Ten Commandments of Good Psychiatry

By  Shaili Jain, MD

So here are the principles that I shared with my audience during the lecture, described as Ten Commandments and listed in no particular order of importance.  Some of the language is specific to the treatment of depression, but the principles are applicable to all mental health disorders.


#1. Thou Shalt Always Aim To Establish And Maintain A Therapeutic Alliance

Perhaps one the biggest challenges to physicians practicing in a 21st century medical environment is preserving relationships with our patients.  Many of us operate in settings where we are pushed for time, have to do more with less, and are bombarded by a constant stream of interruptions that have us focusing more on computer screens, pagers, voicemails, and instant messages than on the patient that sits in front of us.

This is not only frustrating for us (most people I know became healthcare professionals because of a capacity to care deeply for the plight of other human beings, not because of a desire to be stuck in front of a screen, or phone, or to do paperwork) but it is wrong for our patients.  Such an environment inhibits trust, rapport building, and the development of what, in my field, we call alliance.

Therapeutic alliance is a crucial fundamental of good psychiatric practice; it promotes collaboration, trust, and mutual respect.  It can take years to build with false starts and setbacks, but the provider’s commitment to maintaining it must be unwavering.  Any factors or situations that interfere with our ability to maintain an alliance with our patients interferes with our patients’ inclination to fully disclose what is on their minds, share their fears and darkest thoughts freely, and to be truthful in their communication with us.

Our job as the treating clinician is to preserve the sanctity of the relationship between doctor and patient and push back on external factors that impinge on it.  More than just touchy-feely medicine, it is the very foundation upon which good psychiatric care is practiced.


#2. Thou Shalt Always Do A Complete Psychiatric Assessment


Anyone treating a mental health disorder can only do so after they have done a thorough psychiatric assessment; when time is of the essence this can be the first thing that gets short thrift.  At minimum the following areas have to be touched on (and can be done in an efficient way with practice):

  • History of the present illness and current symptoms
  • Past psychiatric history
  • Substance use
  • Relevant social, occupational, and family history
  • Physical examination and appropriate diagnostic tests to rule out physical causes for depressive symptoms


#3. Thou Shalt Always Do A Thorough Evaluation For Safety 


Any clinician who treats patients living with mental illness has do the following, not only on the initial evaluation but on an ongoing basis:


  • Make specific inquiries about suicidal thoughts, intent, plans, means, and behaviors
  • Identify psychiatric symptoms or general medical conditions that might increase the likelihood of acting on suicidal ideas
  • Assess past and, particularly, recent suicidal behavior
  • Assess for potential protective factors that can serve to decrease the chances that the patient will harm themselves or others
  • Identify any family history of suicide or mental illness
  • Have a good sense of the patient’s level of self-care, hydration, and nutrition
  • Evaluate the patient’s level of impulsivity and potential risk to others, including any history of violence
  • Assess the impact of depression on the patient’s ability to care for their dependents


#4. Thou Shalt Always Identify the Appropriate Treatment Setting 


The patient’s treatment needs and symptom severity should determine what setting they are treated in, from outpatient care with a primary care physician to hospitalization in a specialized psychiatric unit. 


Measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.  Unfortunately, because of mental health parity and inadequate access to mental healthcare for many, health care professionals are often put in the very difficult position of caring for those with mental illness in a setting that is not optimal for comprehensive care.  Whilst this is inevitable at times, the clinician has to remain watchful that these circumstances do not interfere with the patient’s clinical progress.


#5. Thou Shalt Focus On The Patient’s Functional Impairment And Quality Of Life

Mental illness impacts many spheres of a person’s life, including work, school, family, and social relationships.  Any treatment interventions should be aimed at maximizing the patient’s level of functioning within these spheres and focus on enhancing their quality of life.



#6. Thou Shalt Coordinate The Patient’s Care With Other Clinicians

American healthcare is famous for being fragmented.  With so many different providers, healthcare systems, and insurance providers involved, talking to each can become a low priority for clinicians involved in a patient’s care.  This lack of communication, however, can have disastrous consequences for patient outcomes.


#7. Thou Shalt Monitor The Patient’s Psychiatric Status 

The patient’s response to treatment should be carefully monitored.  Patients who are on psychiatric medication need ongoing assessment for adherence, symptom control, and side effects.  This is even more important if a patient is new to medication, this is their first episode of mental illness, they have clinical factors that place them at high risk for suicide, or they are not improving clinically.  Ongoing care can be spaced out once the patient is stable, but until that time comes they need to be monitored with sufficient regularity.


#8. Thou Shalt Integrate Measurements Into Psychiatric Management 

An invaluable option for the busy clinician is to integrate clinician and/or patient-administered questionnaires into initial and ongoing evaluations of patients with mental health disorders.



#9. Thou Shalt Evaluate A Patient’s Treatment Adherence

Assume and acknowledge that the patient will have potential barriers to treatment adherence, and collaborate with the patient (and if possible, the family) to minimize the impact of such barriers.

The clinician should encourage patients to articulate any fears or concerns about treatment or its side effects and offer patients a realistic notion of what can be expected during different phases of treatment.



#10. Thou Shalt Provide Education To The Patient And Their Family

Education! Education! Education!  The clinician has to spend time clarifying common misperceptions about antidepressants; emphasizing the need for a full course of treatment; and promoting the benefits of healthy behaviors like exercise, sleep hygiene, and nutrition on mental health.  Family and others involved in the patient’s day-to-day life may also benefit from education about mental illness and its effects on functioning and treatment.


 I believe each of us should be a fundamentalist when it comes to providing mental health care.  No matter the treatment setting or level of training of the provider, we cannot adequately care for our patients when these Ten Commandments are forgotten or ignored.


Shaili Jain, MD serves as a psychiatrist at the Veterans Affairs Palo Alto Health Care System, is a researcher affiliated with the National Center for Posttraumatic Stress Disorder and a Clinical Assistant Professor affiliated with the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. Her medical essays and commentary have appeared in the New England Journal of Medicine, the Journal of the American Medical Association, public radio and elsewhere. The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.

This post was originally published on http://blogs.plos.org/mindthebrain/ licenced under the Creative Commons attribution license. It is republished here.