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Pearls


5 questions guide care of patients with psychosis

Vol. 5, No. 8 / August 2006

Keeping track of outpatients with psychosis can be challenging when multiple clinicians provide care and social services are disjointed. To ensure continuity of care and achieve optimal functional outcome, answer these five questions periodically during long-term treatment.

1. Are you acquainted with the patient’s primary care physician? If not, introduce yourself by e-mail, letter, or telephone.

For some patients, you are the primary physician by default, so know some medical monitoring guidelines such as the Mount Sinai Consensus Conference Recommendations for Physical Health Monitoring in Schizophrenia.1 Also encourage the patient to exercise, stop smoking, and lose weight, if necessary.2

2. When did you last request a written consultation from a specialist? Documenting consultations helps other clinicians follow the steps you took to care for the patient. Requesting and preparing the written consultation also forces you and the consultant to think about the exact nature of the patient’s problem.

3. How strong is the patient’s social network? To identify who can help with the patient’s care, draw a schematic of his or her family tree. Determine who lives with the patient or lives nearby and regularly sees him or her. Repeat this exercise every year because family networks change.

4. Do you have data regarding the patient’s complaints? Get as much information as possible to determine a cause. For example, if the patient has:

  • Insomnia—Have the patient or caregiver complete a sleep log and count the number of caffeinated drinks and cigarettes the patient consumes daily.
  • Overweight/obesity—Weigh the patient at each visit and suggest that the patient or caregiver keep a food diary.
  • Worsening psychosis—Use a psychopathology rating scale such as the Brief Psychiatric Rating Scale. Count pills, and order antipsychotic blood levels and urine drug screens if necessary to test for medication non-adherence or unrecognized drug use.
  • Possible cognitive problems—Order neuropsychological tests, particularly to assess memory, attention, and executive function.

5. How much progress can you expect in 1 year? To help you set feasible rehabilitation goals, make a schedule of a typical week in the patient’s life. This schedule will suggest how to engage the patient in work, family, and the community. Have the patient bring in a resume or work history as a starting point for discussion. Repeat this exercise annually.

Reference

1. Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004;16:1334-49.

2. Goff DC, Cather C, Evins AE, et al. Medical morbidity and mortality in schizophrenia; guidelines for psychiatrists. J Clin Psychiatry 2005;66:183-94.

Dr. Freudenreich is director, first episode and early psychosis program, Massachusetts General Hospital, Boston, MA.

Dr. Querques is an assistant in psychiatry, Massachusetts General Hospital.

Dr. Kontos is associate director consultationliaison psychiatry, Cambridge Health Alliance, Cambridge, MA.

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