Why do so few psychologists offer clinical assessments

[texanpsychdoc]

Yup. Call me old-fashioned but I think that the rank-and-file generalist clinician (hell...even the prescribers (who supposedly base their choice of med regimens on diagnoses)) has the responsibility to at least see the person 2 or 3 times and sink at least 30-60 mins (total) into interviewing and case-formulating the patient as a decent 'first pass' attempt prior to 'ordering' diagnostic 'testing' procedures.

I once did a chart review on a VA patient who had seen multiple providers and even did a friggin THREE MONTH stint in residential where every single clinician 'passed the buck' by retaining a 'R/O bipolar disorder' entry on the guy's chart. So no MH clinician could take the time during a THREE MONTH residential stay? Really?

NOT ONE CLINICIAN spent 15-20 minutes interviewing the individual around pathognomonic symptoms of mania/hypomania (like...has he ever had a distinct change from baseline lasting (continuously) for days-to-weeks representing a change in mood/functioning characterized by things like increased goal-driven dysfunctional behavior (sex, drugs, rocknroll), decreased actual NEED for sleep, etc., etc.

I ruled out history of mania/hypomania in like 20 mins just asking carefully about history of DSM-5 defined criteria for a hypomanic/manic/mixed episode.

He'd had a total of at least 30+ clinical encounters during the time he still had a 'R/O bipolar disorder' entry on his chart.

Ridiculous.

Yup - I have like 3 questions I use in conjunction to the MDQ I use to guide me to DDX bipolar from something else, and one of those questions surrounds a decreased need for sleep during a manic/hypomanic episode. I have yet to come across someone truly with bipolar who said "yup, I really needed 8+ hours of sleep to get stuff done the next day...I really miss sleep." I also gauge mood changes - if someone endorses they fluctuate in mood 4+ times in a WEEK...we probably aren't looking at bipolar as it's typically being triggered from something in their environment vs. a fluctuation in transmitter systems.

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[texanpsychdoc]

In my private practice, my standard therapy initial eval is a comprehensive review of psychiatric systems, a solid biopsychosocial history, a risk evaluation for homicide and suicide, and use of measures (C-SSRS, MDQ, AUDIT, DAST-10, ACE, PHQ-9, GAD-7, PC-PTSD). I use these elements to guide my DDX...I come up with 1-3 main diagnoses or provisionals, and then list out a few R/O that I will circle back to over the course of treatment to rule in or out. I often consider personality organizations and thought disorders as potential underlying factors contributing to any observable "affective" issues, but use those more so as anchor points to test my hypotheses....and this is the approach I take with testing as well, so again, I use my testing background to inform my therapy intake approach.