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In reference to “Discharge against medical advice: How often do we intervene?”
In their study of against medical advice (AMA) discharges, Edwards et al.[1] express surprise that prescriptions were given and follow‐up arranged at a much lower rate than the frequency of warning of impending AMA discharge. The authors assume that when doctors know a patient wants to leave AMA, they will and should, as a matter of course, write prescriptions and arrange follow‐up. Not considered is the possibility that doctors may decide for selected patients that the better response is not to prescribe and not to arrange follow‐up. Prescribing medications to a patient who has already shown disinterest in heeding doctors' advice may be considered dangerous. Similarly, making an appointment for a patient who has already demonstrated a lack of adherence, thereby depriving another patient of that appointment, may be considered an imprudent use of resources. The authors do not provide data on how many AMA discharges may have been averted by this approach. Attempts to minimize the negative impact of capable patients' decisions neglect that some patients do not categorically prioritize health, and that true autonomy entails not just decision making but bearing responsibility for those decisions' consequences. Medical risk reduction is not the only value at play in these complex situations.
- , , . Discharge against medical advice: how often do we intervene? J Hosp Med. 2013;8(10):574–577.
In their study of against medical advice (AMA) discharges, Edwards et al.[1] express surprise that prescriptions were given and follow‐up arranged at a much lower rate than the frequency of warning of impending AMA discharge. The authors assume that when doctors know a patient wants to leave AMA, they will and should, as a matter of course, write prescriptions and arrange follow‐up. Not considered is the possibility that doctors may decide for selected patients that the better response is not to prescribe and not to arrange follow‐up. Prescribing medications to a patient who has already shown disinterest in heeding doctors' advice may be considered dangerous. Similarly, making an appointment for a patient who has already demonstrated a lack of adherence, thereby depriving another patient of that appointment, may be considered an imprudent use of resources. The authors do not provide data on how many AMA discharges may have been averted by this approach. Attempts to minimize the negative impact of capable patients' decisions neglect that some patients do not categorically prioritize health, and that true autonomy entails not just decision making but bearing responsibility for those decisions' consequences. Medical risk reduction is not the only value at play in these complex situations.
In their study of against medical advice (AMA) discharges, Edwards et al.[1] express surprise that prescriptions were given and follow‐up arranged at a much lower rate than the frequency of warning of impending AMA discharge. The authors assume that when doctors know a patient wants to leave AMA, they will and should, as a matter of course, write prescriptions and arrange follow‐up. Not considered is the possibility that doctors may decide for selected patients that the better response is not to prescribe and not to arrange follow‐up. Prescribing medications to a patient who has already shown disinterest in heeding doctors' advice may be considered dangerous. Similarly, making an appointment for a patient who has already demonstrated a lack of adherence, thereby depriving another patient of that appointment, may be considered an imprudent use of resources. The authors do not provide data on how many AMA discharges may have been averted by this approach. Attempts to minimize the negative impact of capable patients' decisions neglect that some patients do not categorically prioritize health, and that true autonomy entails not just decision making but bearing responsibility for those decisions' consequences. Medical risk reduction is not the only value at play in these complex situations.
- , , . Discharge against medical advice: how often do we intervene? J Hosp Med. 2013;8(10):574–577.
- , , . Discharge against medical advice: how often do we intervene? J Hosp Med. 2013;8(10):574–577.
Reducing polypharmacy: When less is more
Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.1 Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.
Do not treat patients’ symptoms indefinitely
William Osler stressed the importance of treating diseases, not symptoms.2 Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.3
Do not use syndrome-oriented drugs to treat symptoms
Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.
Do not accumulate medications when faced with nonresponse
If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.
Do not match ‘soft’ diagnoses with ‘soft’ treatments
“Soft” diagnoses come in 2 types:
- an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
- using imprecise terms as diagnostic proxies, such as “depression and anxiety.”
Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.
1. Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. 2010;67:26-36.
2. Osler W. Aequanimitas. 3rd edy. New York, NY: McGraw-Hill Professional; 1932.
3. Ghaemi SN. Toward a Hippocratic psychopharmacology. Can J Psychiatry. 2008;53(3):189-196.
Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.1 Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.
Do not treat patients’ symptoms indefinitely
William Osler stressed the importance of treating diseases, not symptoms.2 Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.3
Do not use syndrome-oriented drugs to treat symptoms
Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.
Do not accumulate medications when faced with nonresponse
If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.
Do not match ‘soft’ diagnoses with ‘soft’ treatments
“Soft” diagnoses come in 2 types:
- an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
- using imprecise terms as diagnostic proxies, such as “depression and anxiety.”
Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.
Up to one-third of psychiatric out-patients in 2006 received ≥3 medications, compared with 17% a decade earlier.1 Polypharmacy is expensive, increases the risk of adverse effects, and may contribute to nonadherence. Although we recognize that at times long medication lists are justified, we offer 4 principles to help you limit unnecessary polypharmacy.
Do not treat patients’ symptoms indefinitely
William Osler stressed the importance of treating diseases, not symptoms.2 Symptoms without a diagnosis are experiences. Whether physicians should treat experiences is an ethical question; however, even if your answer is “yes,” such treatment should be transient. Symptoms occurring within a diagnosis should be treated conservatively, but humanely, only while waiting for syndromal relief.3
Do not use syndrome-oriented drugs to treat symptoms
Mood disorders are not just unpleasant emotions, and anxiety disorders are more than simply nervousness. Medications that are effective for psychopathologic syndromes might not help isolated patient complaints. For example, antidepressants do not simply lift sadness, nor do they usually relieve the nonsyndromal “anxiety” many patients report. Some clinicians might disagree with this recommendation based on flaws in DSM-IV-TR taxonomy; however, these shortcomings do not translate into pharmacologic efficacy.
Do not accumulate medications when faced with nonresponse
If the first 3 medications you prescribed were working, you wouldn’t need to add a fourth. Consider discontinuing one medication for every new one you start. This principle can help you set limits with patients who demand more medications to try to eradicate nonsyndromal distress or clinically significant symptoms that psychopharmacology cannot address. Nonresponse to aggressive treatment should trigger a reassessment of the original diagnosis.
Do not match ‘soft’ diagnoses with ‘soft’ treatments
“Soft” diagnoses come in 2 types:
- an equivocal or mild psychopathologic picture that may be called, for example, “soft bipolar illness”
- using imprecise terms as diagnostic proxies, such as “depression and anxiety.”
Patients with soft diagnoses often receive combinations of lower-than-standard dosages or drugs with milder side effects but substandard efficacy. For these patients, we recommend postponing pharmacotherapy or “firming up” the diagnosis and then initiating the standard of care.
1. Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. 2010;67:26-36.
2. Osler W. Aequanimitas. 3rd edy. New York, NY: McGraw-Hill Professional; 1932.
3. Ghaemi SN. Toward a Hippocratic psychopharmacology. Can J Psychiatry. 2008;53(3):189-196.
1. Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. 2010;67:26-36.
2. Osler W. Aequanimitas. 3rd edy. New York, NY: McGraw-Hill Professional; 1932.
3. Ghaemi SN. Toward a Hippocratic psychopharmacology. Can J Psychiatry. 2008;53(3):189-196.
Thoughtful diagnoses: Not ‘checklist’ psychiatry
In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,1 while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”2
However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.
“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”
Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.
“This person seems to meet criteria, but I do not believe the diagnosis is correct.”
Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.3
“This person does not meet criteria, but I believe the disorder is present.”
This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.
“This person does not meet criteria, and I believe no disorder is present.”
Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.
1. Kassaw K, Gabbard GO. Creating a psychodynamic formulation from a clinical evaluation. Am J Psychiatry 2002;5:721-6.
2. Freudenreich O, Querques J, Kontos N. Checklist psychiatry’s effect on psychiatric education [letter]. Am J Psychiatry 2004;161(5):930.-
3. Kontos N, Freudenreich O, Querques J, Norris E. The consultation psychiatrist as effective physician. Gen Hosp Psychiatry 2003;25:20-3.
Dr. Kontos is associate director, consultation-liaison psychiatry, Cambridge Health Alliance, Cambridge, MA.
Dr. Freudenreich is director, first episode and early psychosis program, Massachusetts General Hospital, Boston, MA.
Dr. Querques is an assistant in psychiatry, Massachusetts General Hospital, Boston, MA.
In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,1 while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”2
However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.
“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”
Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.
“This person seems to meet criteria, but I do not believe the diagnosis is correct.”
Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.3
“This person does not meet criteria, but I believe the disorder is present.”
This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.
“This person does not meet criteria, and I believe no disorder is present.”
Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.
In our experience, psychiatry residents often are encouraged to present rich psychodynamic or biopsychosocial formulations,1 while diagnostic assessments are relegated to robotic statements about whether patients meet DSM-IV-TR criteria. This practice can lead to “checklist psychiatry.”2
However, thoughtfully invoking DSM criteria can enhance clinical acumen if the following conclusions are chosen and justified during patient assessments.
“This person meets diagnostic criteria, and I believe this is the correct diagnosis.”
Ask the resident to back up his or her conclusion that symptoms are “not due to another condition” and cause “significant distress or impairment” as required by DSM. Emphasize differential diagnosis and understanding illness impact and illness behaviors. Also ask the resident to explain why the patient is considered a reliable reporter of his or her experience.
“This person seems to meet criteria, but I do not believe the diagnosis is correct.”
Seeming to meet criteria is not the same as “having” a psychiatric diagnosis. Ask the resident to discuss alternate diagnoses and confounding factors in the patient’s presentation. Some patients overreport psychological distress to pursue secondary gain or because of idiosyncratic ways of experiencing distress. Likewise, some clinicians interpret too narrowly patients’ endorsements of symptoms and assume that patients share their definitions of terms such as depression and panic.3
“This person does not meet criteria, but I believe the disorder is present.”
This scenario often leads to a rapid “not otherwise specified” (NOS) diagnosis. However, if a patient has an incomplete yet longitudinally consistent and sufficiently severe version of a known syndrome, an NOS diagnosis is not clinically useful (research settings are a different story). Encourage the trainee to justify the diagnosis that he or she plans to treat.
“This person does not meet criteria, and I believe no disorder is present.”
Some people are not mentally ill; in fact, most are not. Yet most residents we supervise cannot recall the last time they diagnosed “no mental illness” or saw a supervisor do so. Adopt this practice, and give trainees overt permission to make this assessment.
1. Kassaw K, Gabbard GO. Creating a psychodynamic formulation from a clinical evaluation. Am J Psychiatry 2002;5:721-6.
2. Freudenreich O, Querques J, Kontos N. Checklist psychiatry’s effect on psychiatric education [letter]. Am J Psychiatry 2004;161(5):930.-
3. Kontos N, Freudenreich O, Querques J, Norris E. The consultation psychiatrist as effective physician. Gen Hosp Psychiatry 2003;25:20-3.
Dr. Kontos is associate director, consultation-liaison psychiatry, Cambridge Health Alliance, Cambridge, MA.
Dr. Freudenreich is director, first episode and early psychosis program, Massachusetts General Hospital, Boston, MA.
Dr. Querques is an assistant in psychiatry, Massachusetts General Hospital, Boston, MA.
1. Kassaw K, Gabbard GO. Creating a psychodynamic formulation from a clinical evaluation. Am J Psychiatry 2002;5:721-6.
2. Freudenreich O, Querques J, Kontos N. Checklist psychiatry’s effect on psychiatric education [letter]. Am J Psychiatry 2004;161(5):930.-
3. Kontos N, Freudenreich O, Querques J, Norris E. The consultation psychiatrist as effective physician. Gen Hosp Psychiatry 2003;25:20-3.
Dr. Kontos is associate director, consultation-liaison psychiatry, Cambridge Health Alliance, Cambridge, MA.
Dr. Freudenreich is director, first episode and early psychosis program, Massachusetts General Hospital, Boston, MA.
Dr. Querques is an assistant in psychiatry, Massachusetts General Hospital, Boston, MA.