Use of structured clinical interviews in the outpatient setting

[reca]

I'm wondering if outpatient psychiatrists utilize structured clinical interviews in their practice? I just finished my first week of outpatient psychiatry ( we have a traditional curriculum and do no outpatient until PGY-3) and have noticed at least two of the patients I've inherited have had (what I think) are missed diagnoses. Both are long time patients in the community health clinic; one reported symptoms of OCD and the other of binge eating disorder to me. Neither patient's chart had any mention of these symptoms and I'm wondering if the previous resident simply never asked about it and thus never picked up on it. It seems like a structured clinical interview or self-reported scale of something like SCID-5 or MINI would be a good starting out point for outpatient patients. A comprehensive form to fill out before the actual intake interview. Is this ever done in practice?

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[wolfvgang22]

Of course it's done in practice, especially with patients new to you that you are just getting to know, which they all are when you are a resident or fellow. Once you know the patient well you can be semi structured yet remain alert to missed diagnoses or new developments. I do this with patients I have seen for years, but not with patients I have seen only a few times. It is good to use self report scales and other tools regularly.

Diagnoses get missed with poor exams, as you may be seeing. Being forced to see too many patients or getting overwhelmed with charting can contribute. Also, many times underlying diagnoses or severity of illness reveal themselves over time as a patient begins to trust you and becomes more forthcoming and relaxed and you learn more about the person. So it's always good to be vigilant with structure in the interview even while you are forming an appropriate therapeutic rapport. There is an art to performing a structured interview whilst establishing rapport.

 

[erg923]

I think this is probably underutilized. Although it can some times suck due to the time intensive nature, and because its sometimes hard to gather good informant/collateral info, it is superior to at least attempt this as opposed to the variations that occur within the traditional psychiatric interview/exam, and often better than referring for an MMPI or something similar.

Our lab in graduate school used the SCID (sometimes MINI or SADs), and with skilled/trained operator, translated to more info and hypotheses for treatment and diagnosis than almost anything else.

 

[dl2dp2]

It's not a bad idea to get training and do them on some regular basis, if only take what you can get by doing an abbreviated version. Remember SCID is very long (1.5 hours), and even MINI is relatively long (let's say give it 30-45 min to be generous), and the purpose of a clinical intake interview is more than simply diagnostic accuracy (i.e. you need to assess for other "big picture" items, like family support, medication tolerability, other medical comorbidities, fit for various psychotherapy modalities, etc), and in many cases might have to do other additional housekeeping things like urine tox screen, physical exam, payment and paperwork, etc. etc.

I had a discussion with someone recently about this: why not just have a masters level clinician do a SCID and give you a list of diagnosis, and just write meds based on some algorithm. IMO this is not more efficient 1) the label, say of MDD, doesn't dictate my med use, has to do with things outside of diagnoses, which means I'd have to repeat a bunch of random questions anyway. 2) in general, most psychiatrists are seeing things that are more complex than a garden variety MDD diagnosis, like a list of random meds, failed trials, suicidality, psychosis, co-morbidities, etc. Diagnostic labels don't address issues relating to the severity and clinical judgement calls relating to the "design" of the right regimen if this makes sense.

Missed diagnoses in psychiatry is *extremely common*, depending on the context. In fact, sometimes what is "missed" is simply intentionally ignored for various reasons (i.e. reimbursement and other systems related issues). A good thorough outpatient intake can be easily 90min+, and for child can be 3 hours+, but most public facilities do not allow for this. A different way to say this is that you can conceptualize your role in this as an extended evaluation, and screen for issues as appropriate.

 

[splik]

structured interviews have their place and I believe residents should get training in this approach but even with them you can miss things. Personally, I do not like the check box approach to psychiatry and rarely ask about "symptoms" at all. A highly skilled psychiatrist using all their senses, assessment of the mental state, transference and countertransference, neurobehavioral assessment and a detailed social and developmental history are still imho gold standard along with review of records and collateral information. structured interviewing (along with psychological testing, where appropriate) can augment this. What I do use is a variety of self-report screeners as appropriate (e.g. HADS, PHQ-9, GAD-7, MDQ, HCL-32, YBOCS-SR, DAST, AUDIT, PCL-5, AQ, ADHDSRS, BEDS-7, IPDE screener, HELPS, Epworth, DES, SSS-8, somatic symptom questionnaire etc). I find these invaluable if the patient completes them prior to the evaluation as this can help focus the evaluation more effectively. In addition, if the patient reveals things during the first evaluation that I want to probe further, I will ask them to fill in further screeners to review, and then probe further and contextualize their self-report with their history and mental state exam and collateral info etc. In real world clinical settings, it is also much more feasible to use the self-report tools than doing structured interviews like the SCID.