Thursday, May 26, 2011

Transfering Care and Do You Have to Meet All Criteria for a Disorder to get Meds?


A college student wrote in and asked the following questions:
1. Do you ever transfer care and how do you decide when to transfer care? If a patient is stable do you transfer care and prescribing over to a general/family/primary care doc? I know that most depression, anxiety, adhd, etc is diagnosed and treated in primary care these days anyways, under what situation is diagnosis and treatment management by a psychiatrist recommended over a
general practitioner or conversely when is treatment management by a general practitioner recommended over a psychiatrist? Do you ever feel like your patient's level of need/functioning/distress doesn’t warrant your care, such as when they are improving with treatment, if so do ever you suggest that they should reduce their visits or seek care elsewhere?

2. Does a patient have to be diagnosed with a disorder in order to be prescribed medications? For example, do they have to fit the clinical criteria in the DSM for depression before you will feel comfortable prescribing antidepressants to them, or is just complaining of feeling sad and hopeless enough? Is complaining of being inattentive and failing classes enough to warrant adhd medications? I know it gets dicey with
controlled substances and insurance coverage/reimbursement, but in general I am curious regarding the indications for medication prescriptions? If a patient doesn’t fit the exact DSM criteria for a disorder but they feel they will benefit from medications, do you give it to them?
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Wow, that is a lot! The student began by telling us she sees a psychiatrist for 7 minutes every three months to get stimulants.

Do I transfer care? Not usually. Maybe the better answer is really rarely. I get patients from primary care docs who feel the patient needed more. I figure people come to me because they want a psychiatrist, they like having someone to talk to (I do Not do 7 minute sessions, but I certainly do see people a few times a year), and they like knowing they have a psychiatrist if something should go wrong. If someone who is stable for a while on a set dose of medicines were to ask, "Can I just get this from my primary care doctor?" I would say "Sure." I really have only been the one to suggest it when the patient makes it clear that scheduling with me is a burden, and I don't think I'm adding to the mix in any meaningful way. When this has happened, I've said, why not just have your primary care doc prescribe it and if you have any problems, I'm happy to see you again. This hasn't happened much. What happens more often is that people drift out of treatment, and I imagine they either stop their medicines, or get them from their internist. Sometimes they come back when they have a problem, and that's fine with me.

Regarding questions about whether meeting DSM criteria is a necessity for medications, that really depends on the doctor. I don't keep a DSM in my office and I never sit there with a check list of symptoms to say "Yup, you got it," "Nope, you don't." Why is that? Because the book was written by consensus-- a bunch of guys in a room agreed these are the symptoms you need to have Panic Disorder, not by a blood test or some thing that clearly correlates with prognosis. Precise diagnoses are really good for insuring that everyone in a research protocol has the same condition, and I don't do research. So maybe the patient doesn't quiet have enough symptoms for a diagnosis of depression, or perhaps they haven't gone on quite long enough, but perhaps the symptoms that are there are intense, incapacitating, or dangerous, and the patient is requesting medications. I'm not likely to send them out saying "You need one more symptom and 2 more days before your suicidal misery meets criteria, so come back when you have another symptom."

ADD may be it's own issue because of the controlled substance/addictive substance question, and the fact that some clinicians feel the diagnosis is over-made. People can be inattentive for many reasons: depression, pretty girl outside the room, boring instructor, cell phone texts keep coming in, worried about not being invited to big party tonight, upset about cat's cancer diagnosis...and the list marches on. Failing tests may be due to lower than needed IQ, partying too much, misunderstanding about what would be on the test, instructor with lower than needed IQ, girl in next seat vomiting, poor preparation, bad night's sleep, substitution of decaf for caffeinated coffee (Clink's version of Hell). Lots of people with ADD do just fine without meds. Being smart helps in the way of compensation. Lots of people with ADD seem to have disabilities beyond what one might expect with some distraction. I don't treat a lot of ADD, and my guess is that it depends on who you go to for this: the people who have large practices and do a lot of this work seem to have somewhat lower thresholds for aggressive prescribing, and a greater comfort level with the problem and the cure.

I hope I answered the questions okay.

16 comments:

Sunny CA said...

A college student might need to know that she is free to choose a different psychiatrist and she is free to visit her general practitioner and if the GP is willing to prescribe the medications for her, she can transfer the care herself. She does not need the psychiatrist's permission to leave care. Perhaps her parents are paying, but when I was in college I paid for all my own medical care so cost may be a factor. She could return to the psychiatrist if she needs additional support, but 7-minutes every 3 months sounds like very little support.

Rob Lindeman said...

Dinah, when all of the diagnostic criteria are subjective, what does it matter if the young lady shows some or all of them?

As your readers know well, the diagnosis of bi-polar disorder is made in children with the squishiest of diagnostic criteria, all of them subjective.

apotential said...

Interesting! I'm glad to hear this - it confirms what I've been assuming about the DSM (that it's not the end-all-be-all to clinical decisions in psychiatry).

I only have 1 more psychiatry lecture left in medical school. I'm glad there's blogs like this one where I can continue to hear cool stuff about psych.

jesse said...

The way Dinah does it describes accurately the way I do it. Flexibility based on experience. Autonomy for the patient to the extent it is safe. The DSM is exactly what she says, very useful for research and as a baseline in that we know when we use a diagnosis another practitioner will understand what we mean.

Anonymous said...

"...we know when we use a diagnosis another practitioner will understand what we mean".

When I went to school we called that professional jargon. I think we still do. Others in the field will know what we mean and it is an effective mechanism for keeping outsiders outside.

jesse said...

Anonymous, I disagree. What it means is spelled out in the book that Dinah doesn't keep in the office, and to which I rarely refer. It is important though when you consider what communication was like in psychiatry before. I was trained in psychoanalysis and the diagnostic terms are virtually Greek to those not trained in it. There are many branches of psychology. Now, when I say major depression anyone with a DSM can at least get an idea of the symptoms observed. It is descriptive and behavioral rather than psychoanalytic.

The definitions are readily available - just look on the web. So rather than keeping outsiders outside it makes the diagnoses understandable to the layman. Perhaps too much simplification to the extent subtlety is lost.

Take for example diagnoses related to personality. Is the human personality truly able to be described in so few words?

Dinah said...

Oops, I meant I do NOT do 7 minute sessions.

jesse said...

Dinah, we knew that is what you meant! We read Shrink Rap. :)

moviedoc said...

Doctors don't transfer care. Patients do. For a practicing psychiatrist diagnosis is just a small bump on the road to selecting the treatment that works.

Sarebear said...

When someone comes to you having seen other psychiatrist(s), do you ever request that patient's records from at least the most recent psychiatrist? I've wondered, not that your response will reflect what mine does, but curious.

Oh, and if you have the new patient write down their medicines history, what was tried, why, and why it was stopped or switched if it was. When I started with this one, she had me do this and it took me 45 min to an hour (all the new pt paperwork took me 3.5 hours to fill out in her waiting room, I shoulda gone home to do it). I also asked th e secretary to copy the medicines history I'd written cause it's alot to remember. I need to update that history with another two pages of what has been done since then, since I have a strong feeling I'll eventually be seeing another psychiatrist . . . .

Sideways Shrink said...

In my area, primary care will only go to a certain level of complexity with psych medications even when a patient is stable. And, depending on the severity of symptoms that have occurred during previous episodes, they will not manage even "simple" depression medications especially if the patient has insurance that a shrink will take/if the patient is willing to see a shrink and pay. Primary care here will not prescribe stimulants for adults. Maybe the family practice docs prescribe it for children?
I have read Rob Lindeman's posts on other web sites about psychiatry and it is reassuring to see the same basic idea repeated here: psychiatrists can't do brain biopsies/brain scans to have "objective" proof to back up their diagnoses therefore what we do is not actual medicine. Repetition is so comforting.

Rob Lindeman said...

Some thoughtful observations on the subject from a thoughtful psychiatrist:

http://thoughtbroadcast.com/2011/05/27/biomarker-envy-ii-ethanolamine-phosphate/

Sideways Shrink said...

It would be helpful if you could offer a synopsis of that link, otherwise reader might not bother going to it.

Rob Lindeman said...

The summary paragraph:

"But I don’t think we’ll ever be able to screen for psychiatric illness the same way a primary care doc might screen for, say, breast cancer or diabetes. To do so would redefine the entire concept of “mental” illness (perhaps making it “neurological” illness instead?). It also takes the person out of the picture. At the end of the day, it’s always the patient’s thoughts, words, and experiences that count. Ignoring those—and focusing instead on a chemical in the bloodstream—would be an unfortunate path to tread."

Sideways Shrink said...

Well I don't know who you are citing, but I doubt they have a license to prescribe medication. As a trained analyst who practices basically from a psycho-dynamic/insight oriented, family systems and substance abuse treatment perspective I can tell you that prescribing medication has everything to do with symptoms, family history, responses to other medications, and other subtle signs a patient exhibits. We don't have tests for "chemicals in patients blood systems" for psychiatric illness at present and there is not push to develop any.
However, the idea expressed that neurological diagnosis is more "scientific" or clear cut is a notion born of lack of experience. Though they have scans, MRIs, blood tests, lumbar punctures with which to test their patients, neurologists still sometime have difficulty diagnosing patients due to the nature of how much is unknown about the brain.

Anonymous said...

This is interesting. I went back to my GP several times, and he was aware I was seeing the psychiatrist, had no problem with it, but the psychiatrist had no idea I was seeing the GP ... it was a bad system where I was, I saw a brand new psychiatrist every time and had to start from the very start (first episode, when, where, why, etc)

So anyway, eventually my case got very boring, I was fine every single time ... and the psychiatrist had nothing to say, so they transfered me out. I find it interesting that it's rare... I started to find it a hassle to spend half an hour to hour every month or two to see the psychiatrist when I was completely fine, but I felt rude to decline.