Psychiatric Consultant Role and Job Description

The Psychiatric Consultant supports the prescribing medical provider and Behavioral Health Care Manager in treating patients with behavioral health problems. They will typically consult with the Behavioral Health Care Manager on a weekly basis to review the treatment plan and provide treatment suggestions for patients who are new or not improving as expected.

The resource below includes a PDF of a comprehensive description of the duties, responsibilities, resource requirements and typical workload of a Psychiatric Consultant.

PHQ-9 Depression Scale

The PHQ-9 is the nine item depression scale of the patient health questionnaire. The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV. The PHQ-9 can function as a screening tool, an aid in diagnosis, and as a symptom tracking tool that can help track a patient’s overall depression severity as well as track the improvement of specific symptoms with treatment.

Advantages of the PHQ-9

  • Shorter than other depression rating scales
  • Can be administered in person by a clinician, by telephone, or self-administered by the patient
  • Facilitates diagnosis of major depression
  • Provides assessment of symptom severity
  • Is well validated and documented in a variety of populations
  • Can be used in adolescents as young as 12 years of age

Using in Primary Care

The PHQ-9 has been mostly validated in primary care environments but has also been used successfully in Behavioral Health Centers. It can be self-administered or clinician-administered. At the initial visit for depression care the PHQ-9 is used to assist with diagnosis and identification of problem symptoms. At the follow-up visit, the PHQ-9 is used to measure treatment response and identify specific symptoms that are not responding.

Scoring the PHQ-9
Research has shown that certain scores on the PHQ-9 are strongly correlated with a subsequent major depression diagnosis. However, not everyone with an elevated PHQ-9 is certain to have major depression. The PHQ-9 is intended as a tool to assist clinicians with identifying and diagnosing depression but is not a substitute for diagnosis by a trained clinician.

Patient Health Questionnaire 2 (PHQ-2)
This is used by some clinicians and organizations to screen patients for undiagnosed depression. The PHQ-2 consists of the first two questions asked on the PHQ-9. If the patient responds affirmatively to either of the two items on the PHQ-2, the following seven questions on the PHQ-9 are asked. This can be a particularly effective way to screen large groups of people for depression. No permission is required to reproduce, translate, display or distribute the Patient Health Questionnaire (PHQ-2).

Patient Health Questionnaire 9 (PHQ-9) 
The PHQ-9 and related resources are available at www.phqscreeners.com. This includes translations of the measure as well as an instruction manual. No permission is required to reproduce, translate, display or distribute the Patient Health Questionnaire (PHQ-9).

Helping Clinic Staff Talk about the PHQ-9
This tool is designed to help clinic support staff with answers to common questions they may hear from patients to help increase their comfort talking with patients about the PHQ-9.

PHQ-9 Visual Answer Aid   English | Spanish 
This answer aid is a visual representation of the PHQ-9 answer scale.

Protocols for Suicide Prevention In Primary Care 
When a patient scores positive on question 9 of the PHQ-9, it is important to have plan for how to respond. This guide helps primary care clinics to refine existing protocol(s) for responding to patients presenting with suicidality or violent behavior in a primary care clinic.

Alternatives to the PHQ-9

The AIMS Center is of the opinion that what screening and tracking tool you choose in your setting is less important than that there is one; the important piece is that you have something in place that promotes “measurement-based treat to target” care – that is, keeping track of patient symptoms and problems and systematically tracking whether or not the treatments are helping. Several depression screening instruments have been developed and validated for use in primary care and other settings. Instruments vary by whether they are self- or interviewer-reported and applicable to patients with cognitive or language barriers.

The Geriatric Depression Scale (GDS)
This self-report instrument has been studied in multiple settings. There is a five-item version and a 15-item version of this measure. (The 15-item measure has excellent psychometric properties when compared to a structured diagnostic instrument in a sample of functionally impaired, cognitively intact, community-dwelling primary care patients.)

The Center for Epidemiologic Studies Depression Scale
This is one of the most common instruments applied in community studies and also used in primary care settings.

Cornell Scale for Depression in Dementia
This incorporates both observer and informant based information and is helpful in evaluating cognitively impaired patients for depression.

Children’s Depression Inventory
The Children’s Depression inventory (CDI) is a validated depression screener for kids ages 7 -17. It can be used in both clinical and educational settings.

Comparing Collaborative Care to Usual Care

Compared to usual care, Collaborative Care is shown to increase the effectiveness of depression treatment and lower total healthcare costs. This handout outlines those differences using data from the IMPACT trial.
Updated 1/2/19

Measurement-Based Treatment to Target

Effective behavioral health integration implementations are informed by measurement-based care and treatment to target. The evidence supporting the effects of these principles is derived largely from the research done on Collaborative Care.

Measurement-Based Care

Using clinical outcome measures is a relatively new idea in the world of behavioral health yet has been in other areas of health care for decades. Every time a patient visits a primary care clinic, someone takes their blood pressure. Increasingly, primary care practices and some behavioral health organizations are using this same principle to screen for the most common behavioral health conditions such as depression or anxiety.

A literature review, led by John Fortney, PhD, examined theoretical and empirical support for measurement-based care (MBC) and found that MBC is at a tipping point in the mental health care field. In addition to the publication, there is a video of Dr. Fortney summarizing the article.

There are a variety of well validated measures that can help identify behavioral health conditions and some track treatment progress over time. The Meadows Mental Health Policy Institute published a comprehensive report outlining a set of validated outcome measures for mental health and substance use conditions. These measures can play an important role in identifying people who may not otherwise be recognized as needing care for a behavioral health condition. However, their most important role is measuring the effect of treatment on symptoms. Once a patient has been identified as having a behavioral health condition and has started treatment for that condition, it’s very important to re-measure the symptoms at each contact so that the treating provider has specific information about whether or not symptoms are improving and which symptoms are or are not improving.

Some people are concerned that the concept of measuring mental health with a validated rating instrument invalidates the patient’s feelings or experience or disregards the complexity of the patient’s story. These measures are an important piece of information about the patient but are not meant to represent the entire clinical picture of the patient, nor are they meant to replace the clinical judgment of the provider. They are an important tool to assist the clinician and the patient with identification of the specific symptoms causing difficulty for the patient and how well those symptoms respond to treatment over time.

Treatment to Target

Adjusting the treatment plan based on symptom measures is one of the most important components of Collaborative Care. Clinicians change the treatment until the patient has at least a 50% reduction in measured symptoms.

Frequent measurement of symptoms allows the treating providers and the patient to know whether the patient is having a full response, partial response or no response to treatment. These measures also provide clues about which symptoms are improving and which are not if there is a partial response to treatment. This information is critically important in making decisions about how to adjust treatment.

Collaborative Care requires a change in the treatment plan every 10-12 weeks if the patient has not had at least a 50% improvement in symptoms using a validated measure. This prevents the clinical inertia that is often found in usual care and is likely one of the key factors behind the better treatment outcomes that can be achieved with Collaborative Care. If the treatment plan started with medication therapy as the primary treatment, the adjustment might be a change in dosage and/or the addition of evidence-based psychotherapy. If the treatment plan started with evidence-based psychotherapy, the adjustment might be the addition of medication therapy.

AUDIT-C

The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument.

Generalized Anxiety Disorder subscale (GAD-7)

The Generalized Anxiety Disorder (GAD) subscale of the Patient Health Questionnaire (GAD-7) is a quick and easy tool to help identify patients with anxiety and monitor treatment response. The GAD-7 is available free for clinical use in a variety of languages at the link below.

Resource Document on Risk Management and Liability Issues in Integrated Care Models

For psychiatrists considering future roles in integrated care systems, it is important to clarify malpractice liability when providing advice about care for patients for whom the psychiatrist may not be the primary prescriber. This resource document provides background information on medical malpractice cases, defines the doctor-patient relationship, distinguishes the different forms of consultation offered to primary prescribers, describes the duty of the psychiatrist across the spectrum of roles on a patient care team, and, finally, makes recommendations to reduce the risk of malpractice issues.

Concise Psychotropic Medication Prescribing Directions

This is a collection of prescribing protocols for commonly prescribed psychotropic medications used for treating adult patients.

The protocols are succinct and tailored to the outpatient setting. These prescribing protocols integrate information from several sources: clinical experience in Collaborative Care; each medication’s FDA labels (available here); published literature; and practice guidelines, including reviews of the Agency for Healthcare Research and Quality National Guideline Clearinghouse. The protocols were organized into three sections: dosing information, monitoring, and general information.

It is important to consider the limitations of these protocols in addition to their utility. Broadly speaking, these prescribing protocols are intended to facilitate the best possible prescribing practices in the outpatient setting. They should always be used with discrimination and, where questions arise (e.g., as new prescribing information comes out about a medication), in consultation with a pharmacist and current FDA drug label guidelines.

This resource will be retired on 8/31/23.

Example Disclaimer for Psychiatric Consultants

It is important to clarify malpractice liability when providing care advice to patients where the psychiatrist may not be the primary prescriber. An example disclaimer regarding EMR reviews is below. Pairing this information with the name and contact information of the Psychiatric Consultant makes it easy to facilitate communication about recommendations. To the AIMS Center’s knowledge, this type of disclaimer has not been tested in a court case.

“The treatment considerations and suggestions in this case review are based on consultations with the patient’s Behavioral Health Care Manager and a review of information available in the care management tracking system. I have not personally examined the patient. All recommendations should be implemented with consideration of the patient’s relevant prior history and current clinical status. Please feel free to call me with any questions about the care of this patient.”

The Resource Document on Risk Management and Liability Issues in Integrated Care Models provides additional information on liability issues.