Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Tuesday, February 17, 2009
When Will I See You Again?
In the out patient mental health clinics in Maryland, regulations make it clear: any patient on medication must be seen by a psychiatrist every 90 days, patients who are not on medications are seen by the psychiatrist every six months. This assumes the patient is stable and all is going well, and certainly some docs in some clinics see the patients more often, but a minimum is regulated.
In the world of private practice, it's less clear. If patients are in psychotherapy, it's easy enough to deal with medications during a regularly scheduled appointment. But what about the patients who are done with therapy, who feel good, who want to continue on their medication? Some patients are fine with coming in monthly, others clearly don't want to, and if things are really stable, I'm happy to see folks every three months, the standard of the clinic. There are people though, who really don't want to come in that often, where it's a hassle for them to get off work. Sometimes their pharmacies start calling for refills (--with the mail order pharmacies, this can include twice daily phone calls and repeated faxes) and there is no contact from the patient. I've taken to ignoring these calls (especially the ones from the mail order pharmacies who want okay's for a 30 month supply) if I haven't seen the patient in a long time because returning them often involves a long time in voicemail hell to convey the message, "The patient needs to call me." Patients know to call me if they are having problems, I'll get them in soon. But for someone who doesn't want to come in, who says they are fine, I'm still not sure how often to insist on face-to-face contact. Here and there someone pops up who I've long ago assumed was gone--- If someone is to call me in 3-4 months, and they don't, I don't always remember to chase them down. And when I do, sometimes they've stopped their meds, or asked their internist for a prescription.
So is there an absolute answer? Is there an absolute minimum that a patient needs to be seen for a refill? Internists prescribe for a year a a time, and so do some psychiatrists (I think). What's your thoughts?
Posted by Dinah on Tuesday, February 17, 2009
Labels: med management
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As a patient? When I was away at school, or overseas, there were logistical reasons as to why I needed 6 months or a year's worth of meds at a time...
It may be that those patients who have a chronic, pervasive mental illness, but are stabilized on a particular medication that works for them, may turn to their family doc for the prescription because the visit is cheaper. That being said, farther down the road you may hear from them when the med stops working and everything falls apart. Dinah, I think you've alluded to this before.
I have those longer-between-visit patients make their follow up appointments at the time of the current appointment so that they have something "on the books."
They rarely forget.
They prefer to have an appointment scheduled and change it as needed in order to get their preferred time of day than chance its availability on one week's notice.
I have one or two people who come in every year. Only because I know from experience that they will call if they need to come in sooner.
My neurologist only needs to see me every six months despite me taking a regular prescription and that works out well for both of us. I also know to give her a call if I am having problems.
I hated it when my old psychiatrist insisted I see her every 2-3 months because a) I didn't need to; b) I couldn't easily get the time off from work; and c) I *really* didn't need to. Why waste everyone's time (and my money) if things are going fine and nothing out of the ordinary is happening?
Ideally this is determined on a case by case basis between the doc and patient depending on all sorts of variables (severity, suicidality, etc).
But if I were to pick a number, I'd say it seems reasonable that as trust grows the length between visits can be extended to say, once a year maximum once patient has shown stability (over several visits) and good results on the Rx.
When certain risk factors are present (seniors, multiple dx, dual dx, chronic illness, multiple meds) the max interval should be shortened (six months max).
I've been on Effexor for 2 full years now, and am quite stable on it. My GP still makes me come in every three months for the refill though. And I'm okay with that, I think. It's nice to know that if anything goes wrong I already have that appt book and it's nice just to have that check in...
My GP wrote me a 12 month supply of prozac the day he prescribed it and told me I could go off of the med anytime after 6 months of feeling better, and I didn't need to come back to see him unless I had problems.
His level of trust in me is flattering, but I don't think is very good care. What was the result? I went off my meds too soon because of intolerable side effects, cold turkey, and have been in a bad spot.
There shouldn't be a set time frame.
We should be delivering patient centred care. A patient who's stable but has frequent relapses and isn't adept at recognising their relapse signature may merit monthly review for ongoing support on why the medication's got value (even though they feel well) as well as enabling ongoing surveillance of symptoms/signs.
In psychiatry that tries to avoid authorative control and advocates patient autonomy, empowerment, coping, personal responsibility and agency, patients should have flexible care planning that's appropriate for and proportionate to their needs at that time.
Some patients I see more than once a week. Some I see every 6 months. For follow up to be both menaingful and appropriate it should be patient centred, not protocol driven, no?
The second issue, of a patient not attending for follow up that's important, puts in to question the use of medication. I'll give patients a lot of latitude, but if I have an obligation to check effects of an acetylcholinesterase inhibitor or assess utility/risk/benefits of a hypnotic and the patient doesn't attend for review or ECGs or whatever, I question my ability to prescribe. I'll only prescribe if it's rational prescribing within an appropriate governance framework, which necessitates appropriate review. If a patient declines review, that's tantamount to declining the medication.
I hate shrinks. i hope never to see one again.I get my own meds just fine.
I am a pharmacist (altho not mail order) and out of mutual respect, please don't ignore our requests no matter if they are by phone or fax. That is just simply rude and unprofessional. If you want me to relay that you do not want to refill the prescription until you see the patient, I'm fine with that and happy to convey that to your patient. I'm even happy to reinforce the reasons why they need to continue with physician visits.
However, if you just don't respond, I don't know if you never received the fax (it happens), your office person did not relay the message (it happens), your post-it note fell off the back of your desk (it happens) or your voicemail went beserk & lost all messages (it happens).
Now, you've put me in a position neither you nor I want to be in. I am obligated to continue medications which have serious & significant side effects if stopped immediately. A weekend does not go by that I don't advance metoprolol, furosemide, Lexapro & others (never a controlled drug - sleeplessness doesn't fall in this category).
So, your patient is upset with me (obviously I didn't contact you - manipulators, I forgot - blamers, I don't care - who knows what to call these), its taken far more of my time & yours than if you'd just call or fax back - patient needs to see me before more refills are given. Heck, you can leave it on my voicemail if you don't want to talk to a person.
Just don't be disrespectful of my time as your colleague. After all, we're both here to help your patient.
I kid you not - my word verify was "imess". and I waited too long to post and the next one was "hatess".
EEEK. ha ha blogger goes crazy (blogger the "software", not blogger the person, me) on shrink wrap blog, hee . . .geez, it only took a sec to type that, now it's bedlyzer . . .
funny, ha ha. woops, i keep forgetting to type the actual thing IN the word verify.
What the The Shrink said... me, too. Needs to be individualized, though I think that here *is* a protocol, it just involves all those factors Shrink mentioned, as well as those that Dr Yogurtry said.
Anon pharmacist: please excuse Dinah for her rudeness. What I've done is call the patient directly (unless pharm gets me on phone, then I ask to have pt call me), then call pharm back for the rx or to say "no rx but am seeing pt next week."
Going back to original question, once a pt is stable, I generally see monthly for 2-4 months, then can go to quarterly for a year. Then may go to q6mo or annual if pt stable AND has good insight into early warning signs of relapse AND has no sig risk factors (ongoing addiction, high psychosocial stressors, serious suicide attempts). Also, recognizing that there is no one-size-fits-all approach. If getting off work is an issue and I can't accommodate pt's schedule or cost is major issue, would either do phone call or reduce cost of visit. (Of course, I don't have an outpt practice anymore, but when I did, that's how I handled things. I'm guessing this is not an issue for Clinkshrink.)
I got refills for a long time by phone - with NO request to see me ever. Like, I'd get a year's supply, and then renew by phone for another year for several years. Gotta love Kaiser.
Note to "The Shrink":
"A patient who's stable but has frequent relapses..."
is not stable.
I am an internist, and require my patients who get any recurring prescriptions from me to come in once a year, minimum. Many come more often; diabetics, hypertensives, etc. A patient with well-controlled depression could possibly come once a year. It also depends on the other doctors the patient sees. I have a few Type I diabetics I see in tandem with an endocrinologist, so one of us sees the patient every 3 months, for example.
Every time I start a patient on an anti-depressant s/he is to come back in a month, so I can determine whether the drug is working.
As a psychologist? I'm not understanding why would you prescribe meds for an individual you are not seeing regularly. Psychological distress is not totally biological it is mostly environmental. People have problems with life and a pill is not going to fix that. Do you really feel better or just numb?? As medical doctors you all should know better...but then again you are psychiatrists....enough said.
The local mental hospital I go to appointments are either 1 week, 2 weeks, 1 month, 2 months, 6 months. If the person can go longer then six months they are replaced by a new patient on the waiting list
I would say 6 months, minimum, although I have one Rx that's expirable and non-refillable. My current PBM allows 90-day fills at a retail pharmacy for about the same price as (ugh) mail order. That said, I usually see my shrink every 6-8 weeks (and book my next appointment before I leave the office). For me,psych med issues are much better handled by a psychiatrist than a GP - psych drugs tend to be odd, and I have had better experience being treated by those who deal with odd drugs daily. If you're just dropping by for a garden-variety SSRI and have no issues, maybe you can see a GP once a year.
we want to see each other all the time, I feel better and he's hot... the feeling is mutual
I WISH my docs would chase me down. I procrastinate and suck at organizing to my own detriment. Am currently putting off abnormal smear follow-up 2 yrs running because have been 'b/w docs' for as long. Not good.
Prescheduled appts help A TON. If I wanted to get out of the dentist I'd probably procrastinate on canceling so I'd just end up going.
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