Abstract:
Because many psychiatric patients are seen in primary care settings, primary care medical records contain valuable information about their mental and psychosocial functioning. Accurate and complete documentation of psychiatric diagnoses, substantiated by the clinical content of office notes and collateral sources of information, is essential for proper treatment and medical error reduction. Primary care medical records should contain observations regarding the patient’s mental status, including any cognitive abnormalities, and the impact of the patient’s psychiatric disorder(s) on temperaments and aptitudes. The severity of psychiatric symptoms can be quantified using rating scales. Patients affected by anxiety, mood, stress, substance use, trauma, and comorbid medical and mental health disorders are commonly seen by primary care physicians. Treatment, whether provided by a primary care physician, psychiatrist, or psychologist, or combination of clinicians, should maximize the clinical effects of psychotherapy and pharmacotherapy for optimal outcomes.
Primary care physicians (PCPs) provide the de facto mental health system for the one in five adults who experience a diagnosable mental illness in any given year.(1) More adult Americans receive mental health treatment from PCPs than from psychologists or psychiatrists. In fact, PCPs are treating approximately one-third of their patients for mental health problems; however, they often lack the time, training, and resources to fully explore and document their patients’ histories and arrive at an accurate diagnosis.(2, 3) Diagnostic specificity has become increasingly important, not only for treatment decisions, but also because incorrect diagnoses are a leading cause of medical errors.(4)
Diagnosis
No agreed-upon method has been established in primary care practice for assessing or documenting psychiatric conditions. However, all would agree that psychiatric diagnoses listed in primary care medical records should be substantiated by factual data recorded in the office notes, collateral sources of information, and other documents comprising the medical record. The diagnoses should meet the clinical criteria described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).(5)
Anxiety and depressive disorders are the most common psychiatric diagnoses made by PCPs. However, terms such as “anxiety” and “depression” are symptoms rather than diagnoses. The symptoms may or may not correlate with generalized anxiety disorder (GAD) and major depressive disorder (MDD), which are the DSM equivalents.
Other common psychiatric disorders encountered in primary care practice include trauma- and stress-related disorders, bipolar disorder, attention deficit hyperactivity disorder, substance use disorders, and personality disorders. Personality disorders, in particular, are associated with high levels of mental health service utilization and a serious degree of psychosocial and occupational impairment.(6,7)
Borderline personality disorder, for example, is characterized by a long-term pattern of unstable relationships, impulsivity, recurrent suicidal behavior, mood instability, and intense, uncontrollable anger. These individuals are very sensitive to environmental circumstances. Yet many patients with borderline personality disorder are not informed about their diagnosis,(8) and many PCPs treating these patients fail to recognize the presence of borderline personality disorder.
Mental Status Examination
The PCP should document a comprehensive mental status examination in the office notes whenever a patient presents with a psychiatric complaint. Typically, the record shows only an abbreviated mental status examination that mentions the patient’s alertness, orientation, and memory. Additional important features that should be noted are speech, mood, affect, psychomotor behavior, thought processes and content, insight and judgment, and cognition (i.e., attention and concentration).
Specifically, it is important to note whether symptoms such as hallucinations; delusions; suicidal, homicidal, grandiose, or paranoid ideation; extreme mood swings; obsessions or compulsions; dissociative states; or significant cognitive deficits exist. These findings almost always warrant further investigation. The presence of suicidal ideation, in particular, should prompt a thorough self-harm assessment.
Neurocognitive Deficits
Major neurocognitive disorders (e.g., delirium, dementia, traumatic brain injury) may cause severe deficits in attention, concentration, planning, decision-making, learning and memory, and other cognitive domains. Neurocognitive disorders are unique among psychiatric illnesses in that their underlying pathology and etiology often are known.
Patients with anxiety and depressive disorders also may have cognitive deficits resulting in problems concentrating, focusing, and paying attention, but symptoms are mild in comparison to major neurocognitive disorders. Unfortunately, many primary care office notes do not contain objective data or measured assessments to clarify patients’ cognitive complaints or confirm the presence of a major neurocognitive disorder.
Mental Health Screening
Clinically observed or patient-reported cognitive difficulties can easily be assessed using a Mini-Mental Status Examination (MMSE) or Montreal Cognitive Assessment (MoCA). If these are positive, additional studies such as neuropsychological testing or neuroimaging may reveal an underlying neurocognitive disorder.
Common primary care screening instruments for MDD and GAD are the Patient Heath Questionnaire 9-item (PHQ-9) and the Generalized Anxiety Disorder 7-item (GAD-7), respectively. These rating scales often are administered together, because anxiety coexists in 30% to 50% of patients with depression.(9) A positive screen on the PHQ-9—a score of 10 or higher—should be followed by a comprehensive evaluation, as is true of all mental health screening questionnaires.
The PHQ-9 does not screen for bipolar disorder. Thus, when PHQ-9 scores are raised, additional questions should be asked to exclude bipolar depression. For example, has the patient had a previous manic or hypomanic episode, defined as an abnormally distinct and sustained period of elevated, expansive, or irritable mood and increased energy or activity, accompanied by symptoms such as grandiose thinking (or delusions), pressured speech, and decreased need for sleep? The Mood Disorder Questionnaire (MDQ) is a screening instrument developed specifically for evaluating signs and symptoms of bipolar disorder.
Diagnoses suggested by positive mental health screens must be investigated by more rigorous methods.
The problem with most screening tests, however, whether for cognitive, depressive, anxiety, or other disorders, is that they do not contain objective validity scales. Purely subjective test measures based on the patient’s self-report, with no validity component, do not diagnose mental health conditions reliably. Many rating scales are susceptible to overreporting, exaggeration, and even manipulation, which is why diagnoses suggested by positive mental health screens must be investigated by more rigorous methods, including in-depth clinical assessments.
Symptom Severity and General Functioning
Because psychiatric disorders often result in significant symptomatology, it is important to assess symptom severity. Of course, rating the severity of symptoms is a subjective process. At the very least, the PCP should document the frequency, intensity, and duration of specific symptoms of the patient’s mental health disorders, because these symptoms are indicators of the severity of the conditions. The documentation in the medical records should reflect whether symptoms are severe enough to interfere with the patient’s psychosocial functioning.
For example, the Global Assessment of Functioning (GAF) Scale considers psychological, social, and occupational functioning on a continuum of mental health illness from 1 to 100. Scores between 41 and 50 indicate serious symptoms or serious impairment in social, occupational, or school functioning. Dangerous behavior and behavior influenced by psychotic thinking is indicated by a score between 1 and 30 and requires immediate attention.
The Social and Occupational Functioning Assessment Scale (SOFAS) is a newer rating instrument that differs from the GAF Scale in that it focuses exclusively on the individual’s level of social and occupational functioning, omitting the severity of the individual’s psychological symptoms. Like the GAF Scale, a range of 1 to 100 is used. A score between 21 and 30, for example, denotes an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).
The field of psychiatry has long been criticized for its subjective approach to determining the severity of mental illnesses.
Although functional rating scales provide only estimates of symptom severity, attempts to quantify an individual’s level of functioning are important. There is no biological test that can measure psychiatric symptoms. The field of psychiatry has long been criticized for its subjective approach to determining the severity of mental illnesses, unlike other specialties that have fairly well established objective measures of impairment and functionality.
For the mental health field to stay relevant, it must adapt by developing empirical measures of well-being. In fact, with each revision of the DSM, criteria for the diagnoses of psychiatric disorders have been refined. Over time, objective, researched-based diagnostic criteria have been developed and now provide the scientific backdrop for understanding how individuals experience mental illness.
Temperaments and Aptitudes
PCPs should try to gain detailed knowledge of their patients’ temperaments and aptitudes (Table 1), because that knowledge provides a snapshot of the patient’s functioning in the real world. PCPs will consider whether the patient can think clearly and articulate facts and ideas. Is he or she able to follow specific instructions? What about the ability to direct, control, and plan activities?
Patients with severe mental health disorders usually have difficulty understanding, remembering, or applying information, as well as adapting to change and interacting with others. A mental health disorder affecting a patient’s ability to interact and cooperate with others, handle conflicts, and respond to suggestions and correction may be indicative of serious and persistent mental illness.
Activities of Daily Living
Until proven otherwise, it is assumed that patients are capable of eating, bathing, dressing, grooming, and other routine activities related to personal hygiene and self-care, so-called activities of daily living (ADLs). More complex skills—such as managing finances and medication, preparing meals, driving, and utilizing computers and handheld devices—are known as instrumental activities of daily living (IADLs). Both ADLs and IADLs should be documented in the medical records as intact, or not.
Patients with mental disorders severe enough to preclude ADLs and IADLs also will show notable deficiencies in most or all other life activities. It is very unlikely that a pervasive mental disorder would have little or no impact on ADLs and IADLs.
Stress and Trauma
Realistically, no individuals have personal lives that are completely free of stress. But stress-related problems in living—relationship discord, financial hardship, and parenting stress—as well as acute stress disorders due to trauma can result in significant morbidity, such as depressed and anxious mood, inability to experience pleasure and happiness, sleep disturbances and nightmares, and intrusive distressing memories and thoughts related to the stressors or trauma.
It may not be recognized that patients who seem medically well may be suffering from the psychological impact of medical trauma.
When assessing the effect of stress on an individual’s well-being, the PCP must determine whether there is an underlying mental illness contributing to or resulting from the stressors, or whether stress-related symptoms are present in an otherwise healthy individual and are expected to be transient. In the latter case, acute stress disorders usually resolve within one month, unlike post-traumatic stress disorder (PTSD), which may persist for years.(10)
It may not be recognized that patients who seem medically well may be suffering from the psychological impact of medical trauma. The nature and effects of trauma stemming from life-threatening medical events, chronic and life-altering illnesses, medical emergencies, and even some everyday procedures may result in PTSD.(11) Increasingly, catastrophic medical incidents are being recognized as traumatic events similar in scope to violence, accidents, natural disasters, war, and other experiences typically associated with PTSD.
The psychological impact of medical trauma remains largely undetected and untreated. However, PTSD is known to result in substantial psychiatric morbidity and impaired functioning across many domains—social, interpersonal, occupational, and educational—as well as considerable economic costs. PCPs are on the frontline of treatment and may be the first to recognize medically traumatized patients and advocate for their treatment by a mental health professional.
Comorbid Conditions
There is a high degree of comorbidity between mental and medical illnesses. In the 2003 National Comorbidity Survey Replication (NCS-R), more than 68% of adults with a mental health disorder had at least one medical condition, and 29% of those with a medical disorder had a comorbid mental health condition.(12) Classic examples are pain associated with major depressive disorder and cardiovascular disease associated with generalized anxiety disorder.
It is difficult, if not impossible, to disentangle psychiatric illness from medical conditions. PCPs must consider not only the psychiatric symptoms resulting from the patient’s medical conditions, but also the gravity of the medical illnesses, their prognoses, and any perceived loss of autonomy by the patient. Determining whether the degree of anxiety and depression associated with the patient’s medical symptoms is appropriate or disproportionate to the medical diagnoses is less important than determining whether the psychiatric symptoms are severe enough to necessitate treatment.
A related issue involves the loss of autonomy due to declining health, which often manifests in grief and bereavement. The grieving process associated with an individual’s physical decline may be understandable and considered appropriate for his or her stage of life. On the other hand, PCPs also should consider the presence of a major depressive disorder in patients grieving medical losses. Psychopathology may be marked in patients suffering from persistent bereavement related to their physical deterioration or thoughts of dying from a progressive or fatal disease.
Referrals
Although PCPs are adept at providing counseling and psychotropic medication for uncomplicated psychiatric patients, more seriously ill individuals usually require referral to a psychiatrist or psychologist, or both. The combination of pharmacotherapy and psychotherapy usually is more efficacious and beneficial than either modality alone.(13)
The most common arrangement today is “split” treatment, wherein a master’s-level counselor or doctorate-level psychologist provides psychotherapy, and a psychiatrist or psychiatric “extender” (e.g., specialized nurse practitioner or physician assistant) provides pharmacotherapy. Split treatment allows patients to spend more time in psychotherapy, enables better use of available resources, provides a greater choice of clinicians, and may enhance compliance with treatment.
PCPs who are well versed in the indications and adverse effects of psychotropic medication may substitute for the psychiatrist or extender, or use them as consultants. Effective collaborative relationships and cross-collateral documentation among providers is essential in split-treatment arrangements in order to avoid misperceptions and misunderstanding between clinicians and patients.
Conclusion
PCPs often are the first stop in the evaluation of patients with mental health disorders, and their clinical purview has expanded to include psychiatric treatment. At the same time that PCPs and patients are developing an increased understanding regarding the symptoms of mental illness, more patients are recognizing the need for quality care. The goal of treatment is to maximize the clinical effects of biological and psychotherapeutic treatments utilizing a team approach.
Primary care medical records should thoroughly document the mental health care of patients. At minimum, records should include a diagnosis that matches DSM-5 criteria; a full mental status examination; an assessment of ADLs/IADLs, temperaments and aptitudes, and psychosocial functioning; consideration of comorbid conditions; and a plan for care. Communication and continuity of care among clinicians involved in the patient’s treatment should be well documented.
PCPs using electronic health records should take great care to ensure that all data entries are contemporaneous and not the result of copy and paste errors. In a recent study,(14 )more than 80% of the notes were copied or imported from elsewhere, painting an inaccurate picture of the patient. Copy, paste, and import functions also resulted in redundant charting and significant “note bloat,” putting patients’ safety at risk due to unnecessary and outdated information.
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