Midweek Medicine: The importance of review

Midweek Medicine Redux

Since I was off sick for Monday and Tuesday, today is midweek for me I thought I’d spend some time on the importance of regular review in psychiatry. I’m not (just) meaning clinical review of patients, or multi-disciplinary team reviews of management; I’m referring to the process of reviewing a patient’s diagnosis, as opposed to continuing along with whatever previous opinions have been (and yes, I am aware this could open up a minefield in relation to the validity and reliability of psychiatric diagnoses; I might not address that today, but it’s definitely worth looking at at some point)

This is something that gets brought home to me regularly, and I’ll illustrate by reference to a young person I’ve seen. This patient hadcarried a diagnosis of schizophrenia, and consequently been treated with antipsychotic medication, for the better part of a decade. The family contacted my team rather concerned, we got involved, and I reviewed the patient with a family member. Importantly, there were no psychotic symptoms described by patient or family, or signs evident at interview. What were evident in history and examination were symptoms and signs of hypomania. This instantly calls into question the diagnosis: raising the possibility this patient in fact has a mood disorder, rather than a psychotic disorder. Asking someone to recall distant past history is always a bit fraught, but this patient did indeed recall having problems with mood (generally mixed: elevated and depressed together – as hard as it is to think about that) and problems with sleep, appetite, and energy, which accompany the mood shifts in mood disorders.

So I embarked on a file review. Sadly, while this patient had been seen quite regularly by an experienced doctor and a case worker, there was little to no exploration or review of the diagnosis. Even when moving from one area to another, the existing diagnosis was accepted at face value, and assessments were ‘deteriorating’ … ‘ improving’ … rather than any attempt to assess whether the previous diagnostic formulation was correct.

Let me stress: this is no academic exercise. If this patient has a mood disorder we could add a mood stabiliser and potentially remove the antipsychotic medication, thereby possibly improving cognitive function and longer-term physical health and longevity (given the unwanted effects of antipsychotic medications).

So … almost a decade, moving between 3 services before seeing me, and no-one had seriously examined whether they’ve been working on the basis of a correct diagnosis.

I always get a bit shirty when I see the phrase: ‘well-known to service’, because it generally appears to be an excuse to turn one’s brain off; to simply continue someone else’s plan.

Some would say that it is unprofessional to not simply accept one’s colleagues’ assessments. I would say bollocks to that. We’re meant to be acting in the best interests of our patients, not looking out for our own hurt feelings and wounded pride. Stretched services also regard it as an unsupportable use of time, to re-examine established diagnoses (and treatment plans) instead of jut continuing what has been done before. To that, I just raise the number of patients whose lives I have improved by re-examing a diagnosis that turned out to be incorrect – thus enabling a more appropriate and targeted treatment plan, and a better overall outcome.

And that is what we ought to be about. The way to deal with inadequate resources is not to sacrifice the proper care of our patients.

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Tags: diagnosis, psychiatry, review, treatment