Paging Dr. Carnac

“If you could read my mind, love, what a tale my thoughts could tell…”

Gordon Lightfoot

She sat across from me, as many teenagers do in my office, sullen and staring and closed off, body language reflecting self-protection and not openness to inquiry. I had just asked her about her family history, wanting to know if anyone in her family had ever been treated for mental illness. 

“I thought you were just for the medicine,” she spat.

“Excuse me?” I asked.

“The pills, the medications. I thought you were just here to give me the medicine. Isn’t that all you’re here for?”

Now I’ll grant you, on busy days when my pen is writing a lot of prescriptions or I’m send dozens of them through cyberspace to the local pharmacies, I wonder myself if that is not true. Of course, what this teen did not know, and what you may not know either, is that a lot of history, information and assessment play into my thinking before I hand you that prescription for Prozac or lithium. 

How do psychiatrists get their information? What do we need to know about you to treat you? My routine varies a little bit depending on the situation and the background for the visit. That is, the information that I review and seek may vary somewhat depending on whether I am seeing you for a probate court examination, a routine medication check, the initial visit to establish a diagnosis, or for an emergency evaluation in an emergency room via telepsychiatry. 

I always try to look at previous records. You may have brought some laboratory reports or X-rays with you. I’ll look those over. You may have had your primary doctor send me her records so that I can see how she is treating your hypothyroidism, hypertension or diabetes mellitus. You may have seen us in the SC Department of Mental Health system in the past, and so I would have electronic access to your outpatient records via my computer. Because of the opioid epidemic in the country, our governor has mandated that we check records of controlled drug prescriptions, who they were prescribed by, which pharmacy filled them, and which doctors are writing for the drugs. There is now a specific database that I can access to get that information, and I must document in your record when I see you that I have looked at the database and reviewed the information there. There are other databases that detail your previous appointments, diagnoses, and doctor visits. There are hospital records that tell me about your previous admissions, what they were for, and how long you stayed. There are court records from previous evaluations, information from the department of social services or adult protective services, the department of juvenile justice and law enforcement. 

Now, this is a lot of sensitive and private information. You might wonder about the ethical or legal nature of a doctor looking up all this detail about your life, and whether or not he might really need it at all. The answer to that is of course yes, if in getting and reviewing that information I can better establish a diagnosis and treatment plan and help you with the problems you presented to me with, or provide the best report to the doctor, judge, or agency who asked for me to report to them on your condition. All of this must be done with your express consent, unless an emergency situation exists or a court order compels the use of such information. I cannot go to the controlled substances database, for instance, and snoop on a friend or neighbor to see how much Xanax they have been using over the last two years just because I am curious. This information is available ONLY for professional purposes.Violation of that rule and unethical access to or use of personal protected information is a punishable offense. Especially in psychiatry, we take privacy and confidentiality extremely seriously. Otherwise, we know and you know that you would never in a million years come see us and divulge the things you do in confidence to your provider. No meaningful treatment could happen.

Collaborative information from families, spouses, friends or others may be extremely helpful as well. This is especially true in emergency room consults, when the patients I see may be intoxicated (I have seen folks come in with blood alcohol levels six times the legal limit and they are still trying to sit up and talk to me!)  or psychotic and incapable of providing their own historical background for the admission. In those cases, speaking with the treating physician or nursing staff in the ED, or trying to contact the referral source may also be helpful. Families are often right there with the patient in the ED and this is very helpful, but you might be surprised how many families simply drop their loved on off at the door and keep going, not answering their home or cell phones afterwards because they do not want to be a part of the treatment process at all. 

Laboratory records, including routine blood work, drug levels, X-rays, CT scans or MRIs and reports of other studies may be extremely helpful in establishing a diagnosis and coming up with the appropriate treatment. I have seen “psychotic”patients who I was consulted on for treatment of their “schizophrenia” who did not have a mental illness at all. Sometimes, thyroid problems mimic severe depression. A pulmonary embolism, a potentially fatal event, can look like severe anxiety and panic. I have seen children in the ED who were “too quiet” that turned out to have what is called status epilepticus, meaning that they are having continuous sub-clinical seizure activity that might not be diagnosed at first. Cocaine and other stimulant medications can make someone look as psychotic as can be, with or without a previous diagnosis of a primary psychotic disorder like schizophrenia. Urine drug screens are very helpful, as someone might tell me that they “have a drink or two every night but that’s all” and end up positive for sedative, narcotics or cannabis, or multiple drugs at one time. 

There are many screening tools in mental health that are also very helpful in figuring out what is wrong and what to do about it. These are beginning to be more and more important as we move into the age of managed care in the state of South Carolina (behind about forty-five other states who already have to worry with this), with providers wanting to see proof that interventions are indeed working and making someone better. Managed care companies do not pay for interventions that are not best practice and that do not show concrete evidence of getting patients better. Screening tools such as depression or anxiety inventories, checklists to assess attention deficit disorder, and questionnaires that look at activities of daily living are all helpful in diagnosing and treating mental illnesses of all kinds. Some of these are self reported and might be filled out in the waiting room as you wait to see your doctor or your counselor, others are given to parents or teachers, and others might be sent to your previous providers. 

Once again, I cannot stress enough that this information is confidential and used only by your provider in treating you UNLESS the interview or encounter is part of a court ordered evaluation, forensic evaluation, or is something that must be divulged as part of a mandatory reporting scenario. That is, if I see someone and suspect that there is child or elder abuse involved, for instance, it is mandatory that this abuse be reported to local authorities so that an investigation may be started by law. 

Is your spouse, simply by virtue of the fact that you are married, automatically entitled to your private information? No.

Is your mother, who loves you dearly and wants what is best for you, able to get the scoop from your psychiatrist about all of your sessions if you are in your forties? No.

Is your information automatically public record after your death, so that anyone might look at it because you are gone? No. 

Although Carnac the Magnificent could hold up a sealed envelope and come up with questions and answers that no one else could see, modern day clinicians including psychiatrists are not prescient or clairvoyant. We must gather background information, ask the right questions, keep our eyes and ears open, listen to what you are telling us, and use our best clinical judgment based on the evidence base, our training, and our experience to make an accurate diagnosis, come up with a reasonable treatment plan, and communicate that to you, enlisting you as a partner in your own treatment. 

Anything less than that would be, as Gordon Lightfoot would say, mind reading. 

As far as I know, mind reading is not evidenced based and is just not good medicine. 

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