Mind expanding on why you do that?
Sure. There are a lot of variables, but it ultimately depends on the patient. Consultation price is certainly a factor, and I know I was getting more non-attendances when I had asked patients to book for earlier reviews. For context, in our public outpatient system where the most severe patients (clozapine, involuntary treated etc) are managed, they are only seen by consultant psychiatrists every 3 months, and most of the care is by trainee doctors - who only review them on a monthly basis. When patients get into crisis, there are teams that can see them daily - or organise admissions if required. As a private practitioner we can also refer patients to said teams if needed but for the most part our patients tend to be higher functioning and have better social supports.
As I already noted it was much easier for me to offer a phone consult in-between appointments adjust doses or change medications. They leave a message with reception – if for instance things are really bad with side effects sometimes I will get a call after a couple of days, other times it’s within a few weeks and sometimes patients don’t even take up that offer. If they have an issue and don’t call, then I assume they were never going to come in earlier in any case. Either way, if I have to it’s easy enough for me to send out a different script which mitigates the need to book immediate followup.
As all my referrals come from GPs or other psychiatrists, I am often switching antidepressants – and these decisions will depend on the current dose, patient’s level of anxiety and previous experience with side effects. I usually offer a cross titration protocol, but some patients prefer a really slow reduction and want to come off their medication completely before starting something new, so it may take anywhere from a month to come off an antidepressant, then allowing a week washout period before commencing something new. Then if I get them back at 6 weeks, they've only been on the new medicine for a week - so too early to be of much clinical use.
On specific conditions - for depression and anxiety, not all patients are keen to start medications immediately (they might want to discuss with family, give therapy another go etc), so it might be a 2-3 weeks before they start anything. Then at 6 weeks there hasn’t been enough time to gauge whether it’s effective or not and 2-3 months is often more suitable. There’s also the issue of expectations – someone starting an antidepressant isn’t necessarily going to experience substantial improvements within the first few weeks, and longer for anxiety conditions.
If it’s an ADHD patient with no major risks, then 3 months to trial a stimulant is fine. If it’s someone who’s been stable on it long term (perhaps their psych is retiring) and there’s documentation to support that, then continuing for 6 months may be possible. For higher risk patients eg. new bipolar patients who are manic and starting on lithium I’m usually treating them quite aggressively and seeing them again in 3-6 weeks at the very latest.
3 months after an initial visit, especially if you're starting meds, is a pretty long time. I do think 4 weeks is pretty standard for something like an SSRI/SNRI/atypical antidepressant (although I'll often do a 2 week appointment to make sure the patient is tolerating it okay and didn't discontinue it because of side effects or something), sooner than that for sure for something like a stimulant/antipsychotic/mood stabilizer or even for like a TCA because of the side effect profile. I mean what if you're on a suboptimal dose and now the patient had to wait 3 months for a dose titration? Pretty rough. There's also so many patients who randomly stop a med in the first couple weeks or never pick it up because there's some problem and totally forget to tell you unless you schedule a followup with them.
I suppose I try not to prescribe suboptimal doses? Not to be facetious, but let's say I start someone on Lexapro and they're antidepressant naive. I'd start them on 5mg for a week, then increase the dose to 10mg if tolerated. If they get unusual side effects immediately at 5mg, I can encourage them to stick with it, but sometimes they do so there's no real point persisting or trying to increase the dose. In this case I can send out an alternative script to their pharmacy or they can pick it up from my rooms. I don't charge for this, as part of me feels like I am responsible if the drug I prescribe hasn't worked, so it seems unfair to penalise them financially in this instance. On the otherhand, if they report that they've been on 10mg for a few weeks and there's still no improvement and no side effects, it's a simple enough matter to advise them to go to 15mg over the phone.
Yeah, three months for a return visit after the intake seems like a very long wait. This is especially true if the patient is not fully stable on their current regimen. Until someone is stable, I also see nothing wrong with 1-4 visits per month depending on acuity (presuming they can make it). As others have mentioned this can avoid escalation of care, which ultimately is a win for everyone involved.
I agree with more frequent visits based on clinical acuity, although for a long time I simply haven't had the appointment capacity to fit these kinds of patients in. If I do have see a patient that frequently, it's more likely I'm going to be trying to organise an admission and managing them as an inpatient. For example, I have one bipolar patient who I normally see monthly - but when she's starting to decline I'll start getting messages every few days - eg. not sleeping as well, more flighty at work, heightened senses etc. While we can do some med changes, I know this is one patient who can deteriorate very rapidly - thankfully it's happened less so in recent years, but the inpatient option is always at the back of my mind.
