Approach to the Interventional Psychiatry Consult
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Interventional psychiatry consultations, often provided through specialized programs, offer expertise for patients whose depression has not responded adequately to front-line treatments. These services are particularly relevant for treatment-resistant depression (TRD). The goal is to provide referring clinicians and patients with guidance on enhanced, individualized treatment options.
A comprehensive assessment is critical in these settings to ensure diagnostic accuracy and informed treatment planning, aiming for the best patient outcomes.
This article will focus on the key components that should be included in an interventional psychiatry consult.
Establishing Diagnosis and Comorbidities
- A primary goal is to establish the primary diagnosis and identify relevant comorbidities.
- Clarifying medical and psychiatric symptoms is essential.
- Key differential or co-occurring psychiatric diagnoses for TRD include alcohol/substance use, eating disorders, sleep disorders, psychotic disorders, posttraumatic stress disorder, and personality disorders. Anxiety disorders are commonly comorbid with depression and can make remission less likely or slower. Alcohol and substance use can impact mood, functioning, and treatment response, even if they don’t meet the criteria for a diagnosable disorder.
- Several medical conditions can cause depressive symptoms that won’t resolve until the underlying cause is managed, such as hypothyroidism, Cushing disease, Parkinson disease, metabolic disorders, cardiovascular events, dementia, and certain cancers. Treatments for medical illnesses, like corticosteroids, interferons, and calcium channel blockers, can also cause or worsen depressive symptoms.
- Assessing the patient’s current psychiatric illness stability is necessary for the consultation to be most helpful; consultations are not recommended during an acute psychiatric crisis.
- Structured or semistructured interviews can be used to increase the accuracy and reliability of diagnoses and ensure critical aspects of the patient’s presentation are captured, which may have been overlooked in prior assessments. Examples include the SCID, MINI, and DIAMOND.
- The diagnostic impression should include the main descriptive psychiatric diagnosis(es), comorbid psychiatric diagnoses, co-occurring general medical conditions, and the relative certainty of these diagnoses.
Clarifying Symptoms and Setting Goals
- Assessment aims to clarify symptoms, chronicity, and establish a current baseline.
- Identifying treatment and functioning goals is a crucial part of the assessment.
- Goal alignment between the treatment team and the patient should be established.
Documenting Treatment History
- Documenting treatment history is a goal of the interventional psychiatry consultation.
- Collecting detailed information about prior treatment experiences helps confirm if the individual has a difficult-to-treat form of depression and informs which treatment classes have been adequately tried.
- A careful assessment includes details about specific treatments, timing, dose, duration, side effects, degree of response, and reasons for discontinuation.
- Gathering this information can be challenging, and multiple sources are recommended, including the patient’s report, medical record review, pharmacy records, and collateral information from involved individuals. Collateral information is helpful for clarifying symptoms, perceived treatment response, functional impairment, and barriers to care.
- Examining previous treatment history through the lens of patients’ meaning and beliefs about medications and therapeutic modalities, as well as interpersonal factors, can provide useful insights into prior barriers to treatment. This can help explain inadequate previous trials due to sensitivities, nocebo effects, lack of trust, or reluctance to disclose.
Identifying Treatment Barriers
- Identifying treatment barriers is another goal of consultation.
- The clinical interview is a vital opportunity for clinicians to probe specific considerations that may have been previously unexplored, such as interpersonal relationship patterns, trauma, or the role of substance use, which could be contributing factors.
Developing Actionable Treatment Recommendations
- A primary goal is to develop actionable treatment recommendations.
- Assessment is directed towards determining which treatment strategy is most likely effective for this patient at this time, considering their symptoms, characteristics, history, barriers, and strengths. Recommendations are personalized.
Clinical and psychosocial factors guide the selection of appropriate interventional treatments
- The case formulation, which incorporates biological, psychological, and social/environmental factors maintaining depressive symptoms despite prior treatments, is a key tool for individualizing treatment decisions. It provides a model for why the depression is difficult to treat and helps prioritize reasonable options based on patient needs and preferences.
- Factors influencing treatment selection include the patient’s current diagnostic and symptom presentation, treatment history, identified barriers to treatment, and personal strengths.
- Differential and co-occurring diagnoses (e.g., psychotic features, schizoaffective disorder, schizophrenia, substance use disorders) can significantly impact treatment recommendations and standard therapy response.
- Comorbid conditions like anxiety, sleep disorders, and personality pathology can influence treatment efficacy.
- Cognitive and meta-cognitive deficits are often present in TRD and predict poor functioning, contributing to a sense of unmet goals.
- Medical conditions and medications the patient is taking must be considered, as they can cause or exacerbate depressive symptoms. The number of nonpsychiatric medications with depressive side effects is linearly related to inadequate response to standard treatments.
- Treatment recommendations should stem from the case formulation and consider descriptive factors like co-occurring conditions.
- The full spectrum of interventions should be considered, including pharmacotherapy, psychotherapy, neuromodulation (like ECT and TMS), chronotherapeutics, lifestyle medicine, and treatment of medical conditions.
- Specific options mentioned include medication augmentation or switching, fast-acting antidepressants like ketamine or esketamine, empirically supported psychotherapies, and interventional psychiatry services like TMS, ECT, or vagus nerve stimulation.
- Recommendations should prioritize options likely to be effective given the patient’s profile and avoid treatments with dangerous interactions, incompatibilities (age, medical conditions), or limited evidence for TRD.
- Recommendations can be presented as a “care pathway” with sequential steps activated by lack of response or intolerance.
A structured, patient-centered approach is used to communicate risks, benefits, and expectations
- The diagnostic impression and treatment recommendations should be clearly communicated at an appropriate level of detail, depending on the audience (referring clinician, patient).
- The diagnostic impression and case formulation elements should be discussed with the patient at the conclusion of the evaluation.
- Recommendations for a higher level of care, if applicable, should be explicitly reviewed with patients and referring clinicians, including the rationale.
- Recommended diagnostic tests and their rationale should be explained to the patient, caregivers, and referring clinicians.
- Verbal feedback should be provided to the patient before the final report is ready, ideally on the same day as the visit or at a follow-up.
- Communication with patients/caregivers should be verbal and written; communication with referring providers should be written, with consideration for verbal discussion.
- Reports should provide sufficient breadth and detail for referring clinicians while avoiding overwhelming patients.
- Federal rules require patients have free access to their health records, including the full consultation report.
- Discussing the meaning and beliefs patients attach to previous treatments and interpersonal factors in prior care can address potential barriers like sensitivities or lack of trust, which is key to maximizing future treatment effectiveness.
- When discussing specific interventions like ECT, acknowledging refinements that have reduced side effects is relevant30. Informing patients about potential cognitive side effects of ECT is important.
Effective coordination with the primary team and necessary medical workups are integral
- Interventional psychiatry consultation programs require an efficient referral process, including screening, triage, gathering outside records (from physicians, therapists, pharmacies), and obtaining patient-generated information.
- Having a designated Intake Coordinator is recommended for cost and time efficiency in managing records.
- In multidisciplinary settings, assessments can be divided among providers (psychologists for testing, psychiatrists for medical/treatment history). This allows for communication between providers to clarify diagnostic questions and reach consensus on diagnosis and recommendations.
- Delegating portions of the assessment to advanced-practice clinicians or trainees can enhance efficiency and contribute to educational goals.
- A systematic consideration of further diagnostics is recommended, including laboratory studies, electrophysiological/neuroimaging/radiographic testing, psychometric/neuropsychological testing, and consultations with other specialists to prioritize treatments and identify factors contributing to resistance.
- The need to address existing medical comorbidities that may be affecting symptoms should be explicitly stated in recommendations.
- Providing sequentially ordered treatment recommendations (“care pathway”) is preferred by referring clinicians.
- Communication with referring/treating providers should include written reports and potentially verbal discussions.
- Post-assessment contact can be scheduled to assess treatment response and provide further recommendations.