How to Asses Mental Illness
The ability for patients to access mental health services these days are more wide ranging than ever before. This is in part due to the fact that the realm of mental health, once simply governed by physicians, is now peopled by staff of all different types and disciplines. In addition, many mental health professionals are now multiply credentialed, so it is not impossible to see a mental health professional who is all at once a family and marital therapist, a chemical dependency practitioner and a social worker.
All these elements only serve to improve the ability of patients/clients to receive quality mental health services, whether it be in a large institutional setting, a community mental health center or in a private clinical office. But what are the different types of mental health professionals who are trained in the identification and treatment of patients with mental health issues? There are many, but for the matter of clarity and brevity, we will focus on just three. Licensed clinical social workers are one type of mental health professional who may be assigned a clinical case.
These are individuals who have received graduate level training in the assessment and management of patients with mental illness. They may choose to specialize in a certain type of therapy, such as marital or family therapy or they may provide a more general practice. Clinical social workers are also found in the hospital setting, whether for psychiatric patients or medical patients and are experts in arranging for social services and referral to assisted living facilities, nursing homes, and other post hospitalization care.
Advanced registry nurse practitioners are one of the newer types of clinicians in the mental health field. These are nurses who have taken graduate level education which allows them to perform diagnosis and treatment for patients. Many nurse practitioners (also called ARNPs) can prescribe medications for their patients, depending on the laws of the states where they live. ARNPs are also unique in that they can open up clinical practices of their own without having to work under the auspices or licensure of a practicing physician.
ARNPs provide medication and counseling services, as well as crisis intervention services. ARNPs are also found frequently in both the inpatient and outpatient settings. Another type of professional who may diagnose and treat a patient with mental health issues is a clinical psychologist. These are men and women who receive post-graduate education and receive a doctorate in psychology. Psychologists are often called “doctor” but the difference is that they are not allowed to prescribe medications.
Psychologists are multifaceted, and are able to diagnose and treat patients with mental health issues, as well as perform and interpret psychological testing to held aid in the diagnosis of patients with personality or learning disorders. Psychologists are usually utilized in the outpatient setting, but it is not unheard of for them to work on an inpatient mental health unit as well. While all these different clinical backgrounds are able to assess patients for the presence of mental illness, the issues which they must consider are the same from patient to patient.
Whether the patient is a self-referral, court mandated or identified by a family member, before a true clinical diagnosis can be made, a thorough mental health assessment must be made. This mental health assessment includes several key issues which must be answered. First, the clinician must know what the problem is which brought the patient in for evaluation in the first place. Does the patient feel sad, or depressed, or anxious? To what degree does the mood problem affect the patient”s day to day life?
Are they able to go on about their daily business, or are they incapable of holding a job or caring for themselves or their families, because of the severity of the illness. Does the patient actually perceive there is a problem, or has the patient been referred by a medical provider, family member, or friend? The high coincidence of mental health problems and substance abuse makes it necessary for the mental health professional to assess if there is any drug or alcohol abuse issues here. How long has the patient had these symptoms, and are they getting worse, better, or staying the same.
A family history is also important, especially as it pertains to issues of mental illness within the family, or a history of physical/sexual or emotional abuse. Above all, when any mental health professional is assessing a patient for mental illness, he or she must assess if the patient has any thoughts of hurting himself or anyone else. This is almost the most important question to be asked of any patient who is being assessed for mental health problems, and when answered in the positive, must be dealt with immediately.
As we are discussing suicidal ideation, it is important for any clinician to understand who is at the greatest risk of self harm. There is a disparity in the rates of suicide between men and women, in that it is more likely for a woman to express thoughts of suicide and it is more likely for a man to actually commit suicide. In fact, men over age 45 are more than four times more likely than women to kill themselves as women in the same age (National Patient Safety Agency, 2001). An unemployed man is two to three times more likely to commit suicide.
Suicide is also believed to account for 20 percent of all death in young people aged 15-24 and is second only to accidental death. The prevalence of substance abuse in this age group tends to be a contributing factor to suicide rates. The additional issues of academic pressure and relationship problems, as well as possible history of physical and sexual abuse are other risk factors. Interestingly, research has also shown that youngsters who know someone who commits suicide are more likely to commit suicide (Shaffi, et. al. 1985).
While issues of race and likelihood to commit suicide have been studied, the pattern changes over geographic distribution. A study done in 1993 by Briget seemed to indicate that gay men and lesbians had higher rate of suicide and attempted suicide than the general population. And, as previously mentioned, research has shown that substance abuse is a significant risk factor for suicide and suicide attempts. One study estimated that among people who abuse drugs, the risk of suicide is twenty times greater than that of the general population (Faulkner, 1997)
Any discussion about mental health in the 21st Century is sure to bring some in some element of the Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA. HIPAA is a federal health benefits law passed in 1996, effective July 1, 1997, which among other things, restricts pre-existing condition exclusion periods to ensure portability of health-care coverage between plans, group and individual; requires guaranteed issue and renewal of insurance coverage; prohibits plans from charging individuals higher premiums, co-payments, and/or deductibles based on health status.
It also places strict limits on the type and amount of information which can be released about patients, and to whom the information can be given, and in what manner. While the privacy of patient care information is important, HIPAA can be a stumbling block to the care of patients. For example, should the patient refuse that any collateral information be obtained about his case from a family member or friend, the mental health professional is prohibited by law from making any contact with this person, even if the collateral information could be of help in the care and diagnosis of the patient.
In addition, it makes it almost impossible for family members to make appointments or even ascertain that patients are getting care. Health care providers are given leeway in one manner, in that should a mental health patient make what is felt to be a credible threat against another person, the healthcare provider is then able to provide information about the threat to the person in the broadest possible terms, known as a “duty to warn”.
Usually now, before a mental health professional takes on a case, he or she will have the patient sign a document explaining the patient”s rights and the clinician”s responsibilities under HIPAA. In this document, the clinician outlines most common reasons for which the clinician may have to release information about the patient”s care, such as coordinating care with another provider or even obtaining coverage information from the insurer. The patient is also generally advised that he or she may revoke all authorization at any time, but in turn the clinician may choose to discontinue treatment.
In this way, both parties are protected. It should be noted, however, that HIPAA restrictions do not apply in cases where abuse is suspected, for clinical health oversight activities, for judicial reasons if evaluations are court ordered, and in cases where the care involves a workman”s compensation issue. The clinician must also provide to the patient a name and number of a person to who concerns about privacy violation may be addressed, and if all else fails, complaints may be made to the Department of Health and Human Services, the federal agency which oversees HIPAA.
But should a mental health professional be incautious about the kind of information he or she chooses to release, then he or she may find that they are subject to high fines, sanctions from federally funded agencies and loss of clinical privilege. To me, HIPAA seems like the extreme end of the pendulum, and does little to take into account common sense. I believe that in the future, different legislation will be made to modify the tone of HIPAA and allow a bit of clinical common sense to be used as well.
Until that time, mental health practitioners will have to tread lightly and practice with care, keeping in mind at all times the needs of the patient and the rule of the law. So in summary, there are many kinds of mental health professionals, of all different backgrounds and disciplines. It would not be difficult to find a therapist or other mental health professional that would be able to help a client with his or her problems. All are highly qualified.
All receive excellent training, and the high degree of diversity allows the mental health patient to almost have a consumer attitude when shopping for mental health care. No matter what kind of practitioner a patient chooses, the patient should be sure that he or she has chosen one who is well versed in the diagnosis and treatment of mental illness. New laws put into affect do much to protect the rights of the patient, but in some ways can tie the hands of the clinical provider. But ultimately, rules are in place to protect both the patient and the practitioner.
