When you call the PCL, you receive written documentation of the recommendations made by the UW Psychiatrist you spoke with via email within one business day of the call. Below is an example consult note that shows the level of detail our psychiatrists provide.
You called about a man in his early 60s with a history of depression, anxiety and paranoia in recent years in the setting of major stressors. He saw a psychiatrist around that time, but the symptoms had resolved by then, and no treatment was started. The diagnosis at that time was unclear. He has been doing well and free of psychiatric symptoms until recently when he became depressed (low mood, anhedonia, some early morning awakening) and anxious. In addition, he has developed paranoid concerns about being followed. He does not have any hopelessness or suicidal ideation. He has had no aggressive behavior or ideation. He is not using alcohol. You are referring him to psychiatry, but wonder what to do in the meantime.
We discussed the following:
- We discussed that the diagnosis is unclear here, the symptoms sound like a major depressive episode with psychotic features rather than bipolar d/o. We discussed that given the late life onset of these symptoms with the presence of psychosis, neuroimaging would be a good idea. We also discussed that such symptoms can sometimes indicate an incipient neurocognitive disorder and that preforming cognitive screening such as MOCA every 6 months could be helpful.
- We also discussed that since the symptoms are most consistent with unipolar depression with psychotic features, SSRIs are first-line treatment. We discussed starting a very low dose of sertraline and titrating it up slowly while monitoring mood and sleep. Activation, decreased need for sleep and overall worsening would be worrisome and indicate the bipolar d/o is a more likely diagnosis. You would stop sertraline if these symptoms developed.
- We also discussed starting a very low dose of quetiapine at night to ensure sleep and help with paranoia (12.5 to 25 mg nightly). While this medication can have long term metabolic side effects, we would anticipate his taking this for a short period of time while the sertraline is being tried and he is waiting to see psychiatry. We discussed that any exposure to dopamine blocking medications can put a patient at risk for tardive dyskinesia. In addition, if he were found to have significant cognitive decline suggestive of neurocognitive disorder, it would be better to avoid antipsychotic use as there is evidence for an increased risk of death in patients with dementia who are treated with antipsychotics.
A suicide safety plan template that you may find useful for this or other patients can be found at: https://www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf
The care suggestions given above are based on information received over the phone. This advice should not supersede the best clinical judgment of you, as the in-person care provider. All suggestions regarding medications and other treatment or referrals should be implemented with consideration of the patient’s present clinical status and include patient preferences whenever possible.
Please feel free to call us at 877-927-7924 if there is anything else we can do to help you.