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The approaches to treatment of psychiatric patients are, in a broad sense, like those in other specialties of medicine. For example, clinicians use not only medical measures such as medications and pacemakers but also psychological techniques to change attitudes and behaviors, social and environmental manipulation to mitigate deleterious influences, and behavioral techniques to change behavior patterns.

Regardless of the methods used, treatment is directed toward an objective, ie, it is goal-oriented. This usually involves (1) obtaining active cooperation on the part of the patient, (2) establishing reasonable goals and modifying them if they are not met, (3) emphasizing positive behavior (goals) instead of symptom behavior (problems), (4) delineating the method, and (5) setting a time frame (which can be modified later).

The clinician should resist pressures for instantaneous results. Time must be spent with the patient, but the frequency and duration of appointments are highly variable and should be adjusted to meet both the patient's psychological needs and financial restrictions. Adherence (collaboration) is the end product of many factors, the most important being clear communication, attention to cost, and simple dosage regimens when medications are prescribed. The clinician can unwittingly promote chronic illness by prescribing medication inappropriately. The patient may come to believe that problems respond only to medication, and the more medications prescribed, the stronger the misconception becomes. Psychiatric medications are implicated in many adverse drug reactions treated in US emergency departments.

PSYCHIATRIC CONSULTATION

Most clinicians are in an excellent position to respond to their patients' emotional needs in an organized and competent way, referring to psychiatrists for consultation or for ongoing treatment of patients whose problems are considered beyond the expertise of the referring clinician. Common reasons for consultation include the following: (1) evaluating suicidal or potentially violent patients, (2) complex diagnostic problems, (3) behaviorally challenging conditions such as bipolar affective disorder or psychotic states (4) psychopharmacologically complicated cases, and (5) referrals for specialized psychotherapy or interventional psychiatric treatment.

When a psychiatric referral is made, it should be conducted like any other referral: in an open manner, with full explanation of the problem to the patient. For some patients, the prospect of a psychiatric consultation is frightening. The stigma of potentially having a psychiatric disorder is daunting for many patients. Most patients can acknowledge stress in their life and framing a consultation referring to a specialist who can help with the impact of stress on an illness can be helpful.

HOSPITALIZATION

Hospital care may be indicated when patients are too sick to care for themselves or when they present serious threats to themselves or others, when observation and diagnostic procedures are necessary, or when specific kinds of treatment such as complex medication trials are required. Symptoms calling for hospitalization may include significant self-neglect, violent or bizarre behavior, suicidal risk, and inability to care for oneself due to severe paranoid ideation or delusions. ...

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