A. Privacy and Confidentiality

Considerations of privacy and confidentiality are an integral component of any psychiatric encounter. Aspects of privacy and confidentiality relating to communication with other medical professionals and with sources of collateral information have been discussed above ( Sections I.A , I.B, II.C, and IV.A.2). In general, the default position is to maintain confidentiality unless the patient gives consent to a specific intervention or communication. However, the psychiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the patient and others (10, 11). This includes the ability to communicate necessary information about the patient to medical personnel in the context of an emergency situation. It is also permissible for the psychiatrist to listen to information provided by family members and other important people in the patient's life, as long as confidential information is not provided to the informant.

The Health Insurance Portability and Accountability Act (HIPAA) contains guidelines for release of the results of psychiatric evaluations. State laws may be more restrictive, and if so, state laws take precedence over HIPAA. According to HIPAA, information can be released without a specific consent form for purposes of "treatment, payment, and health care operations." Otherwise, patients must sign an authorization form that indicates the information to be used or disclosed, the purposes to which it will be put, the recipient of the information, and an expiration date. HIPAA gives special protection to psychotherapy notes if they are kept in a separate part of the medical chart (193, 194). The interpretation of HIPAA and other federal and state laws about confidentiality continues to evolve, and legal or risk management consultation should be sought if there are questions about the regulations related to release of information and protection of psychiatric records (195).

For individuals in treatment for substance use disorders, the provisions of 42 CFR '§2.11 will apply (196) and will generally be more strict and supersede the provisions of HIPAA (197). As with HIPAA, necessary information may be disclosed to medical personnel in the context of treating a condition that poses an immediate threat to the health of any individual and that requires immediate medical intervention. Under such circumstances, documentation in the medical record needs to include "the name of the medical personnel to whom disclosure was made and their affiliation with any health care facility; the name of the individual making the disclosure; the date and time of the disclosure; and the nature of the emergency" (42 CFR '§2.51 [196]).

Medical records may also be viewed by others in addition to the clinician writing the note (198) or other members of an interdisciplinary treatment team. These include third-party payers, quality assurance/peer review evaluators, the patient, and, in certain jurisdictions, the executor of an estate after a patient's death. Furthermore, records may be part of future or current legal or administrative hearings, including disability litigation, divorce and custody adjudication, competency determinations, and actions of medical licensing boards. Such accessing of patient's medical records needs to be taken into consideration when documenting the evaluation, formulation, diagnosis, and plan of treatment.


B. Interactions With Third-Party Payers and Their Agents

Third-party payers and their agents frequently request data from psychiatric evaluations to make determinations about whether a hospital admission or a specific treatment modality will be covered by a particular insurance plan. Despite the blanket consents to release information to payers that most patients must sign to obtain insurance benefits, it is useful for the psychiatrist to obtain, whenever feasible, contemporaneous consent for such communications. In some instances, it may be necessary to inform the patient what specific information has been requested and obtain specific consent for the release of that information. With valid consent, the psychiatrist may release information to a third-party reviewer, supplying the third-party reviewer with sufficient information to understand the rationale for the treatment and why it was selected over potential alternatives. However, the psychiatrist may also withhold information about the patient not directly relevant to the utilization review or preauthorization decision (199, 200).


C. Legal and Administrative Issues in Institutions

When a patient is admitted to a hospital or other residential setting, the patient's legal status should be promptly clarified to establish whether the admission is voluntary or involuntary, whether the patient gives or withholds consent to evaluation and recommended treatment, whether the patient appears able to make treatment-related decisions, and whether an advance directive is in place. If there is a potential legal impediment to necessary treatment, action should be taken to resolve the issue.

The decision to hospitalize a patient involuntarily will depend on multiple factors, including the estimated level of risk to the patient and others, the patient's level of insight and willingness to seek care, and the legal criteria in that jurisdiction. In general, patients at risk for causing harm to themselves or others will satisfy the criteria for involuntary admission; however, the specific requirements vary from state to state (201), and in some states, willingness to enter a hospital voluntarily may preclude involuntary admission. To that end, psychiatrists need to be familiar with their specific state statutes regarding involuntary hospitalization.

Advance directives are attempts to ensure that individuals' wishes about treatment will be honored. Such directives may relate to wishes about treatment at the end of life (202) but may also relate to wishes about psychiatric treatment (203) or assignment of a durable power of attorney or health care proxy to make decisions in the event that the individual lacks capacity to do so (204). Although the specifics of advance directive regulations vary by jurisdiction, psychiatrists should include in their evaluation whether the patient has executed an advance directive—and, if so, the nature of the advance directive should be determined.

In every institution, whether public or private, fiscal and administrative considerations limit treatment options. Usually there are constraints on length of stay and on the intensity of services available. Further constraints can arise from the absence or inadequate funding of aftercare services or of a full continuum of care. The initial assessment of treatment needs should not be confounded unduly with concerns about financing or availability of services, although the actual treatment may represent a balancing of optimal treatment and external constraints. A common example is the situation in which a patient's safety requires a level of supervision not available in a given facility. Another example is when a patient requires a general medical evaluation that cannot be carried out in a free-standing psychiatric facility and requires the patient's transfer to a general hospital. If such issues result in a major negative effect on patient care, efforts should be made to find alternatives, and the patient, family, and/or third-party payer should be informed of the limitations of the current treatment setting and/or resources.


D. Special Populations


1. Elderly patients and patients with medical conditions

While advanced chronological age alone does not necessitate a change in the approach to the psychiatric evaluation, the strong association of old age with chronic disease and related impairments may increase the need for emphasis on certain aspects of the evaluation. The general medical history and evaluation, cognitive mental status examination, and functional assessment may need to be especially detailed because of the high prevalence of disease-related disability, use of multiple medications, cognitive impairment, and functional impairment in older people. The psychiatrist should attempt to identify all of the general medical and personal care clinicians involved with the patient and to obtain relevant information from them if the patient consents. It is also helpful to obtain information from the family.

The personal and social history includes coverage of common late-life issues, including the loss of a spouse or partner, the loss of friends or close relatives, residential moves, the new onset of disabilities, financial concerns related to illness or disability, and intergenerational issues, such as informal caregiving or financial transfers between members of different generations. It is important to evaluate intergenerational strains such as midlife couples with young children who cannot care for elderly relatives or, increasingly, patients in their 90s whose children are now in their 70s and ill themselves.

The psychiatrist may need to accommodate the evaluation to patients who cannot hear adequately. Use of sign language interpreters, amplification, a quieter interview room, and enabling lip reading are possible means to do this. When an elderly patient is brought for psychiatric evaluation by a family member, special effort may be necessary to ensure that both patient and family member have an opportunity to talk to the psychiatrist alone.


2. Incarcerated persons

Increasing numbers of individuals with mental illness are incarcerated in jails, prisons, and other correctional facilities and require psychiatric evaluation (205–208). In addition, suicide is one of the leading causes of death in correctional settings, and urgent suicide assessments may be needed for individuals at risk (11, 209, 210).

The psychiatric evaluation of incarcerated individuals will include the general elements common to any psychiatric evaluation (211–213) but will place additional emphasis on aspects of the individual's alcohol and substance use history and legal history, including previous episodes of incarceration and associated behavioral changes. Psychosocial stressors, including new legal complications (e.g., denial of parole), receiving bad news about loved ones at home, and experiencing sexual assault or other trauma, are also important to assess, as these may increase the likelihood of suicidal behaviors (214). Similarly, the recentness of the incarceration (210, 214, 215) or placement in isolation (216–219) may be relevant to determination of suicide risk. Depending on the likely duration of incarceration, options for care following transfer between correctional institutions or for aftercare following release may also need to be explored as part of the evaluation.

Access to space that allows for auditory privacy and physical safety is necessary to adequately perform psychiatric evaluations in correctional settings (212).


3. Homeless persons

Evaluations of persons who are homeless may require both modifications of the evaluation process and unique interviewing skills. The disengaged lifestyle and mistrust often encountered in homeless persons may make a classically direct approach difficult if not impossible (220). As a result, the first step toward psychiatric evaluation is engagement. This process can take from days to years in nonclinical settings (e.g., on the street, under bridges, in shelters). Evaluation becomes possible when the homeless person believes that engaging with the psychiatrist will not recapitulate previous negative experiences, lost opportunities within the health care system, and encounters in jail and prison that heighten a fear of consequences from talking honestly. By necessity, then, the full psychiatric evaluation of homeless persons typically unfolds over numerous, often brief, and seemingly casual interactions.


4. Persons with mental retardation

The evaluation of individuals with mental retardation presents a number of clinical challenges. Although psychiatric illnesses occur at increased rates in those with mental retardation (221, 222), it is not always possible to establish a definitive axis I diagnosis as a cause for behavioral symptoms (223). Depending on the extent of the patient's intellectual limitations, the diagnosis of mental retardation may have been unrecognized before the behavioral symptoms began.

In interviewing individuals with mental retardation, particular attention needs to be given to the phrasing of questions so that they will be understandable to the patient. The use of general psychiatric self-report scales or other structured interview formats may be problematic in this regard (221, 224). Behavioral observations or functional measures will often carry a greater weight in the assessment process, and patients with more severe mental retardation may be unable to report on their own mental experiences (225, 226). Thus, obtaining a comprehensive description of symptoms, signs, and aspects of history from family members, caretakers, and other professionals is often crucial. This is particularly true when persons with mental retardation present for evaluation in the context of a behavioral crisis, because otherwise minor events (e.g., changes in routine, upsetting interpersonal interactions) may be quite distressing and result in catastrophic reactions. Similar issues with evaluation may be observed in individuals with other developmental disabilities.

Evaluation for co-occurring general medical conditions is particularly important in adults with mental retardation, given higher rates of undetected medical illnesses (222, 227) as well as the tendency for atypical clinical presentations of medical illnesses (140, 227).


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