Articles of Interest
Article Detail
Author:
The Ten Commandments of good psychiatry
Source: KevinMD.com
http://www.kevinmd.com/blog/2014/04/ten-commandments-good-psychiatry.html
Recently, I gave a lecture entitled, “Treating
Depression in Primary Care,” at an annual conference for physician
assistants. I spent a good portion of the talk on the fundamentals that
have been essential to me during my 15 years of practice. When things go
awry in mental health care, the majority of the time it is because one or more
of these fundamental principles was neglected.
My fear is that the current medical climate is
encouraging glossing over these fundamentals. It dawned on me that I have
become a fundamentalist when it comes to my psychiatric practice.
So here are the Ten Commandments of good
psychiatry, listed in no particular order of importance.
1. Thou shalt always aim to establish and
maintain a therapeutic alliance. Perhaps one the biggest challenges to practicing in a
21st century medical environment is preserving patient
relationships. Many of us are pushed for time, have to do more with less,
and are bombarded by a constant stream of interruptions. This is not only
frustrating for us (most people I know became doctors because of a deep empathy
for other human beings, not because they wanted to be stuck in front of a
screen or do paperwork), but it is wrong for our patients. It inhibits
the development of what we call alliance. Therapeutic alliance promotes
collaboration, trust, and mutual respect. It can take years to build, but
the provider’s commitment to maintaining it must be unwavering. Anything
that interferes with our ability to maintain an alliance interferes with our
patients’ inclination to honestly disclose what is on their minds or to share
their fears. Our job is to preserve the sanctity of the doctor-patient
relationship and push back on factors that impinge on it. This is the
foundation upon which good psychiatric care is practiced.
2. Thou shalt always do a complete psychiatric
assessment. Anyone treating a
mental health disorder can only do so after they have done a thorough psychiatric
assessment; when time is of the essence this can be the first thing that gets
short thrift. At minimum the following areas must be touched on:
·
history of the present
illness and symptoms
·
past psychiatric
history
·
substance use
·
relevant social,
occupational, and family history
·
physical examination
and appropriate diagnostic tests to rule out physical causes for symptoms
3. Thou shalt always do a thorough evaluation
for safety. Any clinician who
treats patients living with mental illness must do the following, not only on
the initial evaluation but on an ongoing basis:
·
Make specific
inquiries about suicidal thoughts, intent, plans, means, and behaviors.
·
Identify psychiatric
symptoms or general medical conditions that might increase the likelihood of
acting on suicidal ideas.
·
Assess past and,
particularly, recent suicidal behavior.
·
Assess for protective
factors that can decrease the chances the patient will harm themselves or
others.
·
Identify any family
history of suicide or mental illness.
·
Have a good sense of
the patient’s level of self-care, hydration, and nutrition.
·
Evaluate the patient’s
level of impulsivity and potential risk to others, including any history of
violence.
·
Assess the impact of
current symptoms on the patient’s ability to care for their dependents.
4. Thou shalt always identify the appropriate
treatment setting. The
patient’s treatment needs should determine what setting they are treated in.
Measures such as hospitalization should be considered for patients who
pose a serious threat of harm to themselves or others. Because of mental
health parity and inadequate access to mental health care, health care
professionals are often put in the very difficult position of caring for those
with mental illness in a sub-optimal setting. The clinician has to remain
watchful that this does not interfere with the patient’s clinical progress.
5. Thou shalt focus on the patient’s
functional impairment and quality of life. Mental illness impacts many spheres of a
person’s life, including work, school, family, and relationships. Any
treatments should aim to maximize functioning within these spheres and enhance
quality of life.
6. Thou shalt coordinate the patient’s care
with other clinicians. American health care is famous for being fragmented. With
so many different providers, health care systems, and insurance providers,
talking to each can become a low priority for clinicians. This lack of
communication can have disastrous consequences for patient outcomes.
7. Thou shalt monitor the patient’s
psychiatric status. The
patient’s response to treatment should be carefully monitored. Patients
who are on psychiatric medication need ongoing assessment for adherence, symptom
control, and side effects. This is even more important if a patient is
new to medication, this is their first episode of mental illness, they have
clinical factors that place them at high risk for suicide, or they are not
improving clinically. Ongoing care can be spaced out once the patient is
stable, but until then they must be monitored with sufficient regularity.
8. Thou shalt integrate measurements into
psychiatric management. An invaluable option for the busy clinician is to integrate
questionnaires into initial and ongoing patient evaluations.
9. Thou shalt evaluate a patient’s treatment
adherence. Assume and acknowledge
that the patient will have potential barriers to treatment adherence, and
collaborate with the patient (and if possible, the family) to minimize the
impact of such barriers.
Encourage patients to articulate any concerns
about treatment and offer patients a realistic notion of what to expect during
different phases of treatment.
10. Thou shalt educate the patient and their
family. Spend time clarifying
common misperceptions about medications, emphasizing the need for a full course
of treatment, and promoting the benefits of healthy behaviors like exercise,
sleep hygiene, and nutrition on mental health. Those involved in the patient’s
day-to-day life may also benefit from education about mental illness.
I believe each of us should be a
fundamentalist when it comes to providing mental health care. We cannot
adequately care for our patients when these Ten Commandments are forgotten.
No comments:
Post a Comment