Tips to find a good psychiatrist

Seems like a simple enough question: How do you find a psychiatrist?

It’s not that easy to answer. There are all sorts of psychiatrists who do all sorts of things (therapy, not therapy, specific forms of therapy like psychoanalysis or CBT), and then there’s the overriding insurance question. Not to mention location, location, location.

We’ve talked before about insurance, and if you haven’t read Why Shrinks Don’t Take Your Insurance, please do. It’s a good place to start.

In areas where psychiatrists are in short supply, often, they do take insurances and they only see patients for medication management. In areas where there are more docs and people have treatment options, they may split between those who do and don’t take insurance. You should be aware that if a psychiatrist doesn’t take your insurance, you will likely still get reimbursed, but there may be a higher deductible, you’ll need to mail in the form yourself, and there will be a long wait (and assorted hassles) for the money to come back. Some people are reimbursed very well, others or not. If your insurance is an HMO or has no out-of-network benefits, then a non-insurance doc will costs you the entire fee.

So start here:

Does it matter if the psychiatrist is in your insurance network? If it does, and you live in an area where many shrinks don’t participate with insurance, then call the insurance company and get names and numbers and do hope they aren’t all dead or not-accepting patients.
What kind of psychiatrist? If the patient is under age 16-18, your best best is a child & adolescent psychiatrist. Be aware that many psychiatrists at academic centers run research projects and teach, and don’t see many outpatients. That’s not to say never—and most have a few patients, but they are often a bit harder to reach, especially when they are presenting at conferences or have grants dues, and may have difficult parking. So child, general adult, or is there some specialty need which may be very restrictive—for example treatment of sexual or eating disorders or psychoanalysis? If you are looking for evaluation for a matter pertaining to the legal system, you may want to look specifically for a forensic psychiatrist.
Finally, does it matter to you if the psychiatrist does psychotherapy or are you fine seeing one person for therapy (if necessary) and another for meds? If it matters, you need to clarify this upfront.

Now you’ve got the big three questions. There are other obvious ones: parking is always a biggy, the setting may be a concern (is your ex-lover working in the same practice?), how difficult is it to get an appointment? How long do appointments last? If the first evaluation is routinely scheduled for under 50 minutes and you have a choice as to where you go: then go somewhere else. In an institution—jails, a substance abuse clinic, the medical unit of a hospital, an emergency room— evaluations may be very brief, but in these settings your records may be available for review and the evaluation may have a very specific and limited purpose. But for a thoughtful, comprehensive evaluation before beginning on-going treatment, the usual is a minimum of 50 minutes and often 90-120 minutes. Some psychiatrists do their evaluation over several sessions.

If you have no insurance and no money, your options are limited. The traditional place for treatment in this case is a local Community Mental Health Center or CMHC and the standard has been to have one per geographic catchment area. These clinics usually offer split care, there may be a wait, and you don’t get to choose your psychiatrist. They take Medicare and Medicaid, and they sometimes don’t take private insurance. How do you find your CMHC? Try Google, and then call any clinic in your area and have a heart-to-heart with the receptionist. He may be able to give you the number of the clinic that serves you.

There are other agencies that over care for the indigent. In Baltimore, HealthCare for the Homeless offers psychiatric treatment, and The Pro Bono Counseling Project will give referrals for free or discounted care from professionals in the community who have agreed to volunteer their time. Again, there’s no choice in which psychiatrist you get.

If you have insurance and want to stay in network, call your insurance company for a list of names.

Aside from money concerns, here are the best ways to find a good psychiatrist:

If you know someone who likes their doc, see that doc!
If you know someone who like their doc, but you can’t see their doc, ask your friend to get some names from their doc, or call yourself.
Call your state psychiatric society and ask for a referral. If the office is located near where you live, the staff may well know some of the psychiatrists.
Ask your primary care doctor, they are used to making referrals.
Ask a psychiatrist. Ask any psychiatrist—they tend to know each other … so if you can get one on the phone, they may give you names even if they can’t see you. In our state, we have a psychiatric society listserv, and people frequently post, “Does anyone know a psychiatrist in Timbuktu?” for a patient who is moving, a child of a patient, friend of a friend of a friend. As a rule, psychiatrists don’t know what insurance networks other docs participate in.
Ask a doc, any doc. A random doc may not be able to help you, but they may. My favorite was the friend who asked me for a referral for a breast surgeon in another part of the state. Not something I’d know, but my neighbor the breast radiologist was able to give some names and so I was email-helpful. Between listservs, Facebook, email, etc…people can sometimes find names.
If you’re a student, try the school’s counseling/health center. They may also be able to suggest off-campus referrals.

What to ask on the phone (besides the obvious money issues):

It’s fine to tell someone the one-sentence version of what you want help for and to ask if they are taking new patients. It’s probably a burden to try to tell them your whole history.
It’s fine to ask how long the evaluation is, how long a typical appointment is, and if the doctor sees people for therapy or just meds.

Dinah Miller is a psychiatrist who blogs at Shrink Rap.

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Comments

JoAnne
Not one psychiatrist in my area actually does any talking. They write. In my opinion, you might as well go to your primary care physician for prescriptions. They’ll know you better anyway. And you can get your other medical issues addressed at the same time. It’s a pain in the rear to go to yet another doctor, take time off of work, and then just get a prescription shoved into your hands after 10 minutes of “assessment”. Any doctor can write a prescription.
T
Okay, I am having a problem with this right now. I do not need a psychiatrist (can get meds from my pcp and prefer to get to the root of my problems, not medicate them), but I need a psychologist. My PCP gave me a list of psychologists in the area and three of them were starred b/c patients have told her they liked them. Well I called 2 that participate with my insurance (Cigna/ValueOptions) and they’re not taking new patients. On to the next starred one, she isn’t in network, but I figure it’s my health so I can pay more to feel better. Well, I looked into it and no I cannot afford that. So then I started moving on in that list and no one accepts my ins! I do not want to take a shot in the dark and pick one from my provider directory b/c I already did that, went to one and she wasn’t helpful. So now I am feeling quite frustrated and more depressed that I can’t seem to find the help I need at what I can afford. Suggestions? BTW, I am outside just Washington DC so it’s not like I am in the middle of nowhere!
http://ShrinkRap Dinah
JoAnne: It’s absolutely true that not everyone needs a psychiatrist and that some people find that medications prescribed by their primary care doctors work well.
T: Click on the link about Why Shrinks Don’t Take Your Insurance and the issue is the same for psychologists. Insurance participation is a hassle, so those who don’t have to, generally don’t. I would suggest getting a list of psychologists (?or social workers?) who participate and calling until you find someone who is taking patients. Talk to them on the phone for a few minutes: if they sound like you might connect, make an appointment and go. If you don’t like them, don’t return, and work your way down the list until you do find someone you’re comfortable with.
If you’ve been impressed with someone out-of-network, consider going at a reduced frequency to make it affordable.
horseshrink
One that thinks like this would be nice:
http://www.scientificamerican.com/article.cfm?id=dsm-psychiatric-genetics&page=3
In my own experience, there are a few “real rules” that influence psychiatric private practice.
1. If I don’t diagnose, I don’t get paid. Thus, everybody gets a diagnosis. (Was taught this as early as my residency in the ’80′s)
2. The less time I spend with someone, the more money I make. Once upon a time I had a spreadsheet that calculated $$/minute based on CPT codes and their assigned reimbursements. This is a main reason why psychiatrists are choosing to see over 20 patients a day now.
3. I have one string on my guitar any more – medication. I (my profession) helped to create that, and now that’s what patients expect me to play. Wave the magic wand (prescribing pen) and make me happy, doc! So, if I want that patient to keep coming back (especially if reimbursement is good), what will I do?
JoAnne
Dear Horseshrink,
Your assumption that a wave of the pen is what patients want is incorrect. Perhaps this is part of the problem. Perhaps most of your profession is making erroneous assumptions. I’m sure SOME patients want this, but the m.o. of most psychiatrists (writing rx and not bothering to address actual problems) can be a royal turnoff to many patients and can seriously interfere with the therapeutic “alliance” (which is hard to establish in the first place, from a patient’s perspective, when one does not do any talking – I feel no alliance or loyalty or anything else – my doctor exists and he knows how to use a pen… that’s about it).
Also, your point about needing a diagnosis to get paid is one I had not thought of before. It concerns me because it means that everyone who goes for a psychiatric consult is mentally ill by default, whether they actually are or not. That is not good. Not good at all. And I think it does society a great disservice.
BTW, my psychiatrist double-books and, at times, sees 40 patients/day. I know this because the receptionist told me when I glanced down at the appointment book and remarked in horror that I could not believe how many patients were listed. This, to me, is absolutely inappropriate. Talk about treating symptoms and not addressing the root cause – how can he possibly even begin to do anything but scribble out prescriptions at that rate – that is drug dealing at its finest. Inexcusable. And I don’t bother switching docs because I have been told that they all do that… at least in my area.
I see no reason to recommend that anyone see a psychiatrist, barring something very very serious like schizophrenia… particularly now that I see the rationale behind assigning a diagnosis to every single person who walks through the door, whether warranted or not. Greed is spreading “mental illness” and the medicalization of all things normal. That disgusts me.

horseshrink
I agree. Many patients want more than a wave of a pen. They want a meaningful therapeutic relationship within which to effect change.
Unfortunately, too many psychiatrists are stepping out of that role. They are processing widgets instead.
I thought about returning to private practice a few years ago until a recruiting colleague boasted earnestly to me that patients mean so much to him that he actually spends 20 minutes with them. Ouch.
* * *
I experimented once with coding “No Diagnosis” for an elderly patient’s initial evaluation. In truth, there was no discernable psychiatric diagnosis. Medicare declined to pay me.
In residency, we were explicitly taught to render “benign diagnoses” i.e., the least offensive diagnosis that would still trigger reimbursement. “Adjustment Disorder” was a common “benign diagnosis,” even if the reaction was normal. Third party payers don’t pay for normal reactions to difficult circumstances, and it takes money to run a clinic.
I believe the brevity of diagnostically unuseful widget processing appointments combined with the need to diagnose has something to do with the current pseudo-epidemic of “bipolars.”

JoAnne
This is so sad and wrong on so many levels. It is doing harm. I just don’t believe in a benign psychiatric diagnosis. They are too loaded with stigma. It just seems so unethical to me… and really supports the idea of getting treatment, IF needed, from a PCP rather than going to a psychiatrist and getting a label. Thank you for explaining this, though. It all makes much more (sad) sense now.

JoAnne
Horseshrink,
I am curious why psychiatrists must assign a dx to get paid. I ask this after thinking about appointments with other specialists. I have gone to my PCP thinking I had a UTI when I didn’t. What’s the diagnosis there? I could think I have any number of things and not have anything. I can see a specialist for something and the specialist may be of the opinion that I do not have a problem. What’s the diagnosis there? Why do psychiatrists, whose diagnoses have additional stigma-related implications, feel it is necessary to assign a diagnosis whether there is an actual problem or not? I am probably missing something, not being a physician or coding expert, so I truly am curious.
http://ShrinkRap Dinah
Not all psychiatrists just write prescriptions, many still see patients for psychotherapy, 40 patient/day is fortunately not the normal. One day at this pace would kill me.
Psychiatrists don’t have to make a diagnosis. This is the rule of the third party insurers. Most people who walk in to a psychiatrist’s office, however, do have some sort of problem, whether it a problem with their mood, anxiety, or a reaction to a difficult time. That said, the ‘normal’ response to a difficult time is not to go to a psychiatrist, and by the time a person comes to a psychiatrist, it’s because they are feeling really badly.
Please rest assured that if a patient goes to see a primary care doctor with complaints of anxiety, or sadness/sleep & appetite changes and the primary care doctor prescribes a psychiatric medication, then a psychiatric diagnosis is being made.
horseshrink
40 patients a day is not normal (it’s egregious) … but over 20 a day does appear to be the new norm. It’s telling when physician recruiters highlight the time “allowed” per patient as a selling point for psychiatrist jobs. A really unusual and sweet job nowadays actually allows 60-90 minutes for initial evaluations (including documentation) and keeps the number of patients per day between 15-20.
I thought also about re-entering private practice on a cash only basis. I would then not need to be the chicken pushing the red diagnostic button to be fed a reimbursement food pellet, and I could charge a simple $$ amount per unit time. Unfortunately, I would also have a practice dominated by people functioning well enough to have sufficient money to pay me.
I think my purpose in this profession is clearer when caring for the severely mentally ill. They need our services first, anyway. The more I wander into treatment of neurosis, the more I compete with legitimate, non-psychiatrist providers.
Correct re: primary care docs. They want to be paid, too. So, they code psychiatric diagnoses to justify the services they provide. In my experience, primary care docs are worse psychiatric diagnosticians than most widget processing psychiatrists.
http://psychiatrist-blog.blogspot.com Roy
Echoing Dinah here. Many psychiatrists do the see-as-many-patients-as-you-can thing. There are also many who find that practice unfulfilling, and choose to see a mix of therapy and medication patients because it is more rewarding and enjoyable. They choose to either take insurance and make less money, or not take insurance and price at market rates.
It is not true that one needs to have a psych diagnosis if seen by a psychiatrist. Appropriate non-psych diagnoses include hypothyroidism, fatigue, insomnia, and anergia… depends on the details. Whether one is paid for a non-psych diagnosis depends on the contract with the insurance company. If a psychiatrist only has contracts with mental health insurance companies (eg, Magellan), they usually only pay for mental health diagnoses. If they also contract with the physical health insurance companies too (eg, Blue Cross), then they can use non-psych diagnoses and send the bill to Blue Cross rather than Magellan. Granted, this is cumbersome and a PITA, but some do this.
And if any other specialist codes “no diagnosis”, they probably won’t get paid either. Insurance pays for diagnoses, not for “just came in to say hi”. If you thought you had a UTI because you had burning when you peed, and there was no UTI, the doctor probably diagnosed “dysuria” instead (painful urination). If you don’t have a , but you are tired all the time, she might diagnose . In fact, most primary care docs avoid psych diagnoses because they don’t get paid for them. WHY? Because they don’t have contracts with the mental health insurance carve-outs, like Magellan. The Mental Health Parity Act should eventually make this mess better.

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