Is the Psychiatric History Losing Its Relevance?

One of the axioms of medical practice is that obtaining a good history is key to making a correct diagnosis and developing a treatment plan. This is particularly true in psychiatry, in which laboratory or imaging investigations are not typically of great value. Any factor that compromises a history may compromise care. This area of practice has not been formally studied, although it is widely believed to be true. In mental health settings, there are many factors that affect obtaining the history. Among these are the skills of the clinician in eliciting relevant information in a limited time, the clinician's philosophy regarding the importance of such history, and lack of formal training in history-taking. Nonphysician clinicians may be more likely than psychiatrists to confront these barriers. Practice settings may, in their effort to maximize access, patient turnover, and cost control, convey a here-and-now approach to patient care, implicitly downplaying the importance of a complete history. There may be some cultural factors at play as well, reflecting American society's gradually decreased interest in the study of history. Despite these understandable barriers, the need for a complete history is still the highest priority in an initial evaluation. Some suggestions are offered to support clinicians' and organizations' struggles to keep a comprehensive history at the forefront of care.

E-mails in a Psychiatric Practice: Why Patients Send Them and How Psychiatrists Respond.

CONTEXT: Little is known about what prompts patients to use e-mail with their physicians and how physicians respond to these e-mails. OBJECTIVE: To identify the main reasons why patients e-mail and to learn how psychiatrists manage these e-mails as part of these patients' overall care. DESIGN: One hundred patient-initiated e-mails to each of two psychiatrists in a group practice were studied retrospectively for primary reason for the e-mail and for psychiatrists' handling of each e-mail. Other data were collected to assess how representative the e-mailing patients were of the psychiatrists' patient panels. RESULTS: Age, sex, and diagnoses of the e-mailers were similar to our overall panels. The most common reasons for e-mailing were refill requests (19.5%), questions about prescribed medication (16.5%), and worsening of symptoms (11.5%). The modal e-mail was a patient with attention-deficit/hyperactivity disorder requesting a refill. The psychiatrists' most common responses were authorizing a refill (25%), reassurance (22%), and making or moving up a scheduled appointment (16%). For all patients who reported a worsening of symptoms, responses, communicated by e-mail or telephone, included a combination of an earlier appointment and/or change in medication or dose and/or referral for psychotherapy. Both psychiatrists found e-mail to be an efficient enhancement of their practice, and it was inferred that this was also a satisfying mechanism for patients. CONCLUSION: Physician-patient communication via e-mail is timesaving for both, and the benefits to patient care should reassure physicians who are wary of using e-mail in their practice. Potential risks to patients without face-to-face or telephone contact appear to be minimal.