to cover most likely diagnosis and complicating factors. For example, when
seeing a patient to has been drinking excessively for 20 years and gives a
history of anxiety and depression prior to the onset of that alcohol use and
current anxiety and depression can there be a valid anxiety or depression
diagnosis given the intervening alcohol use. This is a basic level of
complexity that psychiatrists encounter. In covering the diagnosis, I will
typically talk about a most likely diagnosis as well as the provisional or
working diagnosis and my recommendations for clarifying the diagnosis. In some
cases, people are interested in whether or not they have a severe psychiatric
disorder. I encounter a lot of people at the end of the initial interview who
asked me “So am I nuts/crazy Doc?” Some people have a specific diagnosis in
mind that they either want or don’t want and I give them my best assessment.
Some people have studied diagnostic features online or in the DSM and use that
jargon during my interview. They may or may not be right.
I think a formulation is always necessary in addition to a
psychiatric diagnosis. I was first impressed with rapid formulations done in
brief psychodynamic psychotherapy. I also found several courses given at the
annual APA conference in diagnostic formulations to be useful. The patient may
have their own formulation or one that they worked on with the therapist that I
would typically discuss in the original interview. I don’t think the
formulation discussion has to be excessive or detailed and it may complement
the diagnostic assessment. As example the case of the diagnosis of major
depression, it is reasonable to discuss the interpersonal elements relevant to
the depression as well as psychosocial stressors.
2. A discussion of a
no treatment option
A no treatment option should be explicit. It should be
discussed as part of the informed consent process. The potential risks and
benefits of no treatment should be discussed but in many cases no treatment is
a viable option for people. The case that always comes to my mind is the person
who consulted with me decades ago after receiving years long psychoanalytic
treatment who wanted to know if he should find a new therapist and continue.
After reviewing course of therapy and how his anxiety had improved over the years,
he was very relieved to hear from me that he probably did not need to continue
psychoanalysis. He had formally terminated with a psychoanalyst and no further
treatment was recommended but he wanted a second opinion from a psychiatrist.
Other people have mild anxiety and depression but are still functional and they
had concerns about both medication and psychotherapy. With psychotherapy - the time, financial commitment, and past therapy
experience are generally the determining factors. With medication the main concern
is side effects and typically concerns about taking any medication. I commonly
hear “Doc - I don’t like to take any medication, not even aspirin.” I think it is
possible to discuss no treatment in a number of scenarios as well as the
contingencies. The common contingency might be returning for reassessment if
symptoms worsen or there are other complications.
3. A discussion of
potential medical treatments and medical concerns – especially those that may
affect treatment
Outpatient psychiatrists are generally seeing patients
after all the smoke has cleared. If they have access to an electronic health
record (EHR) there are often laboratory results, ECGs, and imaging results and
reports that the patient may or may not be aware of. After taking a complete medical
history and review of systems I generally ask the patient if they had any
questions about recent medical procedures or results and we have a discussion
at that time.
The medical treatment of the identified disorder is
reviewed. There are often several approaches to the problem and when I discuss
all those approaches patients generally want my recommendation. I provide them
with that, the necessary prescribing literature, and both short and long-term
plans. I also talk about rare but serious complications of psychiatric
pharmacology like antidepressant withdrawal, agranulocytosis, Stevens Johnson
syndrome, priapism, serotonin syndrome, akathisia, suicidal ideation, and
neuroleptic malignant syndrome. In a previous post, I describe some of the
discussion. I generally want to make sure that the patient is aware of any
black box warnings, contraindications, and warnings. I will often do a drug
interaction search in front of the patient so that I can discuss it with them
rather than doing it after the interview.
In some cases, my treatment will depend on my discussion
with their primary care physician, cardiologist, or other specialist. It may
also depend on me ordering tests that I view as critical and getting those test
results.
4. A discussion of
potential psychotherapy treatments
There are research proven psychotherapies that should be
part of any informed consent discussion. I commonly inform patients with
posttraumatic stress disorder (PTSD) that exposure therapy and the EMDR variant
are very good approaches to the disorder and may be superior to
pharmacotherapy. That does not mean that I won’t try to treat that patient for
PTSD symptomatology, but I want to give them a clear message that the
psychotherapy results may be much better. I have similar discussions regarding
the psychotherapy of anxiety and depressive disorders specific to those
conditions. The psychotherapy may include supportive and crisis intervention approaches that occur right in the initial interview. In psychiatry treatment interventions that involve psychotherapy can occur right at the time of the assessment.
5. A discussion of
potential environmental/social approaches
One of the commonest problems in outpatient psychiatry is
that there are clear environmental factors that are leading to anxiety,
depression, insomnia, and substance use morbidity. Practically all of the
people in those situations or consulting psychiatrists are looking for a
medical treatment to address those environmental and social factors. I
generally have detailed discussion about the evidence that medication works in
those situations (there is very little) and what can be done. I typically discuss examples like grief responses and the very common scenario of a stressful work environment or boss. I want to be sure that I emphasize the point that medical treatment of these acute and chronic stressors is almost always not enough to solve the problem.
6. General treatment
parameters
If the patient and I decide to proceed with treatment – a discussion
of the general parameters of treatment needs to occur. That would include indications for calling me
and how to address potential medical and psychiatric emergencies. In this day of external control of medical
treatment – prescription refill policy can be discussed and how insurance
company denials or prescriptions (prior authorization) will be handled. In large systems of care, a discussion of who
has access to the information in the chart and systems that deal with emergency
and crisis calls can be a topic for discussion. In the current Internet age modes of communication (email, texts, calls) also need to be discussed especially if there is no formal EHR portal. Limitations on privacy are typically part of the general permission to treat but may require additional explanation like the CFR42 regulations for drug and alcohol treatment.
7. Definition of the treatment alliance
As part of the general treatment discussion, definition the
treatment alliance can be useful for many people. Physical appearance and the appearance of one’s
office can be a projective test for people entering treatment. When I started out, I would get a lot of
comments like: “You seem to be too young to be a doctor!”. Now that I am an old man, my introduction has
stayed the same. Within a few minutes
people know how long I have been in practice.
Most people can get past that and engage in a dialogue, but some people
are overly deferential and seem intimidated.
Others decide to challenge the old man to see what he knows or if he can
be pushed around. Both of those scenarios can be a topic of discussion but that
might be too confrontive for most and lead to more problems in communication. A more neutral approach is to discuss the
typical diagnostic interview and treatment alliance. I find a basic definition that works for most people is: “You and I working on a problem or set of problems
that you identify to see if we can find the solutions.”
There have been entire books written on this topic, but most don’t focus on the ten or 15 minutes at the end that should be for the benefit of the person seeking help. That is my outline so far. Over the years I have had these discussions but not in a structured way. It de-emphasizes the diagnostic template or checklist and puts the emphasis on information that is directly useful for the patient. I plan to take the headings, add bullet points, and see if it adds to the discussion. I think it will because it will at least define the boundaries of the discussion, what I hope to communicate, and provide more solutions to people coming in to see me. And mostly I hope that it will counter the implicit assumption that all psychiatrists do is prescribe medications and that it is an easy thing to do.
George Dawson, MD, DFAPA
Supplementary 1:
The preliminary form described above is contained in the 3 PNG files below. There are 49 bullet points so far. I have it as a Word file and a PDF so if you are interested in it send me an email and I will send you the format you want. I consider this to be a work in progress. Click on the files below to enlarge for easy reading.
As a preliminary screen - I looked at one day of intakes in my practice and discovered that I am routinely covering 30-36% of the bullet points on this form. That seems like a sufficient number but it would be a good idea to run a trial looking at the baseline for a number of clinicians (rated by independent observers) and then a second rating after the patients were provided the form ahead of time.
