Case, Part 1
You are seeing John, a 30-year-old male, who is booked for a 15-minute appointment:
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Identifying data
- Living with spouse and 2 young children aged 3 and 5 years.
- Works as a forklift operator
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Chief complaint
- "Can you give me something for my sleep?"
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HPI
- He complains of feeling “keyed up” and has only been sleeping 4 or 5 hours a night for the past 2 weeks.
- He has been feeling extremely irritable and during one of their arguments put his fist through a wall in their house.
- He reports that he has been drinking alcohol and snorting cocaine for the past few weeks to manage his distress and to help him stay awake for his afternoon shift as a forklift operator.
- In fact, he snorted some before this visit.
- He is now so uncomfortable he tells you he wants to die.
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MSE
- Psychomotor agitation, pressured speech though he is coherent, dressed appropriately, and maintains eye contact. Passive suicidal ideation.
Introduction
The problem
- Undifferentiated, acute mental disorders or those that have recently changed are inherently complex, challenging and may be anxiety producing for the treating family physician.
- There is usually insufficient time to conduct a full psychiatric assessment that includes a comprehensive history of the patient’s concerns, psychiatric symptoms, diagnosis and management plan.
- Many concerns compete for the busy family physician’s attention in a typical encounter. As a result, time pressures, the complexity of mental health issues, and the anxiety they might produce in the physician can result in missing key risks to the patient and others.
The solution
- How should one prioritize one’s time during the brief primary care encounter?
- Safety, as the priority means first focussing on risk and related clinical decisions prior to other issues such as diagnostic clarification and treatment.
- Consider addressing issues in the following sequence:
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Imminent risks |
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Evolving risks, functional deficits, and symptoms that might evolve into immediate risk |
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Long-term risks, diagnostic clarification, ongoing symptoms, functional impairments, and chronic conditions.) |
Assessment / History
Primary care visits are short and the initial interaction with the patient that includes rapport building, eliciting patient’s concerns and desired outcomes can easily take up the entirety of the appointment. This interaction should serve as a bridge to targeted questions that are focused on risk identification. It is important to remember that it is common to prioritize the patient’s story or explanatory model at the expense of identifying risks that require immediate attention. You do not want the patient to leave the office without having ascertained these risks.
Chief complaint
- “What brings you in today?”
Goals
- “How can we make this a helpful visit?”
HPI
- “Tell me more about what’s been happening…” (start with an open-ended exploration of the patient’s chief concerns)
Risk Assessment
- “Thank you for giving me an idea of what’s been going on. I have some more specific questions to ask you…”
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“With all that’s been going on, are you having any thoughts that life isn’t worth living?” |
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“With all the stress, have you been feeling frustrated at others?” “Has it gotten to the point that you’ve had thoughts of hurting others?”
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“Any problems driving?” |
Functional Impairment
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“Any troubles looking after yourself?” |
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“Any troubles looking after your children?” |
| “Any troubles with work?" "Any troubles with school?" |
| "Any troubles with your home? Apartment?" "Any troubles keeping the rent? Mortgage?" |
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“Any troubles with your driving?” |
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“Any troubles with your relationships?” |
Psychiatric Signs/Symptoms Review (if time permits)
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“Any problems thinking?” “Any problems focusing or concentrating?” “Any concerns with repetitive thoughts or worries?” “Any worries that others are against you?” (paranoia) |
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“Any problems with your mood?” “Any problems with depressed mood?” “Any problems with anxiety?” |
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“Hearing any things that others can’t hear, such as voices?” (auditory hallucinations) “Seeing any things that others can’t see?” (visual hallucinations) |
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“How much do you alcohol drink, if at all, these days?” “Do you use any recreational drugs?” “How much do you use?” “Have others told you to cut down?” “Has this caused you any problems?” |
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“Any problems with your sleep?” “Do you ever not sleep and yet don’t feel tired? |
Management
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Summarize your Interview with the Patient |
“I am so glad that you came in today. You’ve told me that (summary of patient’s concerns).” “And yet even despite the challenges you’ve been having, I am grateful and glad to hear about (something positive).” “I’d like to share with you some ideas about what might be helpful in your situation…” |
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Management Plan to Address Risks |
With mild to moderate risks, consider:
With severe concerns, consider:
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If mild to moderate concerns, consider:
If moderate to severe concerns, consider:
If dependants are at risk, consider:
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If mild to moderate concerns, consider:
If moderate to severe concerns, consider:
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Mild to moderate concerns, consider:
Moderate to severe concerns, consider:
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If difficulties, consider:
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If safety concerns, consider:
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If significant social concerns, consider:
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If difficulties at school / work, consider:
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Case, Part 2
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Risks
- You assess John’s suicide risk and decide he does not require immediate admission or medical detoxification.
- He states that he is not responsible for his children during the day while his wife is working or before his afternoon shift.
- He has never been violent toward anyone in the family.
- He does not experience withdrawal symptoms from the alcohol but notices a crash in mood when the cocaine wears off.
- John’s safety as a forklift driver is in question and he has been driving his car while high.
- You advise him that you have a legal obligation to notify the ministry of transportation regarding John’s licences.
- John reveals he has been spending approximately $200 per week on cocaine and alcohol, unbeknownst to his wife.
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Physical exam
- With respect to his substance use, you examine him and his blood pressure is 160/100 mmHg.
- You advise him of his short-term and long-term psychological and physical risks
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Investigations
- You order appropriate bloodwork.
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Feedback
- You ask John if he wants help with his substance use, and his other issues
- John says yes, particularly given the licensing and financial concerns.
- You suggest that John tell his wife about his problems and his spending, and that they return for an appointment together within the next week.
- You tell John that his suicide risk will be monitored for worsening over time, pending clarification of the responsible conditions.
- You are unable to make any DSM-5 diagnoses as you lack details about his psychiatric symptoms, however you can ask about those a later appointment, if you have time and/or when you call him in for a complete assessment
- You start preparing mentally for your next patient, which is an elderly woman who is weak and dizzy………
Conclusion
Remember:
- The primary objective in the initial encounter with the patient with undifferentiated mental disorder is risk identification.
- Although rapport facilitates the patient’s sharing of information and is thus important, establishing rapport per se is not the primary objective.
- Overly focusing on rapport can lead to the failure of identifying risks that require urgent attention.
- The antecedents to a problem can be sorted out over time.
- Risk mitigation is time sensitive -- as per the old adage, time is of the essence.
References and Further Readings
Silveira J, Rockman P, Fulford C, Hunter J: Approach to risk identification in undifferentiated mental disorders. Canadian Family Physician December 2016 vol 62(12): 972-978.
URL: http://www.cfp.ca/content/62/12/972.full
About this Document
Written by Dr’s José Silveira (psychiatrist), Patricia Rockman (family physician), Jon Hunter (psychiatrist), Mireille St-Jean (family physician) and Michael Cheng (psychiatrist).
Reviewed by members of the eMentalHealth.ca Primary Care team which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician) and M. Cheng (psychiatrist).
Disclaimer
Information in this article is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.
Creative Commons License
You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/
Addendum: Sample Recording Sheet
This is a sample sheet to help with writing down responses during a clinical encounter
Risk Assessment
|
Domain |
Sample question for patient |
Patient’s responses: |
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“With all that’s been going on, are you having any thoughts that life isn’t worth living?” |
|
|
“With all the stress, have you been feeling frustrated at others?” “Has it gotten to the point that you’ve had thoughts of hurting others?” |
|
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“Any problems driving?” |
|
Functional Impairment
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Domain |
Sample questions |
Patient Responses |
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“Any troubles looking after yourself?” |
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“Any troubles looking after your children?” |
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“Any troubles with your driving?” “Any troubles meeting your work obligations?” |
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“Any troubles with your relationships?” |
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“Any troubles with school?” “With work?” |
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Psychiatric Signs/Symptoms Review
If time permits, then ask the following:
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Domain |
Sample Questions |
Patient Responses |
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Cognitive |
“Any problems thinking?” “Any problems focusing or concentrating?” “Any concerns with repetitive thoughts or worries?” “Any worries that others are against you?” (paranoia) |
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Emotional |
“Any problems with your mood?” “Any problems with depressed mood?” “Any problems with anxiety?” |
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Sensory including hallucinations |
“Hearing any things that others can’t hear, such as voices?” (auditory hallucinations) “Seeing any things that others can’t see?” (visual hallucinations) |
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Behaviour |
“Any changes in your activities or routines these days?” |
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“How much do you alcohol drink, if at all, these days?” “Do you use any recreational drugs?” “How much do you use?” “Have others told you to cut down?” “Has this caused you any problems?” |
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“Any problems with your sleep?” Do you ever not sleep and yet don’t feel tired? |
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