Essential Concepts
Once you’ve come up with a diagnosis, you have to determine a treatment plan based on that diagnosis. A treatment plan is something you should arrive at with your patient, rather than handing it to her like a prescription. The more you involve your patient in planning treatment, the more likely that she will follow through with the plan.
Compliance was once a popular term for describing good follow-up, but now that term is being gradually replaced with adherence, which implies less passivity. A patient chooses to adhere, whereas he is made to comply. Researchers have found that when clinicians and patients negotiate a treatment plan together, both adherence and clinical outcomes are improved (Eisenthal et al. 1979). Lazare et al. (1975) have outlined an approach to negotiating a treatment plan that makes good sense, from which the following schema is adapted.
Your patient’s agenda may not be as obvious as it first appears. You can begin to elicit it with a simple question, such as
How do you hope I can help you?
Note that this is a less confrontational way of asking about your patient’s agenda than asking
What do you want?
What do you expect?
At this point, the patient may answer vaguely or put the ball back in your court:
I want to feel better.
I don’t know. You’re the doctor.
It’s often important to clarify what sort of information you’re seeking:
How were you hoping that I could help you to feel better?
TIP
Often, patients come into an interview with a few specific requests, such as a desire for medication, therapy, a community referral, a letter to their employer, and so on. Some patients may feel embarrassed about divulging their requests so blatantly and may need some encouragement from you:
Sometimes patients have a pretty clear idea of what they’d like, for instance medication, counseling, or a piece of advice about something, a letter to someone. (A normalizing response.)
However, many patients who come to see a clinician really don’t have a specific request or agenda. This is often the case with patients who are new to the mental health care system or who are less familiar with the modern consumer model of health care. Don’t force the issue with these patients; if they say that they want to hear what your recommendation is and they’ll follow it just because you are the expert, go along with it.
Remember that eventual treatment adherence is enhanced when the patient and practitioner agree on the nature of the problem. The next phase of negotiation involves arriving at this agreement. If you and your patient agree at the outset about a plan, go directly to the implementation phase. However, often enough, you’ll find that your patient’s request is either unrealistic or not clinically indicated. Thank your stars that you elicited the request with time to spare, because now you must negotiate a mutually agreed-on goal. Each negotiation will be different, depending on the nature of the request. Creativity is a plus.
Common problematic requests, along with possible negotiation strategies, are as follows:
Request: Your patient asks you for medication, but you cannot prescribe.
Strategy: Determine how urgent the need for medication is. If it’s not urgent, make a referral to a psychiatrist, and teach the patient a psychological method for symptom relief, such as relaxation exercises, hypnosis, or cognitive restructuring. Now is a good time to reach into your file of patient handouts. If the need is urgent, refer the patient to an emergency room or crisis clinic, leaving enough time for you to call the clinic to inform the psychiatrist of the patient’s diagnosis and medication needs.
Request: Your patient asks for inappropriate medication, such as benzodiazepines for someone with a history of benzodiazepine abuse or antidepressants for mild or transient depressive symptoms.
Strategy: Present a minilecture about the patient’s disorder, complete with handouts and recommendations of books.
Request: The patient seeks hospitalization for a problem that can be treated in an outpatient setting.
Strategy: This has become an increasingly problematic request in our era of managed care, and patients may need some education about this issue:
These days, insurance companies rarely pay for hospitalizations unless the patient is suicidal, because we have a lot of outpatient treatments that work well.
An important thing to keep in mind is the possibility that the patient is suffering much more than she originally indicated and that her request for hospitalization is her way of obliquely disclosing that. You may need to reassess her for SI at this point. If you’re still satisfied that hospitalization is not indicated, discuss some other options, such as
Day hospitalization
Respite care
Staying with a friend or relative for a while if the home situation is intolerable
Taking a few days off from work
Having the patient call you (or another clinician) for daily check-ins during a crisis period
Setting up more frequent appointments
A short course of an antianxiety medication
Your agreed-on plan will likely fall into one or both of the following categories:
Your job is to increase the chances that your patient will show up at the follow-up appointment, regardless of where that is. You’ve already contributed to this cause by involving the patient in the process of deciding on a plan. What more can you do?
The research shows that the highest follow-up adherence rates occurred under the following circumstances (Eisenthal et al. 1979):
The closer you can come to implementing these guidelines, the better. Of course, this requires plenty of preinterview preparation (see Chapter 2 on logistical preparation), including the following:
If you have truly collaborated with your patient in deciding on a medication trial, you’re well on your way toward achieving adherence to the regimen. Here are some practical issues regarding medications and suggestions for dealing with them:
1. Determine how your patient will pay for medication. While most insurance companies pay for medications, copays vary widely, depending on what was prescribed and the generosity of the insurance company’s benefits. Some patients can’t afford the copays, and if so, you may be able to provide samples, depending on their availability at your clinic.
2. Make sure your patient understands the side effect profile of the medication.
3. Simplification increases recall and compliance. Thus, instead of “Take 20 mg of Prozac once a day and 50 mg of trazodone at night, as needed for insomnia,” say, “Take the green capsule every morning and the white pill at night if you can’t sleep.”
4. Having your patient repeat what you say increases her recall of your instructions.