The Anatomy of a Psychiatric Consult


Solving the Puzzle

July/August 2014


For many therapists, an air of mystery surrounds the role of psychopharmacology in mental health treatment. It seems like a parallel universe, standing apart from the usual concerns of psychotherapeutic encounters. In the interview below, psychiatrist Steven Dubovsky—author of Clinical Guide to Psychotropic Medications and chair at the University of Buffalo School of Medicine and Biomedical Sciences—offers a step-by-step tour of the complexities of the psychiatric consultation while exploring the overlap between psychopharmacology and psychotherapy.

What’s the process you go through when a therapist sends you a patient for a consultation?

Steven Dubovsky: For any condition, I go through an algorithm of the most likely causes of treatment being stuck. About 40 percent of the time, it’s because the patient’s diagnosis is incorrect, but sometimes people actually try to hang on to their diagnosis, especially if it sounds exotic. Some people say things like “I’m a rapid-cycling bipolar with mixed and psychotic features” with glowing pride, as if they’d happily write it on a name tag. Or, as if the consultation were some kind of show and tell, they might say, “I’ve got multiple personality disorder. Do you want to see some of my personalities?”

Since I always tell people that they can bring along anyone they want for the initial consultation, when I decide that the diagnosis isn’t correct, which I often do, I’ll ask…

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