Several physician groups can encounter the medico-legal risks of providing mental health care. With ongoing scarcity of access to psychiatric care in many regions of Canada, non-psychiatrists often step in to assess and manage patients’ mental health needs. An interdisciplinary approach, involving working with other health professionals (e.g. psychologists, social workers, nurse practitioners, etc.) can be an important component of making a diagnosis and providing appropriate care to a patient with mental health issues.
Complexities in mental health diagnoses
Establishing mental health diagnoses can be complex. Symptoms are predominantly self-reported during patient interviews, and objective measures and biomarkers of psychopathology remain underdeveloped.1 The cornerstone of diagnosis remains a psychiatric assessment and mental status examination by a physician or other trained mental health professional. The diagnosis can evolve or change between evaluations necessitating repeat assessments to avoid premature diagnostic closure.
In the CMPA review of files involving patients with mental health concerns, peer expert2 criticism underscored the importance of documenting thorough mental health histories and mental status examinations in the patient’s medical record, and of using known diagnostic criteria before arriving at a diagnosis. Patient complaints about diagnosis can be associated with clinical judgments affecting patient autonomy or employability (e.g. employer-directed independent medical examinations, involuntary hospital admissions, and fitness to drive assessments), and peer experts often note the impact of cognitive biases on diagnoses. Additionally, diagnostic overshadowing (when physical symptoms are misattributed to mental illness) was frequently observed.3
Case example: Misattribution of a worsening symptom delaying care
A rural family physician follows a middle-aged man for three years, after hospitalization for acute respiratory distress secondary to pulmonary edema. In addition to managing the patient’s severe coronary artery disease and nephropathy, the physician monitors his treatments for anxiety and depression. A period of rapid weight gain and poor glycemic control then coincides with job loss, and appointments with the physician increasingly focus on discussions of his unemployment, ongoing stressors, and feelings of lethargy. The physician documents the patient’s increased weight, but does not perform a physical examination, attributing the weight gain to the patient’s decreased physical activity secondary to his depression. Soon after an appointment predominantly focused on the patient’s mental status, the patient is hospitalized due to acute heart failure and renal injury, with prominent, generalized edema. He later dies in the intensive care unit.
A complaint is made to the College, and the College is critical of the physician’s failure to broaden her differential diagnosis to include medical causes for the patient’s weight gain. The College directs the physician to undertake remedial education on the management of patients with multiple comorbidities.
Challenges with referrals and the importance of follow-up
Physicians can experience challenges accessing psychiatric consultations and referrals for their patients, a situation that impacts regular follow-up and monitoring. It would be important to consider available options for virtual and in-person shared and collaborative care with other mental health professionals (including psychologists, social workers, and nurse practitioners, etc.) in providing appropriate care to these patients.
Peer expert reviews of CMPA files involving inadequate follow-up and referral for patients with mental health concerns emphasized considerations such as:
- Physicians should apprise themselves of support resources available in the community, such as counselling and social services, mental health crisis lines and mobile crisis teams, detoxification centres, shelters, and addiction services. This information can be provided to the patient as part of a follow-up strategy.
- Consultations should be pursued as needed, even if psychiatric access poses a challenge. These efforts should also be documented.
- When referrals are delayed, appropriate reassessment and monitoring by the referring physician may be required during the interim period. Reassessment of a patient’s mental health history and mental status should be performed regularly.
When access to consultations is limited, alternatives such as teleconsultation or virtual consultation may facilitate care. Physicians should evaluate such consultation services in advance, assessing whether information security safeguards are adequate and whether the services are appropriate for the specific patient.
Case example: Appropriate social service follow-up for a suicidal patient
A student with complex mental health and substance use disorders is evicted from her residence for alcohol-related disturbances. She presents to the emergency department multiple times over the course of a week. On each occasion, she presents intoxicated, with suicidal ideation, and is prescribed diazepam, IV fluids, thiamine, and multivitamins for alcohol withdrawal. She is suicidal only when intoxicated, and expresses a desire to access support resources in order to stop binge drinking. At her last visit, the emergency physician notes the multiple emergency department visits, and refers her to psychiatry. She is assessed by a psychiatrist, who notes no suicidal plans or intentions and clearly documents the mental status exam. On reassessment the following morning, she reports no further thoughts of self-harm or suicide, and is discharged with a follow-up psychiatric appointment, acceptance to a shelter, and information about detoxification resources. She is found three days later, having died by suicide.
The patient’s family initiates a legal action, alleging that inadequate assessment and failure to admit the patient resulted in her death. Peer experts are supportive of the care received, noting that, unless there is active suicidal ideation, the default treatment for patients presenting to the emergency department with suicidal ideation is to avoid admitting them to an inpatient psychiatric ward, and to refer them to community psychosocial resources, lodging facilities, and substance use rehabilitation programs. The case is dismissed.
Managing patients at risk for suicide
Peer experts reviewing medico-legal matters involving psychiatrists will often emphasize the importance of conducting and documenting an appropriate assessment of suicide risk. They also highlight the importance of collaboration with the patient in formulating a safety plan, particularly when physicians anticipate a change or transition in care, such as when planning to discharge a patient.
The bottom line
Coordinated care for patients with mental health concerns can be complicated, especially when access to psychiatric expertise is limited. Recommended practices for reducing medico-legal risk include relying on an interdisciplinary approach to care, conducting and documenting a thorough mental status assessment and following up with reassessments, familiarizing yourself with local social support services, and having an action plan when navigating consultation delays.
Additional reading
References
-
Krystal JH, State MW. Psychiatric disorders: Diagnosis to therapy. Cell [Internet]. 2014 Mar 27;157(1):201-214
-
Peer experts refer to physicians retained by the parties in a legal action to interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
-
Shefer G, Henderson C, Howard LM, et al. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms – A qualitative study. PLoS ONE [Internet]. 2014;9(11):e111682
