I want to talk about an incredibly foundational framework for successful prescribing. This is the key to properly treating patients. This is a framework that’s so deceptively simple that it’s easy to just not follow and jump ahead with prescribing medications to treat your psychiatric patients.
Now the biggest mistake providers make is jumping to treatment too quickly. This makes sense though. A patient comes to you with a problem and you want to fix it. But, if you haven’t set up the proper foundations with assessment and diagnosis first, you can potentially prescribe inappropriate medications which then leads to all sorts of issues including misdiagnosis. Misdiagnosis then leads to trialing patients on many different medications which causes frustration for both the patient and you as the provider.
The Framework
There are three steps to this framework for effectively treating your patients with mental health needs.
The first step of this framework is assessment. Assessment involves conducting a psychiatric evaluation where you’re asking various screening questions and collecting information that often comes from the patient. It’s all about information gathering at this stage.
The second stage of the framework is diagnosis. Here we’re developing a working diagnosis and considering differential diagnoses (we’ll talk about differentials in a bit).
The last stage of the framework is treatment. Here is where we’re considering medication options if medications are indicated based on the diagnosis we’ve made. We’re recommending alternative treatment if necessary such as therapy or other adjunct treatment and developing a follow-up plan of care with our patients.
So it’s super important that these stages are followed in this order and accurately executed to effectively treat your patients.
Why does this framework matter?
Now issues can happen when assessments are done incorrectly or they’re rushed too fast so we don’t have all the information we need. Issues can also occur when the diagnosis is incorrect because then that leads us down a path of treating incorrect diagnoses. Issues can also occur in the treatment stage where the diagnosis was made correctly but the patient is on inappropriate medications that just aren’t evidence-based – this leads to your patients never really getting better and your continual hair loss as you slowly pull it out in frustration.
Truly the best way to show this framework in action is through a case study. Lets walk through applications of a case study to see how this framework can help you accurately and effectively treat your own patients in practice.
A case study
So with this framework in mind, let’s meet Sarah. Sarah is a 41 year old female who comes to your office for an initial psychiatric evaluation for this ongoing anxiety that she’s been experiencing.
Assessment
Sarah was previously seeing her primary care provider for a number of years for management of her anxiety. She was prescribed alprazolam but just not finding it effective anymore – the dose kept needing to be increased.
When her primary care provider would not increase the dose, Sarah decided to seek treatment elsewhere and that’s when she was referred to you.
Current medications include alprazolam 1mg three times daily as needed for anxiety. She’s been on this regimen for the past three years.
Sarah continues to experience this unrelenting anxiety without specific trigger. She really struggles to fall asleep and also stay asleep at night. She describes her childhood as “stressful” but is vague with providing details. She’s always experiencing muscle tension and racing thoughts about her day to day obligations, the future, her health, and her work.
In fact, she’s been having a hard time holding down a job for longer than a month or two, and really struggling to maintain close relationships.
You learn her PCP briefly trialed Sarah on a few different antidepressants but Sarah didn’t find them helpful and stopped taking them.
What more information do you want to collect before you move forward to the diagnosis stage?
At this point, we know that Sarah has anxiety and it’s affecting various domains of her life. We know that the meds she’s on aren’t working. And we know she’s not sleeping. With this information, Sarah could be struggling with anything.
We want to stop from immediately jumping to prescribing at this point. It’s very easy to want to problem solve immediately with prescribing because our goal is to make patients feel better. But when we prescribe based on symptoms, that leads us down a maze of patients being on many, many different medications. Let’s not do that.
Instead we want to continue assessing. Then diagnosing. Before we treat.
So assessment for Sarah should involve knowing, what is the content of her anxiety? When did it start? We also want to gather information about her upbringing and early experiences. She was vague with providing details. We might completely miss a potential history of trauma which can very much point to some sort of trauma or stressor-related disorder.
Delving deeper
We ask a few other questions and find out Sarah was sexually molested once by her uncle at age 12. She didn’t receive any treatment for this and has a hard time recalling details of this part of her life. With more prompting you learn she has these periods of “zoning out” and has difficulty controlling her emotions, particularly anger.
We also want to assess her past mental health history – including suicide attempts and psychiatric hospitalizations – as well as current safety status including suicidal thoughts, self injurious behavior, and homicidal ideation.
I want to make a side note that this doesn’t need to take a ton of time. We obviously have a limited amount of time as providers so we’re systematically asking questions and delving deeper in areas of unclarity briefly before moving on.
Diagnosis
Now that we’ve completed the assessment, let’s talk about the diagnosis.
There are many different types of mental disorders out there, but there are three primary types or categories that you will most commonly encounter in practice. Those are mood disorders, anxiety disorders, and psychotic disorders. And within each of these sorts of buckets, are there particular diagnoses.
So for mood disorders, we think of conditions like depressive disorders, (i.e., major depression) and also bipolar disorders, like bipolar I and bipolar II. For anxiety disorders that includes diagnoses like generalized anxiety disorder, PTSD, OCD, social anxiety disorder. The category of psychotic disorders includes disorders like schizophrenia and schizoaffective disorder.
There are other types of disorders also such as personality disorders (i.e., borderline personality disorder) and neurocognitive disorders as well as eating disorders. But the three primary “buckets” we always want to think about are the most common ones and those are the mood, anxiety, and psychotic disorders. So keeping this in mind will help you organize and categorize your patients a little bit quicker .
Considering diagnoses & differential diagnoses
So now we’ve collected this assessment information, we’re ready to start considering diagnoses and differential diagnoses. Differential diagnoses are just a fancy way of saying, what else could this be? It’s really just a short list of other potential diagnoses. And it’s nice because we don’t need to know exactly what’s going on with our patient at this very first visit.
Differential diagnoses is like saying here’s what I think is going on. You’ll want to include a “working diagnosis” and also a few other differential diagnoses (aka “here’s what else I’m considering that could be contributing to my patient’s presentation”). That’s the frame of mind to be working from when we’re creating diagnoses and differential diagnoses.
So for Sarah, with the assessment information we’ve gathered, we can toss out the category of psychosis and that’s because there’s no psychotic symptoms that we’re seeing in her presentation. There’s no hallucinations. There’s no delusions seen or reported. We’re not really seeing her appear internally preoccupied during the assessment. And so we can cross the psychotic disorders category off the list.
Now we’re left with the buckets of anxiety disorders and mood disorders.
So clearly anxiety is prominent. It’s generalized. There’s no specific trigger. It lasted for several years. It causes physical and mental distress. This is seeming to be possibly Generalized Anxiety Disorder. We also consider her history of trauma and note she exhibits some signs of PTSD including emotional reactivity, gaps in memory, and dissociative symptoms.
What about the mood disorders bucket? Anything that she might meet criteria for in this category? We’re not really seeing any evidence of mania or hypomanic episodes from what we’re seeing and also from her past psychiatric history. She’s also not displaying any depressive symptoms either.
Let’s cross mood disorders from our list. So, we’re left with the “bucket” of anxiety disorders. Our working diagnosis is: Generalized Anxiety Disorder. One of our differential diagnoses is: Trauma and Stressor-related Disorders. Sarah doesn’t necessarily meet criteria for a trauma and stressor-related disorder but we’re not ruling it out, so it’s our differential diagnosis.
Treatment
We’ve completed assessment and diagnosis. Now we’re at the treatment stage of the framework.
We’ve developed the working diagnosis of Generalized Anxiety disorder, now how do we treat Sarah?
It’s first important to know that Sarah is not currently on an evidence-based treatment regimen for someone who’s struggling with this disorder. There’s no current evidence that supports the long-term use of benzodiazepines to treat this anxiety disorder. Remember the only medication Sarah is prescribed is alprazolam 1mg three times daily as needed for anxiety.
So we first need to implement evidence-based treatment. Then we need to remove harmful treatment, which for Sarah is the alprazolam through tapering and discontinuing this medication over a period of time.
We want to treat with first-line treatment, which includes prescribing an SSRI (a selective serotonin reuptake inhibitor). This is the category of medications that we use when we’re treating depression and/or anxiety. After we start an SSRI medication and begin titrating the dose, ensuring medication tolerance and efficacy, we’ll need to slowly taper Sarah off the alprazolam.
Tapering off of benzodiazepines is a more complex process but with alprazolam involves switching Sarah to an equivalent dosage of a benzodiazepine with a longer half life and then slowly tapering her off that medication. By slow, I mean not decreasing the total dose by more than 25% per week. For more details on how to avoid making mistakes when treating patients with anxiety disorders, check out 3 things most providers get wrong when treating anxiety disorders.
A quick recap
Let’s do a quick recap of our journey with Sarah.
We conducted a psychiatric evaluation. We dug a little deeper in certain areas to get a better sense of her anxiety symptoms. Other providers may have missed a diagnosis such as PTSD because they just weren’t conducting a thorough initial psychiatric evaluation which may have led them to an improper diagnosis and possibly incorrect treatment.
After assessing Sarah correctly, we moved from assessment to diagnosis. We considered mood disorders, anxiety disorders, and psychotic disorders. We ruled out psychotic disorders and mood disorders and carefully considered differential diagnoses. Here many providers may not have considered differentials and stuck with a potentially random diagnosis which may or may not have been accurate.
We then moved to treatment after having a solid assessment and diagnosis. We considered treatment options and started appropriate medications and tapered her off of the inappropriate current medication regimen.
What would have happened to Sarah if she didn’t receive proper treatment?
An unfortunate but typical approach is that Sarah would have stayed on alprazolam for years. Long term use of benzodiazepines can lead to cognitive and psychomotor impairment as well as dependence. Sarah’s anxiety would likely not improve with time and she would be left feeling frustrated that she’s still struggling day to day.
Now, there are a few other places where treatment could have taken a wrong turn. In another scenario, Sarah may have encountered an issue with receiving proper medications (i.e. being on an SSRI), but the dose never being titrated to an appropriate therapeutic dose. In this scenario, Sarah would have still struggled with anxiety because the dose was never therapeutic. Or in another scenario, the SSRI may have been discontinued too soon due to side effects without a new agent being trialed. Another typical approach is that Sarah may not have been properly diagnosed with PTSD and then not referred to trauma-based therapy to effectively treat her symptoms. This would have then led to ongoing symptoms that never really fully remitted.
In any of these other potential scenarios, Sarah would still be struggling. Also, you as a prescriber would also be frustrated trialing Sarah on different medications each time she came into your office trying to help her but finding that nothing was providing her relief.
Luckily, because we did follow this framework – which is honestly the simpler way long term – here’s what Sarah’s life looks like.
A follow up with Sarah
Sarah follows up with you in six months after you’ve been seeing her monthly for medication management appointments. She’s completely off of benzodiazepines and starting to feel so much clearer and having more energy. She’s been on the SSRI you prescribed for several months now and finding relief from her anxiety. She also feels like she’s able to handle daily stressors better.
Over time it becomes clear that she does have a diagnosis of PTSD and she’s been doing some trauma-based therapy with a quality therapist who’s trained in CBT with exposure.
Once stable, Sarah follows up with you every three months to assess progress and she’s doing great. She’s held a steady job, is in a new relationship, and she’s feeling better than she has in years.
This is a vastly different outcome for Sarah. And how you provided care made all the difference to her and it also led to your increased effectiveness and efficiency. You’ve followed this simple framework to effectively treat Sarah and you’ve managed to keep all your hair because you’re not frantically wanting to pull it out with the stress of ineffective treatment. You’re able to practice more stress-free.
While this framework is simple, and very straightforward, actually implementing in practice can be challenging at times. If you want a quick 60-minute intro into a framework for how to diagnose and treat mental disorders, you can sign up for my free Mental Disorders Training.
If you want my most detailed, step-by-step support, you can sign up for our Mental Disorders Crash Course and begin practicing more stress-free.
