Is the place to start with a psychiatrist?

[Grenth]

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“Killer Nanny” Sought Psychological Help Just Days Before Murdering Two Children. What Went Wrong?

Obvious click-bait title but it's pulled from this article about the psychologist who saw a woman right before she murdered two children and declared her prognosis "good". The psychologist made some clear mistakes by not doing a thorough evaluation, but the article takes this one example as a way to make a case for all "serious" problems being first evaluated by a psychiatrist "access to psychiatrists as first point of contact were a standard, the most serious cases would have a much better chance of ending in treatment, not tragedy."

A psychiatrist interviewed in the article says “A psychiatrist is trained more extensively, has a broader scope of knowledge with which to define potential diagnoses, and can deliver treatment more expeditiously,” says Lieberman. “They can then refer them to psychotherapy, group or family therapy, or anyone else. There’s no question the place to start is with a psychiatrist, however, the practice pattern is not in place.”

Even as a student I can see a host of issues with this supposed solution and with the underlying thinking, but I wondered what you folks thought about it. Do most psychiatrists feel they should see a person before they are seen by a psychologist?

 

[psych.meout]

This is obviously a tragic situation, but the author is extrapolating endemic problems with mental health and with psychologists doing assessments based on a single case. This is not to say that there aren't problems with mental health in the US, just not the ones the authors thinks there are. Based on what is written in this article (if it is accurate) the psychologist is question did perform a substandard assessment, e.g., no risk assessment, no family history, no medical history, no symptom onset/duration/etc. This is really basic stuff and it's not like this isn't taught in grad school, internship, etc. Hell, I knew this even in my work before grad school.

That said, you can see a little bit of some of the actual problems with mental health in the US in this article, but the author doesn't seem to get it. This psychologist had seven patients after her and seemed to have had patients in the morning before he squeezed her in. There isn't necessarily a shortage of psychologists, but the reimbursements from Medicare, Medicaid, and many private insurers suck, forcing many providers to carry patient loads that are too large. I'm unclear as to how this woman was referred to this psychologist by her insurance company, yet she paid him $200. This can't be her copay and still seems too high to be coinsurance. How much does he charge for an hour?

Regardless, it seems apparent that having too many patients that day (it's unclear if this was standard practice for him) likely prevented him from doing a quality assessment.

 

[psych.meout]

Also, I Googled the psychiatrist quoted in the article and saw this gem from his wikipedia entry.

Jeffrey Lieberman - Wikipedia

Conflict of Interest

Lieberman's work necessitates[According to who?] close work with many leading pharmaceutical companies, and raises questions of improper conduct due to extrajudicial funding. Lieberman has consistently filed disclosure of his funding and has not been accused of any undisclosed improprieties.[citation needed]

On multiple occasions, Lieberman has publicly disclosed information about potential conflicts of interest. This has included a 2006 letter to the editor of the Wall Street Journal,[11] a 2007 release in Primary Psychiatry,[12] and a 2009 disclosure to the American College of Neuropsychopharmacology.[12]

Lieberman's most recent conflict of interest disclosure came in 2013. As of June 2013, as disclosed in Annals of Internal Medicine, the British Journal of Psychiatry, and JAMA, Lieberman's disclosure of financial conflict of interest is on file with the International Committee of Medical Journal Editors (ICMJE).[13]

A note on "competing interests" for contributors to his Essentials of Schizophrenia (2011) stated that Lieberman received no direct financial compensation for his research, consulting and advisory board activities other than Intra-Cellular Therapies.[14]

What the odds that he has a staff member edit his own entry?

 

[PsyDr]

1) show me data that indicates the psychiatric interview has any predictive value for future dangerousness. Because you can’t. Entire premise of article overs.

2) show me studies indicating the reliability of psychiatric interviews. Hint: dsm5 indicates it ain’t there’s. Authors cache over.

 

[psych.meout]

1) show me data that indicates the psychiatric interview has any predictive value for future dangerousness. Because you can’t. Entire premise of article overs.

2) show me studies indicating the reliability of psychiatric interviews. Hint: dsm5 indicates it ain’t there’s. Authors cache over.

http://psycnet.apa.org/buy/2016-54856-001

Wait, did you want an article that supports the predictive value? Well.....

 

[PikminOC]

I wondered about the 200 dollars also.

 

[WisNeuro]

Slate isn't exactly known for it's "journalistic" quality. It's just a collection of poor writers with axes to grind that couldn't get a reputable journalism job after their career on their college newspaper.

 

[psych.meout]

Slate isn't exactly known for it's "journalistic" quality. It's just a collection of poor writers with axes to grind that couldn't get a reputable journalism job after their career on their college newspaper.

Today, "freelance writer" means something far different than what it meant back in Hunter S. Thompson's day.

 

[cara susanna]

Wow, this is freaking ridiculous. Having intake paperwork isn't exclusive to psychiatrists, and it may not have prevented this anyway.

Edit: Just saw this comment and loved it:

I just think it's funny that, a few months ago, Slate had a piece about how "broken" the mental health care system is because a woman was sent for a psych eval during a postpartum check-up, saying it was unwarranted. But here we're saying this woman should have been on a psych hold, based on what happened after. In reality, there will never be a perfect system. Somebody murdering someone after getting a "good" prognosis from a psychiatrist is not a sign that anything went wrong, especially since she came in clearly presenting as anxious and didn't give him any indication anything else was going on. If he had sent her for a psych hold, and she ended up not killing anybody, we'd have been told that the system was biased against poor, working-class women and it was so horrible she had to miss a few days of work due to this psychiatrist's wrong assessment.

 

[Ollie123]

Many potential explanations for the $200 payment that are not at all out of the ordinary. Could be out of network despite the insurance referral. Could be a deductible. Could be a setup where she paid up front and gets reimbursed by insurance. Lots of possibilities.

I have such mixed feelings about the article. Hindsight is 20/20, but I'm hesitant to pass judgment without having been in the room.
- Some patients are overly talkative, especially at an initial appt and it can be tough to do a proper differential over the course of an hour. Though at a minimum, suicide/homicide risk should certainly have been evaluated.
- Evaluations are often ongoing if the intent is to continue seeing the patient. No one does a full SCID in an hour long intake. GAD was diagnosed. I can easily see how someone could get sucked down that path and not evaluate everything else. A typical GAD presentation does not usually leave me overly concerned about homicide. I have no idea if this woman's presentation was typical or not.
- The above nonetheless still hinges on the patient REPORTING those things. Do we know this woman would have responded with "I'm planning to murder two children as soon as I leave your office"? No psychiatrist/psychologist/social worker could have done a damn thing to prevent this if she didn't.
- There is little reason to believe a psychiatrist would have helped. We have no evidence her problems were "medical" and they would have been better able to differentiate. At present, we have no reason to believe they would have done a more thorough interview. Chances are, the appt would have been shorter. They might have done less.
- The only red flag in my eyes was how she presented to the clinic. That is really only a red flag in hindsight.

My takeaways are: 1) Always evaluate risk at an initial appt and document (not that this is news); 2) Use an intake form to at least get a checklist of discussion topics; and 3) Don't take walk-ins unless its an established part of clinic operations. The fact that I have to include #3 makes me sad, as it is risk management at the expense of patient care.

 

[psych.meout]

Many potential explanations for the $200 payment that are not at all out of the ordinary. Could be out of network despite the insurance referral. Could be a deductible. Could be a setup where she paid up front and gets reimbursed by insurance. Lots of possibilities.

I have such mixed feelings about the article. Hindsight is 20/20, but I'm hesitant to pass judgment without having been in the room.
- Some patients are overly talkative, especially at an initial appt and it can be tough to do a proper differential over the course of an hour. Though at a minimum, suicide/homicide risk should certainly have been evaluated.
- Evaluations are often ongoing if the intent is to continue seeing the patient. No one does a full SCID in an hour long intake. GAD was diagnosed. I can easily see how someone could get sucked down that path and not evaluate everything else. A typical GAD presentation does not usually leave me overly concerned about homicide. I have no idea if this woman's presentation was typical or not.
- The above nonetheless still hinges on the patient REPORTING those things. Do we know this woman would have responded with "I'm planning to murder two children as soon as I leave your office"? No psychiatrist/psychologist/social worker could have done a damn thing to prevent this if she didn't.
- There is little reason to believe a psychiatrist would have helped. We have no evidence her problems were "medical" and they would have been better able to differentiate. At present, we have no reason to believe they would have done a more thorough interview. Chances are, the appt would have been shorter. They might have done less.
- The only red flag in my eyes was how she presented to the clinic. That is really only a red flag in hindsight.

My takeaways are: 1) Always evaluate risk at an initial appt and document (not that this is news); 2) Use an intake form to at least get a checklist of discussion topics; and 3) Don't take walk-ins unless its an established part of clinic operations. The fact that I have to include #3 makes me sad, as it is risk management at the expense of patient care.

I agree with your points, but as an addendum, this psychologist definitely seems to be overbooked. Based on how the appointed was scheduled as detailed in the article and the time it occurred, I'm guessing that he booked her for what was probably his lunch break.

I don't really have much doubt that if she tried to book an immediate appointment like this with most physicians, psychiatrists or not, she would have been put off to the next available timeslot or referred out to someone else, told to go to urgent care, etc. There seems to be a distinct difference in orientation between psychologists and physicians. Psychologists often take it personally and regard it as failure when their patients relapse or have other bad outcomes, even when it's not really their fault (just look at the relapse stats for many pathologies). Hell, psychologists often even regard it as personal failings when they have to refer patients out to others, regardless of the reason. Physicians, at least the ones I know, don't internalize these things like our field does. I'm not sure who's right or if there's some other correct position to take, but I do think it's something to consider in this case when people are so inclined to demonize this psychologist, especially with hindsight being 20/20/

 

[smalltownpsych]

One thing I liked about the article was the suggestion to use a standardized intake form. I don't know why we don't use that all the time in our field. I have actually met with resistance to this in several places that I have worked which in my mind is bizarre since any other doctor I see, i have to fill out a basic history form. Sometimes it can be very challenging to get the information from an emotionally distressed patient and when i have used a form, it helps significantly.

 

[Mad Jack]

Aside from no proof this would improve outcomes, there are so many logistical issues. Who is going to filter these "serious" cases to a psychiatrist in the first place? What psychiatrist in their right mind would want this flood of potentially unstable patients in the absence of objective proof that intervention by a psychiatrist would improve outcomes? What happens to these cases when there is no psychiatrist available to evaluate them? What grounds does he have that psychiatrists are somehow more prescient than psychologists with regard to future mental stability?

I could go on, but like, what is this article even?

 

[psych.meout]

I could go on, but like, what is this article even?

A freelance author fearmongering based on an incredibly unfortunate tragedy so they can sell their crappy writing to a rag website?

Just think about the Szasz-esque anti-psychiatry article that would be published if the psychologist had this woman placed on a brief, involuntary hold for observation if she did admit to homicidal or suicidal ideation?

 

[smalltownpsych]

Aside from no proof this would improve outcomes, there are so many logistical issues. Who is going to filter these "serious" cases to a psychiatrist in the first place? What psychiatrist in their right mind would want this flood of potentially unstable patients in the absence of objective proof that intervention by a psychiatrist would improve outcomes? What happens to these cases when there is no psychiatrist available to evaluate them? What grounds does he have that psychiatrists are somehow more prescient than psychologists with regard to future mental stability?

I could go on, but like, what is this article even?

We (people) can't even predict job performance based on a job interview, so of course there is no real predictive power of a diagnostic interview. Nevertheless, I do think that we, as psychologists, are often a little bit weaker in our diagnostic interview skills than psychiatrists. However, we might be better at developing rapport and understanding some of the interpersonal complexities of the case. This is just based on my own limited and biased observations so take it with a grain of salt. If that is indeed the case, I would think that the latter skill might have more predictive utility than the former. I always use the example of suicide risk for this point. If the patient doesn't trust me, they won't tell me so it doesn't matter what my risk assessment strategy or tool is if I can't develop sufficient rapport.

 

[Mad Jack]

We (people) can't even predict job performance based on a job interview, so of course there is no real predictive power of a diagnostic interview. Nevertheless, I do think that we, as psychologists, are often a little bit weaker in our diagnostic interview skills than psychiatrists. However, we might be better at developing rapport and understanding some of the interpersonal complexities of the case. This is just based on my own limited and biased observations so take it with a grain of salt. If that is indeed the case, I would think that the latter skill might have more predictive utility than the former. I always use the example of suicide risk for this point. If the patient doesn't trust me, they won't tell me so it doesn't matter what my risk assessment strategy or tool is if I can't develop sufficient rapport.

That is good to know. I'm yet to begin training but was under the impression that psychologists were quite good at general evaluation. We do get all of that inpatient time with the sickest of the sick during residency though, so I guess it would be reasonable to assume that we've got a better gauge of who is and isn't a danger to themselves or others, but still, to believe that a psychiatrist evaluating would have stopped this is kind of farfetched unless they've got access to her evaluation file and there are obvious red flags (in which case this is more of a clinician issue than a psychologist vs psychiatrist issue).

 

[smalltownpsych]

That is good to know. I'm yet to begin training but was under the impression that psychologists were quite good at general evaluation. We do get all of that inpatient time with the sickest of the sick during residency though, so I guess it would be reasonable to assume that we've got a better gauge of who is and isn't a danger to themselves or others, but still, to believe that a psychiatrist evaluating would have stopped this is kind of farfetched unless they've got access to her evaluation file and there are obvious red flags (in which case this is more of a clinician issue than a psychologist vs psychiatrist issue).

If a psychologist is doing a comprehensive evaluation using standardized tests with validity indicators, then you are likely to get much better information. I was referring more to a standard diagnostic intake for a psychotherapy patient when comparing psychiatrists to psychologists. As far as this case goes, risk assessment is something we should be equally good at, and for a patient in crisis enough to fit into a lunch time appointment, it might have been a good idea to ask about suicide.

Quick poll, how many of us ask about homicide from every patient? I know I don't unless there is some other risk factor.

 

[Ollie123]

If a psychologist is doing a comprehensive evaluation using standardized tests with validity indicators, then you are likely to get much better information. I was referring more to a standard diagnostic intake for a psychotherapy patient when comparing psychiatrists to psychologists. As far as this case goes, risk assessment is something we should be equally good at, and for a patient in crisis enough to fit into a lunch time appointment, it might have been a good idea to ask about suicide.

Quick poll, how many of us ask about homicide from every patient? I know I don't unless there is some other risk factor.

We ask some vague/generic version on our forms, but no I don't always make it a discussion point. I try to, but if I get a reasonably stable but talkative patient presenting with normal-ish concerns (e.g. busy professional presenting for anxiety/stress management) I don't necessarily prioritize it. Not that I'm defending that practice, but I do admit it happens. I consider myself above average conscientiousness when it comes to clinical issues and even if I'm being modest expect I am equally or more thorough than most providers. However, even if we assume I'm 25th percentile...that still means an enormous chunk of professionals are not doing this consistently. I believe I'm 100% (or close to it) on asking about self-harm at intake. I do not routinely ask that every session.

The real question is..should we be spending more time on these things? This fits in with the previous thread about the fairly ridiculous notion of "zero suicide" movements. Is it reasonable to expect perfection? Do we want this to turn into people gaming the system to keep their numbers up (e.g. refusing to take high risk patients) like some medical specialties (have to) do? That seems an inevitable consequence if we are all expected to laser focus on one criteria for performance. Are we willing to provide the infrastructure and support needed to REALLY achieve these goals, or are we just looking to pay them lip service and shift blame onto providers?

One final point...the one situation in which I DO always discuss violence at intake is during informed consent. When I tell them if they tell me they are planning to hurt someone, I will intervene and tell other people. Which probably decreases the likelihood of them admitting it if they are planning on doing so. I am also ethically obligated to do this. I wonder how the author of the article would feel about that?

 

[PsyDr]

I'm unclear as to how this woman was referred to this psychologist by her insurance company, yet she paid him $200. This can't be her copay and still seems too high to be coinsurance. How much does he charge for an hour?

1) Many commercial insurers have referral systems where the patient calls, asks for a specific type of provider, and the insurance employee will find a provider who takes their insurance in their nearby geographical area.

2) The article didn't say she paid him $200, it said he charged her $200. This is a significant difference. Insurance requires providers to put a price on their services, submit a bill, and only then do the insurers pay whatever the insurance's standard rate is. This is why you see those incredible insurance EOBs where the hospital charges $95,000 for a knee replacement, the insurance adjusts the fee to $8k, and pays $5k. It could be that this psychologist charged her insurance $200 in the bill. It could be that this person had a huge deductible that hadn't been met.

3) If Lieberman wants every single psych patient to be seen by psychiatry, he's got his work cut out for him. NAMI puts the incidence of mental illness at about 20% of the population. Estimates of Manhattan's population is around 1.65 MM. So 330,000 patients. Estimates range for between 37k-43k psychiatrists in the USA. Dartmouth puts the number of psychiatrists on the island at around 500.

 

[Ollie123]

And ironically enough....at 660 patients per psychiatrist Manhattan is probably in far BETTER shape than most parts of the country. Which is terrifying.

Yeah, totally makes sense to require everyone be seen by psychiatry first. I'm sure she wouldn't have murdered anyone if she came in and was told the next available appointment was in 17 months.

 

[PsyDr]

@Ollie123 thats new patients. Incidence vs prevalence and all.

 

[Sanman]

There are many issues with what this psychologist did and the ideas presented. If you read the NY Times article, he "reluctantly" agreed to see her on his lunch break after she begged him to do so. That was his biggest mistake, IMO. I have learned not to take people like this on short notice in private practice (or really anywhere). It never works out well and you open yourself up to liability the minute you see them. Book them normally so that you have time assess properly. Either the crisis will pass and you will see them in a calmer frame of mind or something will happen and you are not on the hook professionally. I use a intake eval form (and always have) because it cues me to ask all of the appropriate questions that I can forget. Even then, I find my quality declines if I do more than 4 intakes in a day.

As for the psychiatrist's premise, many holes I can poke in that. However, the biggest joke is the idea that you can find a psychiatrist in Manhattan that accepts insurance. I know several that charge $4-500/hr cash and have a waiting list. They are not clamoring for poorly compensated, high risk insurance work. So, who will be seeing all these high acuity patients for little pay?

 

[WisNeuro]

We (people) can't even predict job performance based on a job interview, so of course there is no real predictive power of a diagnostic interview. Nevertheless, I do think that we, as psychologists, are often a little bit weaker in our diagnostic interview skills than psychiatrists. However, we might be better at developing rapport and understanding some of the interpersonal complexities of the case. This is just based on my own limited and biased observations so take it with a grain of salt. If that is indeed the case, I would think that the latter skill might have more predictive utility than the former. I always use the example of suicide risk for this point. If the patient doesn't trust me, they won't tell me so it doesn't matter what my risk assessment strategy or tool is if I can't develop sufficient rapport.

I think that varies quite a bit based on your program. Interview skills were the first thing that were drilled into us in my program. You had to be able to do a very thorough full interview, SCID and all, as well as a shorter hour-long intake that hits everything that is absolutely necessary in that first visit. In the end, as far as someone went to a reputable program, I think the interview skills are on par, if not better, in many cases. Especially more assessment oriented people.

 

[psych.meout]

I think that varies quite a bit based on your program. Interview skills were the first thing that were drilled into us in my program. You had to be able to do a very thorough full interview, SCID and all, as well as a shorter hour-long intake that hits everything that is absolutely necessary in that first visit. In the end, as far as someone went to a reputable program, I think the interview skills are on par, if not better, in many cases. Especially more assessment oriented people.

This is very consistent with my program.

 

[Mindfulpsych22]

It’s been my experience that most psychologists do a more thorough diagnostic and risk assessment than psychiatrists and mid-levels (generally), though I do think psychiatrists are better about ensuring that physical exams/tests rule out other common causes is psychiatric symptoms (thryroid, etc). We received very thorough diagnostic training in my program, practica, etc. and at my current clinic we do a structured risk assessment, diagnostic screening and sx questionnaires and the SCID.

I’ve also noticed quite a difference between how thorough a first assessment is and the pay source- with patients who are private pay and seeing someone who does not take insurance getting more time and more thoroughness than those seeing an in network provider. For what it’s worth, it’s not uncommon that my patients see a psychiatrist in their network are told after 15 minutes into their first consult that they need to be on lithium because they have bipolar disorder even though the only sx of bipolar they report is “mood swings.” It’s also very hard to find psychiatrists who do thorough and accurate job with assessing children and adolescents.

I echo all the problems everyone else stated regarding access (many patient wait at least a month for an intake appointment with a psychiatrist), reliability with diagnosis, and predictive validity of risk assessment.

 

[PsyDr]

Eh, there are types of psychologists, just like there are types of psychiatrists. If you go to a psychoanalyst of any variety, they are going to use a process approach over the course of several sessions to get a formulation. If you somehow walked into a transplant psychologist or C&L psychiatrist's office, they are going to approach you in a different way. If you go to a forensic psychiatrist/psychologist expecting clinical services, things will be different.

 

[smalltownpsych]

Eh, there are types of psychologists, just like there are types of psychiatrists. If you go to a psychoanalyst of any variety, they are going to use a process approach over the course of several sessions to get a formulation. If you somehow walked into a transplant psychologist or C&L psychiatrist's office, they are going to approach you in a different way. If you go to a forensic psychiatrist/psychologist expecting clinical services, things will be different.

Also, in an outpatient psychotherapy setting, one has to balance developing rapport and providing some immediate benefit with obtaining history and assessing risk. If you don't do this well, you end up with an empty schedule. One reason that I prefer private pay types of settings is that I get rewarded for being good at this aspect. When I worked in community mental health, the reward was that I ended up working more than my colleagues. 😡

 

[Sanman]

Also, in an outpatient psychotherapy setting, one has to balance developing rapport and providing some immediate benefit with obtaining history and assessing risk. If you don't do this well, you end up with an empty schedule. One reason that I prefer private pay types of settings is that I get rewarded for being good at this aspect. When I worked in community mental health, the reward was that I ended up working more than my colleagues. 😡

I have to agree with this. Ironically, I am going in the reverse direction from you. While that skill was helpful in the private sector and has been somewhat at the VA, I find myself wondering why I try so hard at times when there is no pay off behind it. Sometimes I need to remind myself I am at the VA and my customer service skills need to be toned down a bit from private practice. I took this gig for better work/life balance.

 

[cara susanna]

There are many issues with what this psychologist did and the ideas presented. If you read the NY Times article, he "reluctantly" agreed to see her on his lunch break after she begged him to do so. That was his biggest mistake, IMO. I have learned not to take people like this on short notice in private practice (or really anywhere). It never works out well and you open yourself up to liability the minute you see them. Book them normally so that you have time assess properly. Either the crisis will pass and you will see them in a calmer frame of mind or something will happen and you are not on the hook professionally. I use a intake eval form (and always have) because it cues me to ask all of the appropriate questions that I can forget. Even then, I find my quality declines if I do more than 4 intakes in a day.

As for the psychiatrist's premise, many holes I can poke in that. However, the biggest joke is the idea that you can find a psychiatrist in Manhattan that accepts insurance. I know several that charge $4-500/hr cash and have a waiting list. They are not clamoring for poorly compensated, high risk insurance work. So, who will be seeing all these high acuity patients for little pay?

Devil's advocate: if he hadn't seen her, do you think there would have been articles written about this mean psychologist not providing someone the care that she needs?

Also, this makes me feel better about maintaining strict time boundaries. Not to mention I'd be the most ineffective therapist ever if I skipped a meal.

 

[Sanman]

Devil's advocate: if he hadn't seen her, do you think there would have been articles written about this mean psychologist not providing someone the care that she needs?

Also, this makes me feel better about maintaining strict time boundaries. Not to mention I'd be the most ineffective therapist ever if I skipped a meal.

Most likely someone would have written yet another article about the broken mental health system in this country and access to care issues without addressing larger systemic problems or addressing how any changes would be funded. However, at least then this poor guy would not be on the hook. This is the type of thing that can ruin a practice. Now this guy might be at the end of his career, but I am loans and a mortgage to pay. I can't afford to lose my license or pay out a large malpractice suit (making me uninsurable).

Best case scenario is that she admits to the issues and the guy can't do much but derail his day and lose a bunch of money to attempt to get her into an ER immediately for a psych hold. It is possible that she runs from the office after he informs her that she needs a psych hold, he makes a report to 911, and it still may have happened depending on how much info he had on her (if he was out network and she would be reimbursed, no copies of health insurance cards, etc may have been in the file yet given that this was an initial session). An outpatient psychotherapy office is not exactly equipped to treat possible unmedicated psychosis and homicidal ideation. What would a psychiatrist have done? Throw her a script for meds that would be ready at the pharmacy after she had committed the same crime? The truth is it nothing would have likely stopped her short of a full confession of her thoughts (which may not have even occurred yet if the crime was not pre-meditated) as most outpatient clinicians are not doing emergency petitions for psych holds on people after an initial session without damning evidence. A good evaluation and note is more about covering your own ass.

One of the first and most important lessons I learned in my time at a private practice is deciding what type of patients you want to manage and properly screening for those types of patients.

 

[Ollie123]

@Ollie123 thats new patients. Incidence vs prevalence and all.

Oh, I understood.

Better != Good. Perhaps I should have said "less terrible"?

 

[foreverbull]

Quick poll, how many of us ask about homicide from every patient? I know I don't unless there is some other risk factor.

Both suicidal ideation/past attempts AND homicidal ideation are standard in my intake. "Have you ever wanted to harm someone else?" I almost always get a quick "no" and move on.

 

[Sanman]

Both suicidal ideation/past attempts AND homicidal ideation are standard in my intake. "Have you ever wanted to harm someone else?" I almost always get a quick "no" and move on.

I also ask about s/h/i and previous mental health hx as part of the standard intake I perform. However, there may have been times in outpatient PP that I did not. A positive about geriatrics is a captive audience, so I worry less about time in my initial assessment.

 

[WisNeuro]

I don't ask about HI in my dementia evals unless something in the chart makes me curious about it. I always ask about SI. Also, I have a lengthy pre-evaluation questionnaire that gets at these issues, so I always follow up with more questions if anything gets endorsed on those questionnaires.

 

[AcronymAllergy]

I nearly always ask about HI around the time that I ask about SI, but it's not something I typically probe in depth (unless, as WisNeruo mentioned, there is something in the records or that comes up during the interview). It's an entirely outpatient and assessment-based setting, though.

 

[Therapist4Chnge]

I always ask, partly for completeness and partly bc of preference rates of certain patient populations I eval.

 

[PsyDr]

I ask, but I am sure that there is almost no validity to the questioning. The courts don't ask murderers "are you gonna kill someone again?". That should tell you how much the legal system believes in just asking.

 

[psych.meout]

I ask, but I am sure that there is almost no validity to the questioning. The courts don't ask murderers "are you gonna kill someone again?". That should tell you how much the legal system believes in just asking.

The civil side of the legal system seems to care quite a bit about meaningless gestures which don't have much validity or reliability.

 

[PsyDGurl]

I had a patient comment to me the the other day something to the effect of - wow this is a whole lot more information than my psychiatrist asked me for before I walked out with a script for a handful of medications (regarding the intake session).

This is probably a comment that many of you have heard before.


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