Three Clinical Pearls That Enhance My Practice

I had the pleasure of attending the Psych Congress annual meeting for the first time in September in Orlando. Having attended the American Psychiatric Association (APA) three years in a row, I was looking forward to something more manageable logistically and more clinically focused. I was also looking forward to a quiet, beautiful setting.

The Psych Congress fulfilled my expectations on all accounts. The resort was expansive, lush, and green, and I didn’t mind that it rained every day. I attended a number of sessions on psychopharmacology, which provided a great review and update, and I learned about fascinating outcomes research related to exercise, mindfulness, and depression. The presentations were a useful adjunct to my training and I found myself wishing that my fellow residents could be there too.

I’d like to share a few pearls that I brought home and am already incorporating into my practice.

1. Measurement Based Care – Though I did not attend the session devoted to this topic, the theme of measurement recurred throughout the conference.  While I’m not yet administering the PHQ-9 during every patient visit, I’m finding it a helpful adjunct to my normal assessment.  For example, if a patient says she is “not that depressed” but is crying in my office… the PHQ-9 can help me tease out severity.  I have also appreciated that it provides patients a second opportunity for patients to tell me about suicidal ideation. I look forward to using it to monitor recovery and remission as well.

2. Diagnostic uncertainty is OK – Differentiating ADHD and bipolar disorder, for example, can be quite challenging, and I don’t need to feel pressured to make a definitive diagnosis in the first appointment. It may take time to figure out what is going on.  I tried this recently in a longstanding clinic patient with a host of chronic and disabling complaints, none of which have been especially responsive to treatment.  Since nothing much seemed to help, this patient was not taking any medications.  In our next appointment, I reviewed her history in more depth. Though by the end, I did not yet have full clarity about her diagnosis or plan, she seemed appreciative of my attention and desire to consider her case carefully and accurately.  This also built trust and eventually opened the door for her to try a new medication.

3. Insights into Suicidality - Being suicidal is a state of extremely high physiological arousal that renders a person incapable of utilizing their full capabilities of executive function.  It’s a state of profound emotional pain. While perhaps there are variations on this theme, it helped me to think beyond the cognitive dimensions of suicidality and to understand this mental state more deeply. In his session on the topic, Eric Arauz emphasized the importance of connecting with patients on an emotional level and helping them calm their physiological distress.

Other high points for me included Maria Muzik’s session on peripartum mood disorders and George Grossberg’s presentation on managing behavioral issues in the elderly. I also really enjoyed Saundra Jain’s talk on evidence-based ways to promote wellness.

What were your favorite sessions this year?  Any “pearls” that you have taken away?

References

1. Zimmerman M. Measuring Quality: Why You Should Do It and How You Can Do It. Presentation at the 27th Annual U.S. Psychiatric and Mental Health Congress; September 20, 2014; Orlando, FL.

2. Jain R, Maletic V. Two, Too: Commonly Confused Disorders: Differentiating ADHD From Bipolar Disorder. Presentation at the 27th Annual U.S. Psychiatric and Mental Health Congress; September 20, 2014; Orlando, FL.

3. Arauz A, Greene P. Suicide Treatment: Models of Relationships That Work. Presentation at the 27th Annual U.S. Psychiatric and Mental Health Congress; September 20, 2014; Orlando, FL.

Leigh Jennings, MD, is a senior psychiatry resident in the Department of Neurology and Psychiatry at Saint Louis University School of Medicine.