The Ten Commandments of good psychiatry

Recently, I gave a lecture entitled, “Treating Depression in Primary Care,” at an annual conference for physician assistants.  I spent a good portion of the talk on the fundamentals that have been essential to me during my 15 years of practice.  When things go awry in mental health care, the majority of the time it is because one or more of these fundamental principles was neglected.

My fear is that the current medical climate is encouraging glossing over these fundamentals.  It dawned on me that I have become a fundamentalist when it comes to my psychiatric practice.

So here are the Ten Commandments of good psychiatry, listed in no particular order of importance.

1. Thou shalt always aim to establish and maintain a therapeutic alliance. Perhaps one the biggest challenges to practicing in a 21st century medical environment is preserving patient relationships.  Many of us are pushed for time, have to do more with less, and are bombarded by a constant stream of interruptions.  This is not only frustrating for us (most people I know became doctors because of a deep empathy for other human beings, not because they wanted to be stuck in front of a screen or do paperwork), but it is wrong for our patients.  It inhibits the development of what we call alliance.  Therapeutic alliance promotes collaboration, trust, and mutual respect.  It can take years to build, but the provider’s commitment to maintaining it must be unwavering.  Anything that interferes with our ability to maintain an alliance interferes with our patients’ inclination to honestly disclose what is on their minds or to share their fears.  Our job is to preserve the sanctity of the doctor-patient relationship and push back on factors that impinge on it.  This is the foundation upon which good psychiatric care is practiced.

2. Thou shalt always do a complete psychiatric assessment. Anyone treating a mental health disorder can only do so after they have done a thorough psychiatric assessment; when time is of the essence this can be the first thing that gets short thrift.  At minimum the following areas must be touched on:

  • history of the present illness and symptoms
  • past psychiatric history
  • substance use
  • relevant social, occupational, and family history
  • physical examination and appropriate diagnostic tests to rule out physical causes for symptoms

3. Thou shalt always do a thorough evaluation for safety. Any clinician who treats patients living with mental illness must do the following, not only on the initial evaluation but on an ongoing basis:

  • Make specific inquiries about suicidal thoughts, intent, plans, means, and behaviors.
  • Identify psychiatric symptoms or general medical conditions that might increase the likelihood of acting on suicidal ideas.
  • Assess past and, particularly, recent suicidal behavior.
  • Assess for protective factors that can decrease the chances the patient will harm themselves or others.
  • Identify any family history of suicide or mental illness.
  • Have a good sense of the patient’s level of self-care, hydration, and nutrition.
  • Evaluate the patient’s level of impulsivity and potential risk to others, including any history of violence.
  • Assess the impact of current symptoms on the patient’s ability to care for their dependents.

4. Thou shalt always identify the appropriate treatment setting. The patient’s treatment needs should determine what setting they are treated in.  Measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.  Because of mental health parity and inadequate access to mental health care, health care professionals are often put in the very difficult position of caring for those with mental illness in a sub-optimal setting.  The clinician has to remain watchful that this does not interfere with the patient’s clinical progress.

5. Thou shalt focus on the patient’s functional impairment and quality of life. Mental illness impacts many spheres of a person’s life, including work, school, family, and relationships.  Any treatments should aim to maximize functioning within these spheres and enhance quality of life.

6. Thou shalt coordinate the patient’s care with other clinicians. American health care is famous for being fragmented. With so many different providers, health care systems, and insurance providers, talking to each can become a low priority for clinicians.  This lack of communication can have disastrous consequences for patient outcomes.

7. Thou shalt monitor the patient’s psychiatric status. The patient’s response to treatment should be carefully monitored.  Patients who are on psychiatric medication need ongoing assessment for adherence, symptom control, and side effects.  This is even more important if a patient is new to medication, this is their first episode of mental illness, they have clinical factors that place them at high risk for suicide, or they are not improving clinically.  Ongoing care can be spaced out once the patient is stable, but until then they must be monitored with sufficient regularity.

8. Thou shalt integrate measurements into psychiatric management. An invaluable option for the busy clinician is to integrate questionnaires into initial and ongoing patient evaluations.

9. Thou shalt evaluate a patient’s treatment adherence. Assume and acknowledge that the patient will have potential barriers to treatment adherence, and collaborate with the patient (and if possible, the family) to minimize the impact of such barriers.

Encourage patients to articulate any concerns about treatment and offer patients a realistic notion of what to expect during different phases of treatment.

10. Thou shalt educate the patient and their family. Spend time clarifying common misperceptions about medications, emphasizing the need for a full course of treatment, and promoting the benefits of healthy behaviors like exercise, sleep hygiene, and nutrition on mental health.  Those involved in the patient’s day-to-day life may also benefit from education about mental illness.

I believe each of us should be a fundamentalist when it comes to providing mental health care.  We cannot adequately care for our patients when these Ten Commandments are forgotten.

Shaili Jain is a psychiatrist who blogs at Mind the Brain on PLOS Blogs, where this article originally appeared on March 5, 2014.

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