The frequency of visits to the clinic can be a source of considerable irritation. Why do we recommend that people come in once a week, or once ever two weeks, or once a month, or less often?
A wonderful young man I have been seeing for several years got very angry when I replied to his request to reschedule his appointment (going from an appointment one month after the last visit to one scheduled two months after our last visit) by noting that this constituted a significant change in the treatment plan.
He said it was outrageous for me to question his decision. He had a right to decide when he saw me.
I’m not sure that my reply made much sense to him.
I said that I thought that a doctor who did not have opinions about the most appropriate treatment plan would not be much of a doctor and there wouldn’t be much point in seeing a doctor who never shared those opinions.
I am known as a psychopharmacologist, an expert in using medication to treat psychiatric problems, but I think that having the right frequency and length of visits is often as important as choosing the right medication in determining the outcome of treatment.
How do I make a recommendation for the frequency of visits?
There are number of factors that go into this assessment.
- I often use a level of care assessment tool developed by the American Association of Community Psychiatrists to assess factors such as the complexity of the condition, risk of serious adverse events, a person’s support network, and other factors that relate to the appropriate intensity of treatment. The tool is called the Level of Care and Utilization System (LOCUS) and it is helpful at defining major differences in treatment intensity such as inpatient care versus partial hospital care versus residential care, etc.
- A very important aspect of determining the appropriate frequency of visits involves assessing how much a person’s symptoms vary over time and their ability to track those variations. So, for example, someone who is doing daily mood charting often does not need to be seen as often as someone with the same severity and complexity of psychiatric symptoms who is not keeping track of those symptoms in a systematic way.
- When treatment changes, when a new medication is begun or one is discontinued, it is important to get together sooner. If you years ago the Food and Drug Administration highlighted the increased risk of suicide if someone was begun on an antidepressant medication, that would in the long run treat their depression, and not seen for follow-up in a timely fashion.
- The purpose of getting together is also to be collaborative, and developing a sense that we are making decisions jointly requires a certain amount of time. One of the most frustrating situations I deal with is sitting with a patient who is upset that his or her psychiatrist did not listen, made arbitrary decisions and never explained them, and yet who wants to come in for a half hour visit every three months. It is not possible for a psychiatrist to make sense of what has been going on over the last three months, formulate treatment recommendations and engage in a collaborative experience in that amount of time.
Although we often end up searching the internet trying to find clear recommendations about the frequency of treatment, much of what goes into this assessment relies on our years of experience working with other patients and therefore cannot be explicitly defined.
And since what we are recommending increases the cost of treatment, some patients are very skeptical about our suggestions.
Having been on the receiving end of suggestions that seemed self-interested, for example the curious experience of visiting various practitioners when we were suffering from severe back pain, and noticing that none of these practitioners ever suggested that what they had to offer was not likely to be of benefit, we understand the skepticism.
We try to come to a compromise when there are disagreements. Often it is possible to split the difference, at least on a trial basis. If I think you should come in once a week and you would rather come in once a month we can try getting together every other week. Or if the recommendation of the level of care tool is inpatient treatment and you want to receive low intensity outpatient care, it may be possible to try a referral to partial hospital care.
But sometimes no compromise seems to be possible and in those cases we have increasingly come to believe it is part of our responsibility as healthcare providers to make it clear that we don’t agree.
This is an unusual stance and people get upset with us when we say that we don’t agree with their wishes.
Years ago we would go along with what our patients wanted, on the grounds that some treatment was likely better than no treatment. But then we started to notice that when we went along with those wishes and our patients didn’t get better, they tended to conclude that treatment was not likely to be effective, rather than that they were getting an ineffective level of care.
Over time, we have decided that it is better to be clear about our recommendations even though this leads to unpleasant conversations, sometimes.