Private practice docs: How often do you see any follow-ups that are stable?

[abcxyz0123]

In residency/fellowship, it was standard to see my follow-ups every 3 months once stable (if not already discharged to PCP). However, there are some psychiatrists in the community who will see patients (even those on controlled substances), once every 6 months; and there are others who see patients every month (despite them being stable). Patients definitely prefer fewer f/u's per year if possible once stable, as it is less expensive and less of a headache. However, with managing medicines, there are time/overhead expenses involved with prior auth's, signing for refills, etc, that can add up over time, and if you don't take insurance, you can't bill for these unless you have pt's come in for follow-ups. Further, there is also risk of pt declining/decompensating while taking the medicines, that you may not be able to catch until it is too late with too infrequent of f/u's.

Anyway, I figured I'd ask: how often do you see the following type of patients (I'm making these up as I go, figure I'd give varying types to see if there were differences in responses):

1) 30 yo male who first saw you for tx of moderate symptoms of depression/anxiety that were not responding to psychotherapy alone, who after starting Zoloft 6 months ago, is now stable, and (for the sake of this question) would like to stay on it for life, and would like to remain in your practice and not be d/c'd to PCP

2) 36 yo F on Concerta 36mg QD for ADHD, has been on stimulants since childhood for ADHD, just needs refills for same dose throughout the year, has verified dx of ADHD since childhood, no substance abuse hx, etc.

3) Someone who is on a regimen of both controlled substances (maybe an extended release stimulant in AM and immediate release stimulant in afternoon), plus is taking both Lexapro and Remeron for hx of severe depression, maybe had 2 hospitalizations with hx of suicidal ideation but no attempts in past, has been stable on same med regimen for two years and has no desire to change it.

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[TexasPhysician]

My answer is typically 3 months. The DEA only allows 3 months of C2’s at one time - that’s a big hint. Also, a lot can happen in 3 months.

Without controlled meds, stable on meds and not wanting to taper after 1 year can go to 4 months or follow with PCP.

 

[nexus73]

I'd add a 4th patient scenario: stable bipolar I patient on Lithium/Olanzapine combo. How long in between followups?

 

[Liquid8]

1) 30 yo male who first saw you for tx of moderate symptoms of depression/anxiety that were not responding to psychotherapy alone, who after starting Zoloft 6 months ago, is now stable, and (for the sake of this question) would like to stay on it for life, and would like to remain in your practice and not be d/c'd to PCP

3 months for the next 1-2 appointments, then 6 monthly if stable.

2) 36 yo F on Concerta 36mg QD for ADHD, has been on stimulants since childhood for ADHD, just needs refills for same dose throughout the year, has verified dx of ADHD since childhood, no substance abuse hx, etc.

3 months for the first review appointment if I am recommencing them on medication, after that 6 monthly when on a stable dose.

3) Someone who is on a regimen of both controlled substances (maybe an extended release stimulant in AM and immediate release stimulant in afternoon), plus is taking both Lexapro and Remeron for hx of severe depression, maybe had 2 hospitalizations with hx of suicidal ideation but no attempts in past, has been stable on same med regimen for two years and has no desire to change it.

2-3 monthly for first 9-12 months, then increasing to 4-6 monthly depending on stability and patient comfort level. With Scenarios 1 & 2 I will offer them an earlier appointment if things change, but those who have been hospitalised before often don’t want to chance not being able to get an appointment if things take a backward step and often prefer to make frequent appointments just in case.

I'd add a 4th patient scenario: stable bipolar I patient on Lithium/Olanzapine combo. How long in between followups?

Probably would use a similar review pattern to Scenario 3, if only to monitor weight and keep a close eye on lithium levels in the early stages.

As a general comment, if in the early stage of treatment or if I feel patients are high risk or prone to destabilisation I will aim to see them more frequently. Over the last few years I have accumulated a few dependent patients who always seem to book in every 3-4 weeks regardless which is probably par for the course in private land. Some of the borderlines will do similar, but this is often due to presenting better in person than they actually feel or at the insistence of a partner or family member who feel that they need more containment.

 

[romanticscience]

The scope of my practice is "psychotherapy with or without medication." I base frequency on a balance of clinical indication and patient preference. When patients are acutely ill (e.g. active MDE), I try to see them weekly up to 16 weeks (time limited therapy/IPT/CBT) or until symptoms stabilize or remit. At this point, for maintenance/continuation, I offer either continued interpersonal-focused follow up (every 1 or 2 weeks for 60-min) or symptom-focused follow up (every 1 or 2 months for 30-min). If patients have severe personality disorder, I share with them that the treatment indicated is weekly and will not agree to see them less frequently. I also generally will see patients who are on controlled medications every 1-month.

My follow-up schedules may seem overly conservative but that is because of the incentive to keep patient volume and related admin time down. I see it as a balance between overly strict (eg, requiring weekly hour appointments) v. overly flexible (q6-12 month, med checks). If patients want less frequent that 2-months, I offer to refer them back to their PCP.

So:

1) q2months, 30-min

2) qmonth, 30-min

3) qmonth, 30-min

 

[dl2dp2]

The scope of my practice is "psychotherapy with or without medication." I base frequency on a balance of clinical indication and patient preference. When patients are acutely ill (e.g. active MDE), I try to see them weekly up to 16 weeks (time limited therapy/IPT/CBT) or until symptoms stabilize or remit. At this point, for maintenance/continuation, I offer either continued interpersonal-focused follow up (every 1 or 2 weeks for 60-min) or symptom-focused follow up (every 1 or 2 months for 30-min). If patients have severe personality disorder, I share with them that the treatment indicated is weekly and will not agree to see them less frequently. I also generally will see patients who are on controlled medications every 1-month.

My follow-up schedules may seem overly conservative but that is because of the incentive to keep patient volume and related admin time down. I see it as a balance between overly strict (eg, requiring weekly hour appointments) v. overly flexible (q6-12 month, med checks). If patients want less frequent that 2-months, I offer to refer them back to their PCP.

So:

1) q2months, 30-min

2) qmonth, 30-min

3) qmonth, 30-min

I don't think this is "conservative". I think your approach is the correct one and try to do the same in my practice. In particular, a lot of people with personality disorders are not advised that they need weekly for a long period of time, to their detriment.

 

[finalpsychyear]

Most PP that take insurance are seeing all controlled substance users monthly from what I have seen. Drugs are a big problem in my state. Nearly no one gives refills on any controlled substances in our community aside form 75 year old pcps.