I was going to start a new thread, but in a happy coincidence, this seems to be an appropriate place for this question.
To contextualize the knowledge I'm bringing to this: I just finished my first year of medical school, and have an interest in psychiatry but haven't taken our school's behavioral science class or done my psych rotation. Today I was volunteering at our clinic for homeless patients and had an experience that I'm sure many students/residents encounter at some point. We had a patient whose chief complaint was recent weight loss, but over the course of the interview, with some prodding, turned out to harbor significant delusions/paranoia (I may or may not be using these terms appropriately) regarding plots to assassinate her, as well as a citywide network of protectors looking out for her and intervening before these assassinations could happen. According to EMRs and the patient, she had never been treated for psychiatric illness before, despite being a 50-something person with an advanced degree in science who had now been homeless for almost five years.
My question is this: When something like this comes up in the history, what is the best way to address it with a patient so that they will be receptive to the idea of trying antipsychotics (or whatever meds are appropriate)? Obviously the reality that matters to them is the one they perceive-- if they believe in their gut that everyone is plotting against them, telling them otherwise will not convince them, and may even make them believe you're in on it, right? Simply giving them a drug and telling them it's to help them sleep at night without telling them it's an antipsychotic seems unethical (and if they're highly-educated/pharmaceutically-literate as this pt was, they'll just look it up and find out themselves what it's for), and confronting their delusions as being false or telling them you think they have schizophrenia/insert other disorder here seems like it risks them reacting badly to that label and maybe rejecting all the other medical treatment they need and came in for.
Is there any literature out there on how to conduct a good psychiatric history and how to gently ease someone into accepting a psychiatric diagnosis based on a closely-held (but obviously false) delusion that's causing impairment and distress? This patient almost seemed prodromal-- again, don't know if that is the accurate word, but it seemed like she had insight into the belief-defying improbability of the plots she was describing. I felt uncomfortable addressing this stuff as just a pre-clinical student, but neither the senior student working in the clinic with me nor the attending brought it up with the patient. They ended up giving him a script for respiridone but never mentioning that it was an anti-psychotic or that he might have schizophrenia. Attached to it, of course, is the prescribing info that describes as it as an anti-psychotic indicated for the treatment of suchandsuch, which I'm sure she'll read. I just don't know whether she'll shrug and take it anyway, or be angry at her doctors for treating her for a psychiatric illness without being explicit with her that that's what they were doing.
For what it's worth, in our city, the waitlist for uninsured patients to be seen by a psychiatrist is months long (probably true in a lot of places). In absence of SI/HI, it's really tough to get people seen. There aren't any psychiatrists on staff at the walk-in clinic, so a consult wasn't really an option here.
Any advice/links/readings/etc. would be greatly appreciated. Thanks.
I can only give advice from a patients point of view, but I hope a viewpoint from the otherside of the table, so to speak, might still be helpful.
When I had my first episode/experience of psychotic symptoms, the way the Psychiatrist at the time responded, was not a way I'd personally recommend, unless you wanted to risk completely freaking your patient out. There was no gentle lead in, no calm explanation as to why a diagnosis of Schizophrenia was being considered, it was just straight out (paraphrased) 'I want you in hospital by tomorrow, we need to assess you for the possibility of Schizophrenia, and I want you started on Largactil immediately'. My response was basically 'Say what?
Oh hell no, excuse me whilst I bolt out the door and never return.
Compare that to how my latest Psychiatrist broached the subject of anti-psychotic medication with me.
First of all he took the time to reassure me that the symptoms I was experiencing did not automatically mean I was either Schizophrenic, or 'Crazy'. He then went on to give a basic overview of how the brain, due to the misfiring of certain neurotransmitters, sometimes misinterpreted sensory input, which could result in someone experiencing both disturbances of thought and perception, and also how, because I had a family history of psychotic illness, I was more at risk for these types of disturbances occurring. Although the explanations that were given was still very much couched in lay man's terms, I was spoken to intelligently, and without being made to feel patronised at any stage.
When it came time to present the possibility of medication, first of all we discussed a number of non medication treatments that could be used, including mindfulness training, and continuing CBT. It was also made clear that if I did decide not to give medication a go, my decision would be respected. The fact that my Psychiatrist was prepared to work with me on a non medication basis, rather than presenting it as if I didn't have any choice in the matter, actually made me for more willing to at least listen to what he had to say regarding medication (in this case, Seroquel) and how, in conjunction with other therapeutic techniques, it could really benefit me. Having had some prior bad experiences with Psychiatric medications he also took the time to assure me that he would start me off on a very low dose, and monitor me very carefully as the dosage was slowly raised up to therapeutic levels.
Because of all of this, the fact that I felt respected, that my concerns and opinions were taken into consideration, I was spoken to intelligently, not made to feel patronised, and was also offered a number of reassurances, I did decide to give medication a go, and I'm happy to report with great success so far.
