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The Shrinklady Demystifies Psychiatry - Introduction
"But
I Don't Wanna Be
the Shrink!"
Introduction
to The Frontline Approach
Yeah,
and unless you're twisted, you don't want to watch your waistline
grow or hairline recede, or pay taxes, either. But you're a realist,
so you accept and deal with these aggravations as best you can.
That's what this book is about.
You
Can't Pass the Buck These Days
Whether
or not you enjoy the behavioral medicine aspect of your practice,
it comprises a huge portion of your workday. The fact is that
only 5-10% of Americans with psychiatric illness ever receive
treatment from a psychiatrist. The few that do are rarely self-referred.
Even though more patients are willing to see a psychiatrist now
than in years past, it can take months to get in to see one,
as you well know. In rural areas, access is even more of a problem
and the turnover of psychiatrists at community mental health
centers tends to be rapid. Even in the infrequent circumstance
when access to psychiatric referral is relatively easy, primary
care clinicians tell me that they are concerned about
what they see as a huge lack of consistency among psychiatrists
in their approaches to evaluation and psychotropic medications.
These obstacles put you between a rock and a hard place; you
find it difficult to stand
by and do nothing, but don't want to make the wrong intervention
and inadvertently harm your patient. Unless managed care
companies magically decide to provide adequate reimbursement
and legislatures pass laws demanding that health insurance include
parity of coverage for psychiatric treatment, this situation
isn't likely to change.
Scary Clinical Vignette
The minimum time requirement
for some insurance companies to pay for a med check is 8 minutes.
Several years ago, I heard a business-minded psychiatrist brag
about seeing 60 patients in one afternoon. That shrink, for whom
I had the misfortune to be employed for one year before I fled
screaming in the opposite direction, had the audacity to tell me
that once I "had enough experience", I'd be able to see that many
patients, too, and still provide good care. Talk about self-delusion!
Several Reasons Why the Quality of Psychiatric Care is So Inconsistent
The primary care clinicians
I've spoken with have been surprised to learn that "mangled care" companies
often will not allow psychiatrists to bill using the 99--- Evaluation & Management
codes of the CPT, and restrict billing to 2 codes. These are a
1 hour psychiatric evaluation (even if 90 minutes or more are spent)
and a 15 minute-or-less med check (even if 45 minutes or more are
required to deal with the kind of train wreck that is now my average patient.)
No allowances are made for complexity of the decision making process,
and believe me, few cases that make it as far as a psychiatrist
are at all simple these days. Most insurance companies won't pay
a psychiatrist to do psychotherapy anymore, either. The incomes
of most psychiatrists are steadily declining, unless they
feel OK about running patients through like cattle. Or find additional
sources of income to allow them to maintain their preferred quality
of care.
RED
FLAG: If
your patient tells you that her psychiatrist spends less than
10 minutes with her for follow-up visits, she'd probably be
better off seeing you than the shrink, in my opinion.
Clinical
Pearl: A
bad shrink can be worse than no shrink at all.
The Reluctant Shrink
Like it or not, as a primary
care practitioner, you truly are at the frontline of treating mental
illness in this country. Most of the patients who are aware of
suffering mood and anxiety symptoms present to primary care clinicians
for initial treatment. Patients who are not necessarily aware of
feeling depressed or anxious often present with somatic symptoms
related to psychiatric illness. These are your "frequent flyers",
the ones that keep calling and coming in with headaches, fatigue,
gastrointestinal problems, musculoskeletal pain and vague complaints
that don't respond well to treatment. The ones who make you shudder
and want to hide when you read their names, because you're not
sure what else to do for them.
I know you're tired and overworked.
Medical professionals dedicated to doing a thorough job put a lot
more physical, cognitive and emotional energy into their work than
the cattle-prod type. The standard of care for good clinicians
is to treat the patient the way you would want one of your own
family members to be treated. The fact that you are taking the
time to read this indicates that you are such a professional (or
that you're looking for one for yourself or someone you love).
You Have the Opportunity to Transform Lives
Instead
of continuing to feel resentful about having this behavioral
medicine responsibility shoved down your throat, you could choose
to welcome the opportunity to make an enormously positive impact
on the lives of your patients and their families. You could derive
more personal satisfaction from your work by becoming more adept
and comfortable with your skills in the evaluation and treatment
of mental health problems in your own office. I want to
help you accomplish these goals as efficiently and with as little
indigestion as possible. This manual is not a comprehensive,
ivory tower academic tome; it's a practical guide written by
a common-sense clinical psychiatrist willing to share what works
for me with my patients, with clinicians working "in the trenches".
Attention Non-Medicos:
If you are a non-psychiatrist
mental health provider who refers psychotherapy or counseling clients
to primary care practitioners (family physicians, internists, physician
assistants, nurse practitioners) for medication management, this
book should also be helpful to you. It simply isn't safe for therapists
to "tell the doctor which medication to prescribe", as
they lack the medical training needed to factor in issues pertinent
to choosing which medication/to use. It is, however, appropriate
to let the consulting physician know your opinion about whether
an antidepressant or mood-stabilizer might be the best way to begin,
after thoroughly screening your patient's symptoms.
Just as "location, location,
location" is the mantra for successful real estate investment,
the key to a good mental health assessment is "history, history,
history." You can't assume that just because the patient has been
evaluated by a psychiatrist, that he or she has been diagnosed
thoroughly or correctly. The average
patient with bipolar disorder has consulted 4 physicians over the
course of 5-10 years before the correct diagnosis is discovered.
70% of the time, these patients are misdiagnosed as having unipolar
depression.
Contemporary
Realities
The
time it would take to obtain a comprehensive history in face-to-face
interviewing simply wouldn't be feasible for you in
today's managed care environment. Ten years ago, a one hour psychiatric
evaluation was plenty of time for me to diagnose and formulate
a treatment plan via face-to-face interviewing alone. The patients
that I treated then weren't as sick then as they are now, because
by the time he gets through the managed care barriers and lands
on my schedule, you can bet that he has a complicated and/or
treatment-resistant illness. These days, without a chance to
ask a zillion screening questions before
the patient ever walks into my office,
the odds are that I won't be able to have a clear diagnostic
understanding of that patient upon which to base treatment strategy.
That's why I developed this questionnaire for use in my own practice
several years ago.
The
road to Hell is paved with good intentions.
It's
easy to determine that a patient is "depressed". It
is much more of a challenge to be reasonably sure that the patient
has a unipolar rather than a subtle form of bipolar mood disorder,
as do up to 25% of people who present with "depression". This
distinction is crucial since antidepressants can make patients
with bipolar symptoms much worse.
One
of the reasons that patients treated by psychiatrists are so
much sicker these days is due to the widespread use of the SSRIs
during the past 10-15 years. This mixed blessing has made family
physicians much more comfortable with prescribing antidepressant
medication. Fifteen years ago, the potential for fatal overdoses
associated with the tricyclics and monoamine oxidase inhibitors
made family physicians skittish about prescribing antidepressant
medication. Depressed patients used to be referred to psychiatrists
right off the bat. In the event of the tricyclic or MAOI making
the patient more agitated/irritable/sleepless, the psychiatrist
was usually knowledgeable enough to ask about other symptoms
suggestive of a bipolar mood shift. Then the shrink would amend
the diagnosis and prescribe mood-stabilizing medication.
Unfortunately,
now that primary care practitioners are treating the majority
of depressed patients, these bipolar dysphoric hypomanic symptoms
are usually misinterpreted as "anxiety associated with unipolar
depression". The dose of SSRI is increased, making the patient
even worse over the course of time. The patient eventually becomes
more severely depressed, but also agitated, explosively irritable
and impulsively suicidal. This is the kind of mess that typically
ends up at my door these days. Much of this scenario could be
prevented by screening every single patient for bipolar symptoms
before prescribing any medication, and educating patients and
their loved ones about the need to monitor for the possible emergence
of bipolar symptoms during the course of treatment.
Details,
Details
It's
also important to differentiate among the types of unipolar depression,
because the type determines length of treatment and how aggressive
to be with doses of mediation. Last, I want to emphasize the
need to screen for the co-existing psychiatric conditions that
are the rule, rather than the exception, in behavioral medicine.
Failure to recognize and address comorbid psychiatric conditions
will complicate treatment and lead to frustration for you and
your patients.
Definition
for the non-physicians reading this: In
medical jargon, "morbid" means
"pertaining to illness", not to anything gruesome, gory
or gross. (Unless, of course, the particular illness is gruesome,
gory or gross.)
Getting
it Right the First Time
Since
successful treatment depends upon making an accurate and complete
diagnosis, right from the start, this book's mission is
to help you in this process. It will show you how to make use
of The Frontline Questionnaire to gather and interpret
a large volume of pertinent information in a time-efficient manner.
Next, you'll learn how to follow up with a targeted interview,
so that you can quickly and confidently make the right assessment.
Then it will help you figure out how to approach treatment, layer
by layer, in the case of comorbid conditions. This "how-one-shrink-appraches-things" guide
should help you develop the skills of customizing the choice
of medication to the individual patient's needs and adjusting
it for optimal response. For patients who are more resistant
to treatment, a variety of optimization and augmentation strategies
will be described.
Make
It Easy On Yourself
For
those who are interested, the appendix contains copy-able treatment
plans for the more common illnesses you will likely have to deal
with. Because good, accessible, and affordable psychotherapy
is hard to come by, this book also provides copy-able educational
material on stress management strategies and a reading list including
suggestions for self-help workbooks your patients can use. Common
obstacles to treatment, such as affording medication and disability
issues, as well as strategies for dealing with them will be discussed.
In
For a Penny, In For a Pound
We
know that without timely, aggressive treatment with the goal
of achieving full remission of symptoms, patients with clinical
depression are at risk for developing a chronic, treatment-resistant
clinical course. We also know that inadequately treated psychiatric
illness complicates the treatment of just about every other form
of medical illness and increases overall morbidity and mortality
rates. A primary goal of this book is to help improve your odds
of getting your depressed patients "all the way to good",
instead of settling for "kind of better".
The
Bottom Line
Your
patients and their families will be enthusiastically grateful
for the interest you show in their well-being and you'll find
your work more satisfying and less stressful as a result. The
ultimate goal of this manual is for you to be able to experience
the pleasure of having more patients shake your hand and say, "Thanks,
doc, I've got my life back!" and still
be able to eat dinner with your own family at night.
Carolyn Seifert, MD
President, Shrinklady, Inc.,
www.shrinklady.com
Executive Director, Frontline
Behavioral Medicine, Inc., frontlinebehavioralmedicine.com
-
This book discusses off-label use of several medications. This
is noted where appropriate.
-
I'm on the Speaker's Bureau of several pharmaceutical companies
including GlaxoSmithKline, Shire, and Wyeth.
-
My investment advisor manages the paltry amount of stock I own
or have owned in the following pharmaceutical companies: GlaxoSmithKline,
Shire, Elan and Sepracor.
Plain English Disclaimer:
The information in this book shares the observations and treatment
approaches of a board certified general psychiatrist with 16 years
of post-residency clinical experience in a wide variety of settings,
treating patients of all ages. It is NOT indended to offer specific
medical advice regarding any specific case. The approaches described
in this book reflect the author's treatment style and philosophy.
Though most of the treatments described are "mainstream", my approach
sometimes differs from the current "conventional wisdom" ** in the
psychiatric medical community. You may or may not see this as a "plus".
Because I didn't want to end up with a book the size of the New
York City Yellow Pages, rather than extensive bibliography, I have
chosen to list suggested readings only on topics or treatment approaches
that are somewhat controversial. You can find this list at the end
of the book.
** Of course, it's important to remember that at various points
in history, "conventional wisdom" included advice:
· Not to bathe (it was considered dangerous to
one's health)
· To keep windows closed to prevent attack by evil vapors
· That just about any medical disorder could
be treated via
the application
of a leech
A Disclaimer in Legalese
My attorney is a friend of mine. He's worried about me getting sued,
because he knows that in our beloved republic, there are too many
lawyers with not enough to do. So, we're plastering the book with
disclaimers, because the man doesn't need a heart attack.
By
continuing to read this book, you agree to the following terms:
The information
contained in this book and on the shrinklady.com and the frontlinebehavioralmedicine.com
websites is intended as an educational aid only. Information
is not intended as medical advice for individual conditions
or treatment and is not a substitute for a medical examination,
nor does it replace the need for services provided by medical
professionals or independent determinations. Individual doctors
and other clinicians must make their own independent determinations
before authorizing a course of treatment or prescribing drugs.
A person's individual doctor or clinician must determine what
is safe and effective for each individual person or patient.
Neither the author, Shrinklady, Inc., or Frontline Behavioral
Medicine, Inc. assumes any responsibility or risk for the use
of any information contained within this book or the shrinklady.com
or frontlinebehavioralmedicine.com websites.
Warranty
Disclaimer: With respect
to any third-party products or services described, referenced
or made available in connection with this book or the shrinklady.com
and/or frontlinebehavioralmedicine.com websites, you acknowledge
that any warranty provided in connection with such third-party
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… and
a partridge in a pear tree. |
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