This week, a long-time patient came to see me for her regularly scheduled appointment. After checking-in on her own (now stable) mental health, she wanted to discuss her niece’s recent evaluation by a psychiatrist in another city.
She said, “My niece is 19. She went to see a counselor because she was stressed out about college. At the first session, the counselor thought she needed to be taking an antidepressant, and so she sent my niece to a psychiatrist. Her sister took her to the psychiatrists’ office hoping to go in with her, but was told that even with consent by the patient no family members were allowed in the room while the doctor evaluated a patient. After 35 minutes speaking to my niece alone, he prescribed an antidepressant and gave her instructions she didn’t really understand. My niece walked out confused, overwhelmed, and feeling all alone. She didn’t know whether to take the medication. Nothing about the situation seems appropriate to me. Do you think this is good medical care?”
Her story was typical of the standard of psychiatric care for young adults with a crisis brought on by stress. I could see a number of problems:
1. Brief visits. Thirty-five minutes may be enough time to run through short list of medical questions like, “How much alcohol do you drink?” and “How many hours do you sleep each night?” but it’s certainly not enough time to get to know a person’s normal baseline or to diagnose disease.
When searching for a psychiatric evaluation, it might be important to ask how long an appointment is expected to last. If the visits are routinely short, consider looking for a doctor who spends more time with patients.
2. Refusal to receive collateral from family members. Mental health professionals can be sticklers for confidentiality rules. Families often complain that they aren’t allowed to express important observations of a loved one’s behavior, or even serious medication reactions, to psychiatrists, even when the patient offers consent.
Contact with family members is not strictly forbidden by privacy rules, but a signed consent form may be required. Common reasons for refusing to included family members in sessions may include misinterpretation of the rules of privacy, or limited time (see item number 1) since additional parties in the room can extend the time required for an evaluation. If having family members involved to share information is important, ask about a doctor’s policy ahead of time.
3. Refusal to discuss the treatment plan with family members, even when the patient has requested to have someone present.
Whatever the specialty of the doctor, having a family member sit in to the educational portion of the session reduces forgetting and errors. Inquire about the doctor’s policies in advance.
4. Rush to DSM-5 diagnosis without considering the long-term ramifications. When a young adult receives a new mental illness diagnosis, she may absorb the illness into her sense of self, see it as who she is. But not all young adults with an episode of depression will go on to experience another one.
Patients and families should ask specifically to discuss the doctor’s opinion about the long-term prognosis. After a single episode, even if treatment is required, there is usually no clear indication a person will suffer from lifelong depression.
5. Rush to prescribing medication. The use of medications for depression is based on research in a broad range of adults, not a group of 19-year-olds. Since young brains are different than mature brains, the effects of medications in young people might be different from the effects in mature research subjects.
Because young brains are different than the average adults who volunteer for research studies, prescription medication should be considered for young adults only after non-medication alternatives have been exhausted. It is unclear why the 19-year-old described above was referred to a psychiatrist so early in her course.