When ‘informed’ patients think they know what treatment is best

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In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

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