When should a psychiatrist refer a patient to you for psychological testing?

[reca]

This is something I'm still quite fuzzy on despite being a PGY-3. For what reasons should a psychiatrist refer a patient to psychologists for psychological testing?

It seems we refer all of our suspected ADHD patients for neuropsych testing in order to role our learning disorders. Guess that makes sense. What are the other reasons we should refer a patient for testing? Also, what exactly should we ask for? At my institution, we ask for "psychological testing." I feel like I read a thread somewhere on SDN where psychologists said that was pointless and to be more specific about the type of testing being required. Any help?

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[RejectClinical]

Actually, I would say that you should not refer ADHD patients for neuropsych testing. There is no "profile" of neuropsychological results that is diagnostic of ADHD. Any psychologist or psychiatrist should be able to assess for ADHD. That's another long discussion. Can you be more specific about "psychological testing"? Do you mean psychodiagnostic or neuropsychological? Also, I think this also depends on how you're practicing as a psychiatrist (e.g., how much time do you have with patients in your practice?).

 

[WisNeuro]

Actually, I would say that you should not refer ADHD patients for neuropsych testing. There is no "profile" of neuropsychological results that is diagnostic of ADHD. Any psychologist or psychiatrist should be able to assess for ADHD.

If assessing for LD, they need testing. ADHD is a diagnosis made by clinical history, LD is made by diagnostic criteria that require some testing to tease out. I won't do either of these, generally because insurance does not pay for it. So, totally appropriate for a school aged person to get a neuropsych test if LD is suspected. Generally, the school system is supposed to provide this, otherwise it's usually paid out of pocket.

 

[erg923]

This is something I'm still quite fuzzy on despite being a PGY-3. For what reasons should a psychiatrist refer a patient to psychologists for psychological testing?

It seems we refer all of our suspected ADHD patients for neuropsych testing in order to role our learning disorders. Guess that makes sense. What are the other reasons we should refer a patient for testing? Also, what exactly should we ask for? At my institution, we ask for "psychological testing." I feel like I read a thread somewhere on SDN where psychologists said that was pointless and to be more specific about the type of testing being required. Any help?

It can often be both. And your tax dollars pay for the school systems to assess LD and other educational/academic needs and deficits. That's not what health insurance is for. Gathering some standardized information is advised for a suspected ADHD diagnosis, but more formal "testing" is not really needed. The DSM5 criteria for ADHD are all behavioral, and there is no requirement (per DSM) that they have any kind of objective deficits in attention or another cognitive functions. That said, some situations/conditions (e.g., suspected malingering/exaggeration, Autism, extremely bizarre or contradictory presentations, no collateral to speak of, etc.) often do require more standardize data than most psychiatrists can reasonably be expected to do on their own.

Generally speaking, when you have done a thorough job with the traditional psychiatric exam and still cant figure it out, then I think asking for a second opinion that uses different methods is warranted. But most psychiatric diagnoses are still based on behavioral criteria, developmental/symptom history, and DSM criteria rather than any psychological testing profile/results. Further, as much as the profession of psychiatry/psychology doesn't like to admit it, we treat symptoms rather than diagnoses for the most part, and because psychiatric diagnoses are quite fluid over time, pinning down the exact right diagnosis prior to initiating treatment is not really needed. It is only within the past 30-40 years or so that we started with this incessant pursuant of a "for sure diagnosis" prior to treating people on the OP level. Insights that better guide treatment often come during the course of treatment.

Quite simply, a psychological evaluation referral question should state what you suspect, but aren't sure of yet, and why you need an answer to adequately treat them. Often times we will/can utilize psychological tests to assist in answering your question, but it's not always necessary. You are essentially referring for a second opinion, not necessarily for testing.

 

[WisNeuro]

The two dont really that much overlap, so I'm not sure why you need to do that. It can often be both. And your tax dollars pay for the school systems for help with the dxing LD. Thats not what health insurance is for.

I will say that it's hard to tease apart LD/ADHD in many instances, especially by non-psychologists. Though with an almost 50% comorbidity rate, it's both. Still good to identify LD if it exists, as the stimulant script will do little to help address say, an underlying reading LD.

 

[AcronymAllergy]

Agree with what's been said above. Anecdotally, we've had psychiatrists refer their patients for evaluation when they want a better/more in-depth understanding of the patient, including psychopathology and possibly personality. This being because they're only able to see the person for 30 minutes every 3 months, and can't delve that deeply during that time. Also sometimes happens when the person isn't responding to treatment.

The more specific the referral question, the easier it (typically) is to give a specific answer. The more vague the question, the more vague and meandering the response.

 

[erg923]

Agree with what's been said above. Anecdotally, we've had psychiatrists refer their patients for evaluation when they want a better/more in-depth understanding of the patient, including psychopathology and possibly personality.

I think that's fine. But they really need to be specific about how that will be used, or why its needed to treat them/treatment plan that particular patient. Personality variables are factor in ALL cases in treatment. Referring every psych patient who is in treatment for this question is cost (and resource) prohibitive.

 

[AcronymAllergy]

I think that's fine. But they really need to be specific about how that will be used, or why its needed to treat them/treatment plan that particular patient. Personality variables are factor in ALL cases in treatment. Referring every psych patient who is in treatment for this question is cost (and resource) prohibitive.

Agreed. I would reserve it primarily for treatment-resistant cases, and/or those situations in which unidentified personality or psychopathology factors are suspected as interfering with treatment.

 

[Therapist4Chnge]

I don’t receive many trad psych referrals or referrals from psychiatrists in general, though the ones I do get are mostly about wanting to understand barriers to treatment, patient non-compliance, and/or differential diagnosis. I’ll also get chronic pain patients with significant psych overlay...this is a growing group bc it’s my most frequent referral to a psychiatrist, so I often get looped in the other way now.

I’m more likely to refer to a psychiatrist than vice versa, particularly for the patients with a strong pre-existing psych history who then sustain polytrauma injures. Coping is usually non-existent and having the PCP try and adjust meds after years on a stable regimen is a tough ask.

 

[PsyDr]

@reca

I. The best advice is to provide a specific referral question. Don't write, "testing". Write something like, "rule out ADHD". Or " Evaluate substance abuse."


II. Common referrals

Differential Diagnosis (e.g., "is this Bipolar II or a personaoity d/o?)
Cognitive complaints (e.g., Are the subjective concentration complaints due to MDD or ADHD or OSA?)
Somatic symptoms inconguent with pathology
Course of psychiatric illness exceeds known natural history.
Disability work, because this is indicated by SSA and private forms.

 

[erg923]

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[StellaB]

I would say any time cognitive (such as LD, ID) or developmental issues (autism) are suspected, testing is warranted. And though assessing for personality disorders does not require testing per se, I frequently find myself wishing psychiatrists would refer patients diagnosed with bipolar disorder in order to rule out borderline PD, as this misdiagnosis is common and potentially fatal. Psychologists are trained to recognize and assess for personality disorders.