From the Editor

Errors of omission and commission in psychiatric practice

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There are many rewards for full-time academic psychiatrists such as myself, including didactic teaching, clinical supervision, and 1:1 mentorship of freshly minted medical school graduates, transforming them into accomplished clinical psychiatrists. The technical and personal growth of psychiatric residents over 4 years of post-MD training can be amazing and very gratifying to witness.

But the road to clinical competence often is littered with mistakes. It is the duty of the clinical supervisor to convert every error into a learning opportunity to hone the skills of a future psychiatrist. Over time, fewer mistakes occur, not only because of maturity and seasoning, but also because psychiatric residents learn how to thoughtfully deliberate about their clinical decision-making to select the best treatment option for their patients.

Yet, even with exemplary training, the rigors and constraints of clinical practice inevitably lead to some unforced errors, mostly minor but sometimes consequential. Even experienced practitioners are not immune from making a mistake in the hustle and bustle of daily work (exacerbated by the time-consuming pressures of electronic health record documentation). No one is infallible, but everyone must avoid making the same mistake twice, even if mounting demands lead to “shortcuts” that may not necessarily put the patient at risk but could lead to suboptimal outcomes. But once in a while, a serious complication may ensue.

Here are some common errors of omission or commission that even competent practitioners may make in a busy clinical practice.

Rushing to a diagnosis. To arrive at a primary psychiatric diagnosis, all potential secondary causes must be ruled out. This includes systematic screening for possible drug-induced psychopathology related not only to drugs of abuse, but also to prescription medications, some of which can have serious iatrogenic effects, including depression, anxiety, mania, psychosis, or cognitive dulling. The other important cause to rule out is the possibility of a general medical condition triggering psychiatric symptoms, which requires targeted questioning about medical history, a review of organ systems, and ordering key laboratory tests.

Skipping a baseline cognitive assessment. Cognitive impairment, especially memory and executive function, is now well recognized as an important component of major psychiatric disorders, including schizophrenia, bipolar disorder, major depressive disorder, anxiety, and attention-deficit/hyperactivity disorder. A standardized cognitive battery can provide a valuable profile of brain functions. Knowing the patient’s cognitive strengths and weaknesses before initiating pharmacotherapy is essential to assess the positive or negative impact of the medications. It also can help with patients’ vocational rehabilitation, matching them with jobs compatible with their cognitive strengths.

Inaccurate differential diagnosis. Is it borderline personality or bipolar disorder? Is it schizophrenia or psychotic bipolar disorder? Is it unipolar or bipolar depression? Is it a conversion reaction or a genuine medical condition? The answers to such questions are critical, because inaccurate diagnosis can lead to a lack of improvement and prolonged suffering for patients or adverse effects that could be avoided.

Using a high dose of a medication immediately for a first-episode psychiatric disorder. One of the least patient-friendly medical decisions is to start a first-episode patient on a high dose of a medication on day 1. Gradual titration can circumvent intolerable adverse effects and help establish the lowest effective dose. Patient acceptance and adherence are far more likely if the patient’s brain is not “abruptly medicated.”


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