Psychiatrist–Patient Relationship: Models of Delivery of Psychiatric Services

Psychiatrist–Patient Relationship: Models of Delivery of Psychiatric Services

The psychiatric care of persons with mental retardation has often followed a path different from the care provided to the general population. A common service model has been the medication clinic, in which the psychiatrist is given little, if any, time to ex-amine the patient and to interview the caregivers. Instead, behav-ioral information, which is often brief and sketchy, is presented by caregivers and focuses primarily on disruptive behaviors. The psychiatrist is expected to prescribe medications and has no voice in, or knowledge of, other interventions that might be used. In some cases, the psychiatrist does the actual prescribing; in others, the psychiatrist serves as a consultant to primary phy-sicians who may or may not follow the recommendations given. This model is obviously inadequate, even if there is another professional providing psychotherapy or behavioral therapy. It also exposes the psychiatrist to legal responsibility (Woodward et al., 1993). This model has been used in institutions, especially to save on the expense of having a staff psychiatrist to provide adequate services.

The proper psychiatric care of persons with mental retar-dation is actually more time-consuming than the care of persons without mental retardation because of the multifactor nature of the treatment described previously. To understand the patient’s clinical presentation and provide the input necessary to all rel-evant aspects of treatment, the psychiatrist has to have adequate time to interview all involved caregivers, observe and interview the patient, make a home or program visit if necessary, and dis-cuss the recommendation with all involved. Thus, the interdisci-plinary team approach is necessary. It might not be realistic for all patients seen in the community, but it should be followed in all treatment-resistant cases and in residential facilities where, as a rule, there are more difficult patients (Szymanski et al., 1980; Szymanski and Leaverton, 1980). In most cases in the community, if a team forges a good working relationship and regular commu-nication, exchange of information and coordination via e-mail or telephone might be sufficiently productive. Some states have de-veloped successful models of such coordinated care (that provide for health, housing, vocational and social services) for persons who have both mental retardation and mental illness (Polgar et al., 2000). In all situations, psychiatrists will use their knowledge and training in biological and behavioral aspects of medicine to help other professionals synthesize the biopsychosocial aspects of a patient’s clinical presentation and treatment program.

Comparison of DSM-IV/ICD-10 Diagnostic Criteria

The methods of defining the levels of severity differs slightly between the two systems. The ICD-10 Diagnostic Criteria for Research define the levels using exact cutoff scores: Mild is defined as 50 to 69, Moderate is defined as 35 to 49, Severe is defined as 20 to 34, and Profound is defined as below 20. In contrast, DSM-IV-TR provides somewhat greater flexibility in relating severity to a given IQ score by defining severity levels using overlapping scores (i.e., Mild is 50–55, Moderate is 35–40 to 50–55, Severe is 20–25 to 35–40, and Profound is below 20–25). Within the overlapping range, the severity is determined by the level of adaptive functioning