How the mental health system loses its grip on comprehensive care.

Who’s responsible for full oversight of complex patient’s care?

In many mental health systems, sadly, the honest answer? No one.

A Typical Case

A 35-year-old woman meets with a psychiatrist for an intake. Her therapist discontinued care due to an illness. Over the past year she visited the emergency room and had several outpatient crisis visits with multiple psychiatrists. She has complex trauma (both sexual and physical) and is afraid to meet with a male psychiatrist without her husband present. Her husband needs to travel for business next month. She works in a daycare and has very recently developed panic attacks. Current medications: fluoxetine 60 mg, bupropion 100 mg, lamotrigine 200 mg.

The intake psychiatrist suggest voluntary hospitalization. The patient considers this, but declines. Instead, a referral to an online partial program is made. The program is busy scheduling an intake but asks whether they should take over managing her medications. Two weeks later, still waiting for the start of the program, the patient returns to the psychiatrist with panic attacks and is started on clonazepam 1.5 mg/day.

The Core Problem

This patient’s care involves many providers and lacks a designated treatment leader. No one is directing a comprehensive approach to her care. This is not a failure of individual clinicians. Rather, it’s a case of Diffusion of Responsibility. Most mental healthcare systems work this way. The result is reactive, episodic treatment, formulated by no one in particular.

Eight Pathway to Diffusion of Care and Responsibility

1. Multiple Providers Fragment Care

During the psychiatrist’s intake, information from her former therapist is lacking. As she is awaiting an appointment the partial program intake everyone assumes someone else is managing her care. The patient can easily fall through the cracks.

2. Absence of a Treatment Leader

Every case need a single clinician to lead. The psychiatrist should:

1. Create a longitudinal case formulation
2. Monitor progress
3. Keep the treatment on track.

Without a captain, treatment flounders and clinicians react to crises rather than focusing on long-term goals.

3. Poorly Constructed — or Absent — Treatment Formulation

Initial Case Formulation:

“Referral for therapy, partial program, medication management. Follow up in 2 weeks.”

This is scheduling care, not a proper a treatment plan. A solid formulation should answers these FIVE (5) questions:

1. Why is the patient seeking care now? What was the reasoning for past treatment approach? Was it working?
2. Who will quarterback the treatment plan and communicate with all clinicians?
3. What are her core psychological, biological, and social needs?
4. Where is the case formulation and treatment approach documented?
5. What is long-term outpatient treatment plan (while managing the acute care) and who is overseeing it?

Better Brief Formulation

The ‘why now’ is she lost her therapist, and the husband will be traveling. Should the husband go away? The acute problem is also panic attacks which needs a psychological focus and clonazepam, so she can function in the short term.

A trauma informed perspective suggests it may be helpful to transfer her to a female psychiatrist. Her complex trauma will eventually require cognitive processing therapy. Her diagnosis need to be clarified and her medications need to be reviewed for possible changes. The current appropriate level of her acute care is the partial hospitalization program (PHP). Long term care will be outpatient with a trauma focus so an appointment should be made.

4. Documentation that Describes Rather than Directs

Most progress notes focus on was said in session instead of a case formulation or long-term treatment goals. New clinicians often can’t discern the past clinical reasoning driving the case, which often leaves them starting from scratch. At best, the chart notes are fragmented; at worst, there is no case formulation at all.

5. Siloed Electronic Health Records

Different clinicians often use separate electronic medical record systems which are invisible to each other. The patient is left to describe their own treatment plan. Often, they miss the full picture of their plan for care.

6. Bystander Effect at the Institutional Level

When a patient deteriorates, each provider points to their own narrow role. The psychiatrist prescribes; the partial programs does therapy. The larger the team, the greater the diffusion — everyone assumes someone else is in charge.

7. Handoffs Without Transmission of Formulation

Transitions can be risky. In this case, no notes from the prior therapist arrived at intake and there was no obvious rationale for current medications. Each new provider starts from scratch, often repeating failed approaches.

8. Patient Complexity as Justification for Drift

Complex patients like this one — and others with personality disorder(s) and comorbid disorders, often receive the least coherent care. This “difficult patient” becomes an excuse for the lack of direction instead of being a reason to sharpen the case formulation and treatment approach.

The Clinical Consequence

The patient feels treatment as something happening to her, not for her. Without a formulation and a designated captain, the patient’s psychopathology fills the void: avoidance grows, resistance builds. Clinicians accommodate instead of confronting the challenges with a thoughtful and reasoned case formulation and treatment approach.

This is Part 1 of 2. Be on the lookout for Part 2 next week.

---

Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell

Psychiatrist, Psychoanalyst, Educator, and Supervisor Contact: Feinster@RobFeinsteinMD.com

Owner & Founder Empathian LLC ( An Online Mental Health Education Company) Empathian.com

Add me on LinkedIn