Friday, April 21, 2006

Plan: Continue treatment, return when?

Our hypothetical patient enters the office; he's never seen a psychiatrist, and he's here because he is overwhelmed with sadness after being laid off from work. He isn't sleeping well, he's lost ten pounds, he's having trouble organizing his job search, he's irritable and arguing with his wife. He is clearly a bright guy, but tells us he's lost jobs before and feels he isn't living up to his potential. He's not psychotic, he's not dangerous. A full evaluation is done and some decisions are made about what type of treatment to begin.

So here's my question: When do we have him return for the next visit?

Is that a silly question? And do I really want an answer? You want to ask more questions about our patient, talk about how you would treat his depression, or his adjustment disorder, wonder why he repeatedly loses jobs and is there perhaps a personality disorder as well? And no, I don't want an answer, what I want to do is throw out the idea that there probably is no consensus among us about how often patients should be seen. If our patient is seen in a clinic, he may well be started on an antidepressant and told to return in three to four weeks. In a private office, perhaps he'll be told to return in a few days, or maybe not for week or two or three or four. And if there isn't enough disagreement on how often to see patients at the beginning of treatment, what happens if he has a good response to a medication, his symptoms are alleviated, but he still fills the sessions talking-- do we continue to see him daily/weekly/biweekly/monthly if he isn't asking to come less often and if he's paying his bill?