Treatment Planning - Clinical Evaluation and Treatment Planning: A Multimodal Approach

Treatment Planning

The psychiatric evaluation is the basis for developing the case formulation, initial treatment plan, initial disposition and com-prehensive treatment plan.

Case Formulation

The case formulation is the summary statement of the immediate problem, the context in which the problem has arisen, the tenta-tive diagnosis and the assessment of risk. The latter two areas are described next in more detail.

Assessment of Risk

The assessment of risk is the most crucial component of the for-mulation because the safety of the patient, the clinician and oth-ers is the foremost concern in any psychiatric evaluation. Four areas are important: suicide risk, assault risk, life-threatening medical conditions and external threat.

Suicide Risk

The risk of suicide is the most common life-threatening situation mental health professionals encounter. Its assessment is based on both an understanding of its epidemiology, which alerts the clinician to potential danger, and the individualized assessment of the patient. Suicide is the eighth leading cause of death in the USA. In the past century, the rate of suicide has averaged 12.5 per 100 000 people. Studies of adults and adolescents who commit suicide reveal that more than 90% of them suffered from at least one psychiatric disorder and as many as 80% of them consulted a physician in the months preceding the event. An astute risk as-sessment therefore provides an opportunity for prevention.

For those who complete suicide, the most common diag-noses are affective disorder (45–70%) and alcoholism (25%). In certain psychiatric disorders, there is a significant lifetime risk for suicide, as listed in Table 19.18. Panic disorder is associated with an elevated rate of suicidal ideation and suicide attempts but estimates of rates of completed suicide are not well established.

Suicide rates increase with age, although rates among young adults have been steadily rising. Women attempt suicide more often than men, but men are three to four times more likely than women to complete suicide. Whites have higher rates of sui-cide than other groups.

A patient may fit the diagnostic and demographic profile for suicide risk, but even more essential is the individualized

assessment developed by integrating information from all parts of the psychiatric evaluation. This includes material from the present illness (e.g., symptoms of depression, paranoid ideation about being harmed), past psychiatric history (e.g., prior attempts at suicide or other violent behavior), personal history (e.g., recent loss), family history (e.g., suicide or violence in close relatives), medical history (e.g., presence of a terminal illness) and the MSE (e.g., helplessness, suicidal ideation).

The most consistent predictor of future suicidal behavior is a prior history of such behavior, which is especially worrisome when previous suicide attempts have involved serious intent or lethal means. Among the factors cited as having an association with risk of suicide are current use of drugs and alcohol; recent loss, such as of a spouse or job; social isolation; conduct disorders and antisocial behavior, especially in young men; the presence of depression, especially when it is accompanied by hopelessness, helplessness, delusions, or agitation; certain psychotic symp-toms, such as command hallucinations and frightening paranoid delusions; fantasies of reunion by death; and severe medical ill-ness, especially when it is associated with loss of functioning, in-tractable pain, or central nervous system dysfunction. Table 19.19 lists risk factors for suicide. It should be noted that assisted sui-cide is now more openly discussed among people with terminal illnesses and has gained some measure of acceptability. None-theless, the vast majority of people who are bereaved or suffer from a serious medical illness do not end their lives by suicide. Adequate end-of-life care should forestall requests for assisted suicide. Although suicidal intent may be lacking, patients who are delirious and confused as a result of a medical illness are also at risk of self-injury.

It is essential to be clear about whether the patient has pas-sive thoughts about suicide or actual intent. Is there a plan? If so, how detailed is it, how lethal, and what are the chances of rescue? The possession of firearms is particularly worrisome, because nearly two-thirds of documented suicides among men and more than a third among women have involved this method

Factors that may protect against suicide include convictions in opposition to suicide; strong attachments to others, including spouse and children; and evidence of good impulse control.

In addition to the assessment of risk factors, it is important to decide whether the possibility of suicide is of immediate con-cern or represents a long-term ongoing risk.

Risk of Assault

Unlike those who commit suicide, most people who commit vio-lent acts have not been diagnosed with a mental illness, and data clarifying the relationship between mental illness and violence are limited. The most common psychiatric diagnoses associated with violence are substance-related disorders. Conduct disorder and antisocial personality disorder, by definition, involve aggres-sive, violent and/or unlawful behavior.

In the absence of comorbid substance-related disorders, most people with such major mental illnesses as affective dis-orders and schizophrenia are not violent. But data from the Na-tional Institute of Mental Health Epidemiological Catchment Area Study suggest that these diagnoses are associated with a higher rate of violence than that found among individuals who have no diagnosable mental illness. The MacArthur Violence Risk Assessment Study found this was only true for psychiatric patients with substance abuse (Steadman et al., 1998).

Table 19.20 lists risk factors for violence. As with suicide, the best predictor of future assault is a history of past assaultInformation from the psychiatric evaluation that helps in this as-sessment includes the present illness (e.g., preoccupation with vengeance, especially when accompanied by a plan of action), psychiatric history (e.g., childhood conduct disorder), family his-tory (e.g., exposure as a child to violent parental behavior), per-sonal history (e.g., arrest record), and the MSE (e.g., homicidal ideation, severe agitation). Other predictors of violence include possession of weapons and current illegal activities. There is considerable overlap between risk factors for suicide and those for violence.

Life-threatening Medical Conditions

It is essential to consider life-threatening medical illness as a po-tential cause of psychiatric disturbance. Clues to this etiology can be found in the present illness (e.g., physical complaints), family history (e.g., causes of death in close family members), medical history (e.g., previous medical conditions and treatments), physi-cal examination (e.g., abnormalities identified) and MSE (e.g., confusion, fluctuation in levels of consciousness). Laboratory assessment, brain imaging and structured tests for neuropsychi-atric impairment may also be essential.

Probably the most common life-threatening medical sit-uations that the psychiatrist evaluates are acute central nerv-ous system changes caused by medical conditions and accom-panied by mental status alterations. These include increased intracranial pressure or other cerebral abnormalities, seve metabolic alterations, toxic states and alcohol withdrawal. Pa-tients may be at risk of death if these states are not quickly identified.

External Threat

Some patients who present for psychiatric evaluation are at risk as a result of life-threatening external situations. Such patients can include battered women, abused children and victims of ca-tastrophes who lack proper food or shelter. Information about these conditions is usually obtained from the present illness, the personal history the medical history and physical examination.