How to be heard by your psychiatrist

How do I get my concerns heard about the direction of my treatment?

On the surface, it seems easy. Just tell your psychiatrist what you want him to pay attention to.

On the other hand, there are many reasons why it not so simple.

  • Many psychiatrists diagnose a patient’s illness after a 45-50 minute interview, without doing any tests to rule out potential medical causes of psychiatric symptoms and without obtaining history from corroborating sources, as recommended by diagnostic experts.
  • They see patients in follow up for 15 minutes or less.
  • In those 15 minutes all they care about is that the patient says he is better. Once again, they don’t use rating scales or obtain corroborating history to confirm the degree of improvement.
  • In general, patients who take still unfortunately difficult step of seeing a psychiatrist want to believe that they are getting better even when they are not.
  • For a patient, telling a psychiatrist they are not feeling heard might feel too risky – the psychiatrist might get upset at them and might not like them as a patient any more.
  • You could just change psychiatrists. But it’s not easy. You have to reveal the workings of your mind to yet another stranger.

To be honest, the best way to be heard is to build a routine from the very first appointment.The key components of the “Getting Heard Routine” follow.

First appointment. Go to your first appointment with a notebook. Be honest in your responses to the psychiatrist. Before you leave, ask the him what is the formal diagnosis he is giving you and why. Ask questions about medications being prescribed. At the end of the appointment, in your notebook, write down a summary of discussion with the psychiatrist, treatment changes and your honest, gut-level rating of that psychiatrist on the qualities that make a good, competent psychiatrist (see previous blog posts).

Between appointments. Note any particular changes in your own or loved ones’ emotions or behavior that indicate to you change, for better or worse, in your psychiatric symptoms. Especially, note how you are sleeping and how you are feeling about work and about interacting with others. Note side-effects of medications.

One day before your next appointment. Take 15 minutes to think about how you are doing overall since the last appointment, and jot down in your notebook all the questions and concerns you want to discuss in your appointment with your psychiatrist.

At a follow up appointment. Do not reflexively answer “fine” when the psychiatrists asks, “How are you doing?” Insetad, say, “I took some notes and want to share my observations and questions with you” as you open your notebook and begin sharing and asking. At the end, of the appointment, note down if you felt satisfied with the psychiatrists response.This becomes a concern to discuss in the next appointment. Note any change in your gut-level impression of this psychiatrist.

At occasional appointments. Take a loved one to the appointment to make it easy for the psychiatrist to get corroborating history and corroborate your own impressions of that psychiatrist.

If none of this works, unfortunately, there’s not much you can do other than voting with your feet, assuming there are no constraints to you choosing another psychiatrist.

Dheeraj Raina is a psychiatrist who practices at the Depression Clinic of Chicago.

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  • http://natickpediatrics.net Rob Lindeman

    “…without doing any tests to rule out potential medical causes of psychiatric symptoms…”

    What tests do they do to diagnose mental illness apart from talking to you?

    What is a psychiatrist doing ruling out organic disease? I thought primary docs started (and sometimes finished) the process, followed by specialists as needed?

  • http://www.emotioinalfitnesstraining.com Katherine Levine

    Always be a wise consumer. Adding these questions to those above helps. What is your personal theory of change? How long will I be needing treatment? On a rating scale of 1 to 10, 10 being total cure and 1 hospitalization, what rating can I expect from your treatment, where am I now, where do you expect me to be in terms of that rating.

  • http://www.dialdoctors.com Dial Doctors

    There are both objective and subjective tests that psychiatrist may use to clear up a diagnosis. In my practice among the tests that we have available are NEO-PI, PAI, Millon Clinical Multiaxial Inventory-III, ADHD Connors Test, Rorschach and TAT. These don’t include more specific tests which measure a specific symptom such Connors test (ADHD) or BDI (Depression). Now onto your second question, primary docs usually rule out organic diseases but psychiatrist may test other areas which haven’t been covered or that simple were overlooked by the primary doc. This doesn’t mean that the primary doc wasn’t doing his job or neglected the patient. Psychiatrists are just trained to look in different places.

    • http://natickpediatrics.net Rob Lindeman

      Rorschach? I repeat, what does a psychiatrist do apart from talking to people? Is special training required to interpret a Conners test or a BDI, or any of these tests for that matter?

      • Michael Rack, MD

        Many psychiatrists would check basic labs- For example TSH (thyroid) for depression. The older the patient, the more necessary and extensive the organic work up usually is.

      • http://www.dialdoctors.com Dial Doctors

        We learn from these tests in school and some curriculums do teach you how to perform evaluations. Most of these I have taken courses for but I believe it’s been worth it. Many psychiatrists also work alongside psychologist who may handle tests. It varies according to setting (hospital vs. private practice) and personal choice

  • Frenzied

    Rob,

    I will answer this from my perspective as a psych patient. At the beginning of treatment, my psychiatrist ordered a complete blood work up that involved looking at things like my T3, T4, TSH levels for thyroid – Thyroid abnormalities can cause mood disturbances. The Dr. also ordered a CBC,a lipid panel and a comprehensive metabolic panel – all to rule out underlying medical conditions that may have been the cause for the mood disturbances. Then referrals to the appropriate specialists if something comes back out of the normal range, from the lab results. Then this Dr. spent 90 minutes getting a complete history. On a follow up visit, they spend another 45 minutes getting a history from my spouse, to verify the suspected diagnosis. Then psychotrophic drugs were prescribed, slowly building up dose amounts and visits every few weeks to monitor progress. The psychopharmocology is more work than you think. Not every person responds the same to drugs. It takes time and patience from both Dr. and patient. Then work on my part, following up on homework that I am given to help get better, and monitoring any changes – both good and bad.

    I agree with what was said, good psychiatrists are trained to look in areas that other Dr.s are not. Most primary cary Dr.s won’t necessarily do a complete blood workup… they prescribe you an anti-depressant in a 15 minute appointment and send you on your way… not so bad, right? Too expensive to order a complete blood workup… they just don’t have the time to spend with every patient to find out what is really going on… and that anti-depressant? Well it just sent your undiagnosed bipolar patient into rapid cycling.

    Psychiatrists do a lot more that you think.

  • rob lindeman

    Frenzied,
    Please do not assume ignorance on my pasrt as to what psychiatrists do. I’m sure some of them work very hard, especially at psychopharm. That is not my point.

    Fwiw, a cbc and a cmp have no part in a work-up of mental illness. I don’t know why your doc did this. Thyroid function tests are a good idea to investigate some mood disorders.

    My point is that outpatient psychiatry SHOULD consist, in part or IN FULL, of talking. If a pcp isn’t working up your complaints, it isn’t that he is rushed so much as he isn’t doing a very good job taking care of yoy

    • Kevin N.

      A CBC has no place in the part of a mental health workup? I don’t even know where to start! How about anemia? You think anemia might be a cause of depressive symptoms?

      • rob lindeman

        Maybe I was dozing during hematology. I didn’t know anemia was in the ddx of depression (please show the refs in any case). What does wbc and platelets have to do w/anemia? If it’s anemia you’re trying to w/u, do hgb as a screen and go from there. Let me restate, then, cbc has no place in the w/u of depression OR anemia!

        • rob lindeman

          …Unless you’re working up cancer, which I hope psychiatristsarent doing!

  • rob lindeman

    PS. Sorry about the misspellings. I wrote this at red lights while driving home.

    I wish someone would address my issue with psychiatry’s “diagnostic modalities”. What are these, really, beyond a series of questions and answers? At Columbia in the 80′s, Michael First was developing an application (called “D-Tree” at least at one stage) that made psych diagnoses based on the DSM by prompting the user/patient with structured questions. I don’t know what became of the project.

  • Michael Rack, MD

    the lipid panel, parts of the comp metabolic panel and perhaps the cbc may have been a baseline for medication treatments- psych drugs can affect these labs and these labs need to be monitored for certain meds

  • rob lindeman

    “…baseline for medication…”. So much for ruling out medical explanations for mental symptoms!

  • Peter

    Don’t know how we got on the subject of lab testing in psychiatry, but I remember on my psych clerkship back in med school, psychiatrists often ran similar tests as neurologists (B12, folate, VDRL, TSH, etc) in an initial workup to screen for neurological illness which may explain or contribute to behavioral symptoms. On consult service, they would often recommend specific labs or imaging studies to evaluate for things like metabolic encephalopathy on patients who were delirious or psychotic to rule out medical illness. I did 2 elective weeks in on a psychiatry research unit, where they worked with neuroradiologists on interpretation of PET, SPECT, and fMRI in clinical settings for psychiatric patients, though they made sure to tell me that this was not routine practice.

    The psychiatrists did spend a lot of time talking to the patients, but what impressed me most was their keen grasp of the unspoken conversation that was occurring during an clinical interview, such as paying very close attention to body language in contrast with what the patient was saying verbally, often reading between the lines to fill in the real story of what was going on much more accurately (almost magically) than a 3rd year medical student could every imagine. I also enjoyed the discussions the psychiatrists had with patients regarding humanistic or existential topics such as ‘meaning’ and ‘relationship’…sandwitched between OB-GYN and surgery, my psych clerkship was a chance to breathe deeply and be a human being again, if only for a little while!

  • Frenzied

    Rob

    It is hard to fully understand where you are coming from and try and answer your question based on a few lines you have written here. I have no idea what your background is, whether you are a medical professional or not, a patient or not. I have no idea… I was merely giving you my opinion and expertise and first hand account as a patient. I just know that I spent 10 years without getting the best treatment for myself – psychotherapy with a PhD and having a GP manage medicine, …The psych was able to do what the GP couldn’t. It was after 4 months with the therapist, that they recommended I needed to see a psych for my meds and not the GP. there is just not enough time for a GP to become versed and stay abreast with the latest with Psychiatry. Whether you believe in psychiatry or not, that is entirely up to you. And yes, blood work ups are required before starting certain medications – as is the case in other aspects of medicine.

    Perhaps a psychiatrist could chime in on here and give you their expertise. You may also go over to ShrinkRap and pose your question there. They could give you a more detailed explaination and perhaps answer your question better.

    • http://natickpediatrics.net Rob Lindeman

      ” there is just not enough time for a GP to become versed and stay abreast with the latest with Psychiatry.”

      Nonsense. Please forgive the characterization if you find it offensive, but I don’t know another way to characterize it.

      To reiterate, what medical doctors don’t have the time for is talking therapy. The rest is therapeutics.

  • Frenzied

    true, very true. they do not have time for talk therapy. it is hard to squish everything into a 15 minute appointment, make sure the Dr. is asking the right questions, and make sure the patient is disclosing everything!

    I feel fortunate to have a psych that not only does talk therapy, but is very knowledgable in psychotrophic drugs. I am also fortunate that this Dr. calls and checks up on me between appointments to see how things are going. That is incredibly rare in this day in age – at least based on my experience.

    Back to the article, those are some great ideas on how to get the best out of your relationship with your psychiatrist. The key items I think, are journaling or keeping a mood chart between appointments. And disclosing everything, no matter how hard or embarassing…it really does help speed up the process of getting better, and maintaining stability.

  • killroy71

    I wonder what is becoming of your profession. My friend is was in the middle of a nervous breakdown and can hardly find anyone to treat her. She says they all just want to deal with bored housewives and dispense medication. Finally a psychiatric nurse explained to her that the reason no one (talked to about 10 psychiatrists on the phone looking for one) can “take” her as a patient is that she is too acute and needed to be stabilized. Now that she is, she still can’t find a psychiatrist who wants to do any talk therapy to deal with the severe childhood abuse/neglect issues. Geez, isn’t this bread and butter? Plus, she’s getting a tag of “difficult patient” because she doesn’t take any condescending BS (“oh, we all go through that at times”). I am sending this column to her, because she does need to be heard.

  • http://psychiatrist-blog.blogspot.com/2011/04/shrink-rap-survey-on-attitudes-towards.html Dinah
  • http://www.the-first-step.com Char Brooks

    I agree with the importance of going to your appointment prepared to discuss what’s going on with you and have devised a simple form you can download for free to help patients communicate clearly.
    http://the-first-step.com/newsletter-signup/

    Give them facts like – are you sleeping? what does it feel like when you wake up in the morning? do you have anxiety during the day? what helps? what makes it worse?

    Dealing with any doctor is all about our awareness of what’s going on with ourselves as patients, giving them the clearest most concise information you can so they can do their best work, and finding someone competent that gets your story.

    We as patients have control over how we communicate and who we select to help us.

    As a patient as well as a coach who helps others make informed choices about their healthcare, I want patients to be very clear first with themselves and then with their providers about what’s going on so that provider’s can do their best work (or the patient can see the provider isn’t a match for their needs.)

  • Sideways Shrink

    Attitudes like Rob Lindemann’s about the simplicity of prescribing psychiatric medications seems to be fairly common among physicians now that a 30 day supply of a psychiatric medication can’t be used to commit suicide like with the old tri-cyclics or cause a CVA like MAO-I’s. Of course, bipolar patients frequently experience an almost amnesia about manic episodes and present to primary care with exclusively depressed symptoms. No matter, the therapeutics are so simple. In 8 minutes (after the MA has seen them, etc. etc.) getting a full family history from a 25 year who does not know their father because his parents divorced when he was 3 is no problem. The SSRIs work like a charm and are generic. No prior authorizations, no tapering. Or what if they have never had a manic break before, but just have that unknown family history of it, which, in a 50 minute interview in which you ease gently into questions about why his parents divorced, he reveals that his father had mood swings which his mother “could not tolerate because they would go on for days”. But failing this knowledge, you prescribe SSRI #3, patient goes home, takes medication as prescribed, becomes manic, and with the aid of a fifth of whisky blows his brains out 8 days later. I would rate the pharmacotherapeutic intervention a failure.
    You may not talk to your patients in your practice to diagnose them, but in psychiatry it is essential. It requires a particular finesse as does the mixing of sometimes 3 – 5 different medications to achieve symptom remission without deal breaking side effects.
    The dismissive attitude toward psychiatry has lead to the devaluation of the RVU’s assigned it by Medicare and hence a long trend of the underproduction of new psychiatrists. According to AMA data, the mean and median ages of psychiatrists is 62 and 64. Good luck finding a shrink to refer to in 5 years–let alone one who can afford to take a Medicare patient because we are too strapped down with student loans. Insurance companies, following Medicare, reimburse very poorly. But, hey, it’s so easy, no on one will need a shrink, right?

  • Shrinkraproy

    Rob, I am amazed at your apparent lack of knowledge about psychiatry. CBC is indicated for new depr dx (fatigue-anemia), CMP (diabetes, renal insuff, hepatitis, etc).
    http://www.google.com/search?q=anemia+depression&ie=UTF-8&oe=UTF-8&hl=en&client=safari

    • rob lindeman

      And I am similarly amazed, but at your myopia regarding lab tests. CBC stands for COMPLETE blood count. Why on earth, if you are ruling out anemia, do you draw white blood cells and platelets (or God forbid, a differential?)

      I repeat, what is a psychiatrist doing practicing medicine? If internists and pediatricians aren’t working up medical disease, then WHY NOT?

      • Shrinkraproy

        There is probably only a small minority of misinformed or myopic physicians who aren’t working up medical disease for pts with psychiatric presentations, because they believe any such symptoms must be psychiatric in nature and thus do not require laboratory or radiologic investigation. Agreed, some of the testing may be defensive in nature, trying to not provide fodder for lawsuits for failure to diagnose.

  • http://natickpediatrics.net Rob Lindeman

    By the way, the first page of your Google search turned up 11 hits, the first 10 of which were from message boards and other unreliable sources. The 11th actually pointed to a journal article, that demonstrated an association between anemia and depression, but no causal relationship between low hemoglobin and depressive symptoms.