Give an example of when the regular clinician should treat a psychotic patient in a regular doctors office. At what point should the clinician refer the patient to a psychiatric doctor?
For the most part, there are not many examples where a general clinician should be treating a psychotic patient. One can make the argument that if the patient is brought to the clinician for an overall assessment or for a general checkup, then the regular clinician can assess the patient's status. This might be one of the only times when a general medical doctor should be interacting with a psychotic patient.
Part of the reason for this is because psychosis is a diagnosis of exclusion. The diagnosis has to be undertaken with outside consultation and referral in order to rule out other conditions that might be present: "Psychosis can be attributable to a combination of factors, and all possible causes must be systematically examined, hence the lack of a hierarchical organization in this nosology." Due to this reality, the need to examine "all possible causes" demands that the general practitioner must embrace outside consultation and external opinions at the outset. It is at this point that the clinician refers the patient to a psychiatric doctor.
There are psychiatric referral guidelines that all medical professionals must follow in treating psychotic patients. The most elemental of these is that the psychotic patient is most likely a threat to themselves or others. This makes referral almost immediate, something that cannot be delayed or deferred:
In general, the aims of psychiatric consultation in the medical/surgical setting are 1) to ensure the safety and stability of the patient within the medical environment, 2) to collect sufficient history and medical data from appropriate sources to assess the patient and formulate the problem, 3) to conduct a mental status examination and neurological and physical examinations as necessary, 4) to establish a differential diagnosis, and 5) to initiate a treatment plan.
These standards are not immutable laws. Rather, they are understood as principles that guide the general practitioner to help navigate the challenging terrain of interacting with patients and conditions outside their scope of expertise.
It is understood that patients who suffer from psychoses or psychotic breaks with reality might encounter a general clinician before they interact with a trained professional. Establishing a protocol that should be followed ensures that doctor and patient are protected in a zone of maximum development for both: "These guidelines are not intended to delineate universal, professionally mandated regulations and actions. Instead, they are meant to serve as an outline for the training and knowledge that are generally necessary to guide the clinician's approach to the patient." The psychotic patient is in need of help in the form of a distinct "treatment plan." In order to get them the help that is sorely needed, the general clinician must almost immediately refer to outside care and to a psychiatric doctor. In doing so, the general clinician upholds both their commitment to the patient in not doing harm and ensures that they are not endangering their own practice by interacting in a realm that might not be one of immediate training.
In the event that a patient presents with psychotic behavior in a regular office out patient setting, the proper protocol suggests that the physician should either immediately refer the patient to someone with a psychiatric background within their office, refer them to the nearest emergency room, or (depending on the severity of the psychotic behavior) admit them to a local inpatient facility. While it is technically within the power of most doctors and nurse practitioners to prescribe medications for a patient when they see fit, most anti-psychotic medications take at least 24 hours to kick in (some take as long as three weeks). In the case of psychotic behavior related to schizophrenia or a manic episode associated with bipolar disorder, the best course of action would be to get the person into an inpatient or hospital setting asap with follow up appointments scheduled with a licensed mental health professional as well as a prescribing physician.
A clinician can treat a psychotic patient in a regular doctor's office if they have a "more simple" type of psychotic disorder. A patient may have a brief psychotic disorder that can be due to a highly stressful event. In this case the disorder is temporary and they can recover quickly and may only need some medicines to help them get through until their body can return to homeostasis and the brain can release chemicals and hormones at normal levels again. Another time a psychotic patient can be treated in a regular doctor's office is when it is due to a substance-induced psychotic disorder. This is due to withdrawal from harsh drugs. They can be treated in a regular doctor's office to see that the drugs are continually out of their system as they recover. In this case, some people may need help with recovering if they had a strong addiction to the drugs.
A clinician should refer a psychotic patient to a more specialized doctor, such as a psychiatrist, if the root of the psychotic disorder is due to problems that need to be talked through or if they have a more severe disorder that may require the use of both drugs and therapy, or a more strict drug regiment. People who have schizophrenia, bipolar disorder, severe depression, a shared psychotic disorder, or any other disorder that is not due to a hormone/chemical imbalance should be sent to a psychiatrist or a specialized doctor.