Providing Excellent Psychiatric Care: A Structured Framework for New Providers
To provide high-quality psychiatric care and ensure good patient outcomes, establish a systematic approach to comprehensive assessment, evidence-based treatment planning, and proactive monitoring that integrates the patient's values with clinical best practices. 1
Core Assessment Framework
Conduct Thorough Initial Evaluations
Your psychiatric evaluation must systematically identify symptoms requiring pharmacological versus psychosocial interventions while uncovering factors that could impede treatment or confound outcome assessment 1. This comprehensive approach increases the likelihood of well-conceptualized medication interventions and reduces treatment failure and poor adherence. 1
Essential components to document include: 2
- Reason for presentation and patient's treatment goals and preferences
- Comprehensive psychiatric symptom review across all major diagnostic categories
- Complete substance use assessment (prescribed medications, over-the-counter drugs, complementary/alternative treatments, illicit substances) 1
- Detailed psychiatric treatment history, including past successful and unsuccessful treatments 1
- Physical health status with baseline vital signs, height, weight, and BMI 2
- Psychosocial and cultural factors that may influence treatment 1
- Detailed mental status examination with cognitive assessment 2
Perform Systematic Mental Status Examinations
Document the following elements in every evaluation 2, 3:
- General appearance, nutritional status, coordination and gait
- Involuntary movements or abnormalities of motor tone
- Sight and hearing (sensory deficits can masquerade as psychiatric impairment) 3
- Speech fluency, articulation, rate, rhythm, and volume 3
- Current mood state and anxiety level through both patient report and clinical observation 3
- Thought content and process (logical flow, coherence, tangentiality, circumstantiality, flight of ideas, thought blocking) 3
- Perception and cognition (orientation, memory, attention, executive function) 3
- Skin examination for stigmata of trauma, self-injury, or drug use 2, 3
Assess Safety Systematically
For suicide risk, evaluate: 2, 3
- Current suicidal ideas (active or passive thoughts)
- Specific suicide plans and access to methods
- Past suicide attempts (including aborted or interrupted attempts)
- Level of hopelessness (a critical risk factor) 3
- Patient's intended course of action if symptoms worsen 3
- Reasons for living 3
For violence risk, assess: 2, 3
- Current aggressive or psychotic ideas
- Thoughts of physical or sexual aggression or homicide
- Prior aggressive behaviors
- Current impulsivity 4
Document your estimated risk level with specific factors influencing that assessment 2, 3.
Treatment Planning Excellence
Create Documented, Person-Centered Plans
Your treatment plan must be comprehensive, documented, and include both evidence-based nonpharmacological and pharmacological interventions as indicated. 1 This documentation should include the rationale for treatment selection with discussion of specific factors that influenced your choice 2, 3.
Educate Patients and Families Thoroughly
Before initiating medication treatment, educate the patient and family about 1:
- The child's or patient's problem
- All available treatment options
- The specific treatment and monitoring plan
- Expected benefits and potential side effects
This education sets the stage for obtaining informed consent and enhances confidence in both the treatment and prescriber. 1 For patients on antidepressants, families and caregivers must be alerted to monitor for emergence of agitation, irritability, unusual behavioral changes, and suicidality, with instructions to report symptoms immediately 5.
Obtain Medical History Before Pharmacotherapy
Complete a medical evaluation to ensure no medical problem accounts for the psychiatric presentation and that the patient can safely participate in medication treatment 1. The medical history should determine 1:
- Current or past medical problems
- All medications (prescribed, over-the-counter, complementary/alternative, illicit substances)
- Medication allergies
- Personal or family history of medical problems associated with increased risk for side effects
However, routine laboratory testing is not indicated for patients with normal vital signs and non-contributory examinations. 6 A focused medical assessment based on history and physical examination is superior to protocolized laboratory testing, which has a pooled yield of only 1.1% for detecting clinically significant findings 6.
Monitoring and Follow-Up Strategy
Establish Predictable Monitoring Visits
Once the patient is stabilized on medication, schedule regular and predictable monitoring visits to 1:
- Enhance patient and family confidence in treatment and prescriber
- Ensure effective management of longer-term treatment
- Monitor for both benefits and side effects
- Address safety issues proactively
Monitor for Treatment-Emergent Problems
All patients on antidepressants must be monitored closely for clinical worsening, suicidality, and unusual behavioral changes, especially during the initial months of treatment or at times of dose changes. 5 Specific symptoms requiring immediate attention include 5:
- Anxiety, agitation, panic attacks
- Insomnia, irritability, hostility
- Aggressiveness, impulsivity
- Akathisia (psychomotor restlessness)
- Hypomania or mania
These symptoms may represent precursors to emerging suicidality and warrant consideration of changing the therapeutic regimen or discontinuing medication. 5
Use Quantitative Measures
Incorporate standardized rating scales to identify symptom severity and functional impairments that may be treatment targets 1, 2. In patients with agitation or psychosis, response to treatment should be assessed with a quantitative measure. 1
Diagnostic Accuracy and Conceptualization
Interview Both Patient and Collateral Sources
Conduct interviews with both the patient and family members or other collateral sources whenever possible 1. Patients often lack insight during acute episodes, and family members can describe behavioral changes and episodic patterns more objectively. 4 Balance confidentiality needs against the requirement for all involved to have a common information base for treatment decisions 1.
Review Previous Records
Assess past successful and unsuccessful treatments to ensure your proposed intervention is the next logical treatment step and reduce the chance of repeating previously ineffective treatments 1.
Screen for Bipolar Disorder Before Antidepressants
Prior to initiating antidepressant treatment, patients with depressive symptoms must be adequately screened to determine if they are at risk for bipolar disorder. 5 This screening should include 5:
- Detailed psychiatric history
- Family history of suicide, bipolar disorder, and depression
Treating a major depressive episode with an antidepressant alone may increase the likelihood of precipitating a mixed/manic episode in patients at risk for bipolar disorder 5.
Use Longitudinal Perspective
Organize clinical information using a life chart to characterize the course of illness, patterns of episodes, severity, and treatment response 4. This longitudinal perspective enhances diagnostic accuracy 4.
Critical Pitfalls to Avoid
Never Skip Systematic Assessment
Even when patients drive the agenda, never skip systematic symptom assessment. 2 Patients may be reluctant to reveal emotional problems due to stigma, leading to missed diagnoses 2.
Never Assume Stability Means No Psychosocial Assessment Needed
Psychosocial factors predict healthcare utilization and relapse independent of symptom severity 2.
Never Misinterpret Mental Status Without Context
Always maintain careful attention to abnormal vital signs and complete neurologic examination 2, 3. Consider education level, language barriers, and cultural factors when interpreting findings 3.
Never Use Protocolized Laboratory Testing Routinely
History and physical examination have substantially higher yield (15.6% and 14.9% respectively) compared to investigations (1.1%) 6. History and physical examination should be undertaken for all patients, while investigations should be reserved for specific clinical indications. 6
Never Practice Inconsistently
Clinicians who do not use a rigorous consistent approach to assessment and treatment introduce unacceptable variability into treatment, underuse effective approaches, and may succumb to ineffective treatments. 1 Children and families who do not receive high-quality care may become demoralized and drop out of treatment or not seek treatment in the future 1.
Reflective Practice and Self-Care
Establish Procedures for High-Quality Care
The prescriber who establishes procedures for these tasks and uses them routinely will practice more consistently and have patients and families who understand, adhere to, and actively participate in intervention and outcome assessment. 1 A proactive and positive approach may also decrease stigma that patients and families experience from participating in psychiatric care 1.
Promote Your Own Self-Care
Acknowledge that maintaining your individual health and wellness is essential for the overall stability of patients and the care delivery system 1. In addition to using your own internal coping skills and resources, be aware of local, state, and national support resources available to healthcare workers 1.
Plan for Medication Discontinuation
When clinically indicated, identify a time for medication discontinuation trial and have a follow-up plan that allows patients to discontinue medication with minimal risk for unmonitored relapse or recurrence of symptoms 1. A gradual dose reduction rather than abrupt cessation is recommended whenever possible to minimize discontinuation symptoms. 5