Providing Context at Psychiatric Appointments

What Psychiatric Prescribers Need To Know When Assessing and Treating Individuals

With Developmental Disabilities

What Is In A Snapshot?

Psychiatric appointments occur out of context.

Psychiatric appointments are brief and in the moment.

Sometimes people ‘aim to please’ when meeting with professionals.

Without context, what is directly observed during a psychiatric appointment can be challenging to evaluate.

Cognitive Delays & Provision of Verbal Context

Abstractions such as time frames, reasons why, and relative seriousness of events might be distorted.

Memory gaps and inability to fully describe a situation might impact what is shared.

A patient might not understand questions in a diagnostic interview.

Lack of trust with a clinician or saying “Yes” as a strategy to please might distort what is shared.

Deep Listening

Though psychiatric prescribers necessarily depend on others to provide context, it is important that patients with developmental disabilities are accorded respect and are the central treatment focus.

Supports to Persons With Developmental Disabilities

Family supports.Medicaid Personal Care and COPES

supports.Adult Family Home supports.Group Homes and Boarding Home

supports.Supported Living supports.Community Protection supports.

Treatment Modalities

Be sure that physical pain, neurological conditions, and other physiological issues are being treated.

Ask if there is a Functional Assessment, Positive Behavior Support Plan, and a Cross-Systems Crisis Plan for patients with very challenging symptoms.

Address the adequacy of residential, educational, and vocational supports.

Is the patient using counseling therapies? Access Speech Therapy, OT and PT when helpful. Psychiatric treatment is not a stand alone solution.

How Systems Skew Psychiatric Assessments and Treatments

In frustration, support providers may over-state symptoms to effect a strong response.

Unrealistic expectations are sometimes placed on psychiatric prescribers.

There is a tendency to look for the most powerful pill.

There is the idea that using medicine is the easiest (cheapest?) way to fix problems.

Changes in Community Mental Health Services

More money is being spent on pharmaceuticals and less money is being spent on mental health case management per client.

Mental health caseloads have essentially doubled in Washington State in the past fifteen years.

Collaboration and consultation between mental health case managers and prescribers for each client has substantially decreased.

Requesting Contextual Information at Appointments

Psychiatric prescribers depend on families and agency staff to provide supports to individuals with developmental disabilities at psychiatric appointments.

Patients are better served if families and/or support providers understand psychiatric treatments.

Good care requires good sharing of information – both ways.

Psychiatric Appointment Information Sheet - GOALS

Minimize unnecessary psychotropic medication use. Limit the number, dose and toxicity of necessary

psychotropic medications as possible. Obtain as accurate and detailed information as possible to

make medication decisions. Identify treatable psychiatric conditions. Identify environmental, social and medical causes of

concerning behaviors. Determine efficacy of existing psychotropic therapy. Identify any side effects

Demographic Information

Patient Name

Psychiatric Prescriber

Appt. Date

Person(s) Completing Form

Relationship to Patient

Who else provided input?

Guardian (if any)

Guardian phone #

Date of last visit

General Information

Who is providing information?How well do they know the patient?Are there differing opinions or an agenda?What is the patient’s weight and why is it

important?

Basic Medical Information

Recent Weight & Date when weighed

     

Date of last Blood Draw

     

Pharmacy Name and Phone Number

Name(s) of other involved medical specialists (general practitioner, neurologist, gastroenterologist, dentist, etc.)

Medications and Diagnosis

List all current psychiatric meds, dosages, & times administered.  

List all current non-psychiatric meds, dosages, & times administered.

Current DSM Diagnosis (if any):Axis I:      

Axis II:      

Axis III:      

Reasons For The Appointment

Please address the following issue(s):      

Describe other efforts to address symptoms of concern:

How is the client doing in general

Great OK Doing Poorly

Since the last appt. is the client doing:

Better Same Worse

Information From Patient’s Support System

How is the patient doing now?Has anything changed since the last

appointment? 

Stress Related To Life Events

Loss of job

Significant change in support staff

Victim of crime or assault

Move to a new residence

Death in family

Loss of preferred activity

Death or loss of a friend

Change in family circumstance

Increased stress at home

Exposed/witness to violence

Law enforcement contact

Change in physical health

Medical tests/MD visits/ER visits

Other -      

Physiological Symptoms

Constipation

Nausea/Vomiting

Diarrhea

Rectal bleeding/discomfort

Abdominal pain

Weight gain/loss

Urinary difficulties/excess

Edema/swelling

Chest pains

Tingling/numbness

Dizziness/fainting

Slurred speech

Rapid or slow pulse

Stumbling/unsteady gait

Stiffness

Tremor/shaking/ticks

Seizures

Fatigue

Headache

Physical weakness

Injury requiring medical response

Physiological Symptoms - II

Unusual facial/ mouth/eye movement

Unusual movements of extremities

Drooling

Dry mouth

Increased thirst

Unusual tastes/smells

Appetite change

Choking on food

Dental pain

Change in skin color

Rash/Itching

Breast discharge

Sexual function difficulties

Menstrual changes

Excessive sleepiness

Loud snoring

Breathing abnormalities

Wheezing or cough

Sweating or chills

Hearing/vision changes

Hair loss/unusual growth

Other -      

What Physiological Symptoms Can Tell Us

Is the patient experiencing a medical condition as a potential cause of behavioral concerns?

Is a psychotropic medication causing a physiological symptom?

Is a psychotropic medication causing a medical condition?

What physiological symptoms are associated most commonly with what psychotropic medications

Behavioral Symptoms

Assaultive Behavior

Anger outburst(s)

Sleep/awake change

SIB causing self-harm

Poor attention to hygiene

Restlessness or anxiety

Nightmares

Suicidal behavior

Reported hallucinations

Intrusive/pressured

Elopement or Wandering

Peculiar rituals

Listless, low energy

Criminal activity

Has dangerous friends

Increased irritability

Pacing/repetitive

Obsessively organized

Indiscriminate sexual activity

Excessive neediness/dependent

Crying/tearfulness

Behavioral Symptoms II

Substance Abuse

Medication refusal(s)

Changes in food/drink intake

↓ interest in activities

Property destruction

Talking about death/dying

Hoarding/stealing/collecting

Possible delusions/paranoia

Labile, rapid change in mood

Dramatic reduction in need for sleep

Poor phone use (making 911 calls)

Isolative, withdrawn

Low response, flat affect

Repeated police/ER contacts

Making false accusations

Work/recreation activity refusals

Pressured/rapid speech

Disorganized/tangential speech

Stripping/exposing self in public

Change in sexual activity

Other -

What Behavioral Symptoms Can Tell Us

Behavioral symptoms as side effects of medication. Behavioral symptoms associated with various psychotropic

medications. Behavioral symptoms associated with various psychiatric

diagnoses. When is it appropriate to treat behavioral symptoms with

psychotropic medication? Which behavioral symptoms are most likely to respond to

psychotropic medication and which are not? Why are changes in circumstance important to consider in

making decisions about psychotropic medications?

Team Building

Accurate psychiatric assessment and treatment of individuals with developmental disabilities is best done with a team approach.

Detailed information sharing improves the quality of care. For a number of reasons there are powerful pressures on

the mental health system to pursue efficiencies, decreasing time resources for adequate assessment and monitoring of psychiatric services.

Formalizing ways to share information across systems may be a helpful structure for collaborations.