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Synopsis: Finding a good psychiatrist can be difficult and stressful. It's hard to know if online ratings are of any use or who can tell you who the good doctors are in your community. If you desire the best treatment, read this article on finding excellent psychiatric care and medication management as well as psychiatrist red flags to watch for.
BY LEN LANTZ, MD, author of unJoy / 1.8.2020; No. 8 / 7 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post also contains affiliate links. Please click this LINK for the full disclaimer.
How do you find a good psychiatrist?
I love technology, the internet, and computer-savvy people, but I have to break it to you. The internet will never tell you who the good psychiatrists are. This is because credentials, consumer rating sites and resumes do not reliably indicate quality. The spectrum of quality within psychiatric care is huge. This is due in part to limitations in science’s understanding of psychiatric illnesses and limitations of treatments that have been developed for psychiatric illness. High-quality psychiatric care is a combination of knowledge, competence and interpersonal skills. Anyone who tells you otherwise is ignorant or a liar.
All is not lost in finding a good psychiatrist. Word-of-mouth in your community can be a very effective means of finding the best psychiatrist near you. The next best method is to schedule an appointment with one or more primary care physicians and ask them point-blank, “Who are the best psychiatrists in our community?” If the primary care physician looks uncomfortable or defensive and starts to name psychiatrists who are only in their hospital system, they are giving you bad information. If they smile and seem relaxed and can easily name off the top one, two or three psychiatrists in your community, you are in luck!
What if the best psychiatrists in your community are not taking new patients?
At this point, your positive attitude, persistence and flexibility in paying for their services will likely win the day. First, you need to get on the waitlist. Waitlists never get shorter unless you are on them. If the psychiatrist you want does not have a waitlist, leave them a friendly, monthly voicemail to let them know you continue to desire to see them and are willing to get on the “waitlist for the waitlist.” It can take time to get in with a good psychiatrist for several reasons. One is that there is a dramatic shortage of psychiatrists in the US. Part of this is due to poor reimbursement by insurance companies and a lack of support from our federal government. The other difficulty is that the psychiatric workforce is an aging workforce. Currently, the average age of psychiatrists in America is 55 to 60. There is a growing workforce of psychiatric providers in the US, which mainly includes psychiatric nurse practitioners. Some psychiatric nurse practitioners are quite skilled and competent. To be clear, a psychiatrist is a medical doctor, therefore their medical training and experience are more extensive.
Duration of the visit
You should expect an initial psychiatric evaluation to take somewhere between 45 and 120 minutes. All psychiatrists are different in terms of how long they take for an initial evaluation, but if your psychiatrist has an initial evaluation lasting less than 45 minutes, you should be concerned about the degree of their thoroughness. You can expect a psychiatric follow-up visit to be 15 minutes at a minimum. Shorter visits would suggest that your psychiatric provider may not be fully evaluating the context and life circumstances of the symptoms you are sharing.
Use of rating scales
Not all psychiatrists utilize evidence-based rating scales, but if they do, they are more likely to be paying close attention to your progress and outcomes in an objective manner. They are more likely to notice and act on a small problem that is becoming a larger problem. This is because there is not measurable physical testing in psychiatry like there is in the rest of medicine. For example, if a person has high blood pressure, their actual blood pressure can be measured. Conversely, there is no instrument or “thermometer” that can be placed against a person’s head that could show a readout of “47% depression.” Psychiatric rating scales thereby assist psychiatrists in diagnostic assessment and in following the progress and improvement of someone’s mental illness.
How much time does your psychiatrist spend with you?
Does your psychiatrist know anything other than psychiatric medications? Can they talk with you about non-medication strategies for insomnia, depression, anxiety, binge eating, weight loss, panic attacks, ADHD, etc.? What do they know about research-based psychotherapies, relationships, parenting and work-related difficulties? You should expect your psychiatrist to know a lot about common life stressors and solutions for those stressors. If you ask for a nonmedication strategy, and your psychiatrist comes up empty, you should be concerned. However, even though there are nonmedication strategies for every condition under the sun, not all solutions are equally effective. At a minimum, your psychiatrist should be able to explain both psychiatric interventions and psychotherapy interventions for common mental health conditions. All psychiatrists should be trained in different evidence-based psychotherapies, however, not all psychiatrists perform psychotherapy. For example, in my small town, there are over 200 licensed psychotherapists and only a few psychiatrists. I have found that I am able to make a greater impact in my community by focusing on psychiatric diagnostic evaluation and medication management, even though I am skilled in psychotherapy.
When you bring up a concern to your psychiatrist, how often do they ask about what is going on in your life, what is new, and what are your thoughts about causes and solutions for your concern? No one knows you better than yourself, so you should be an active participant and decision-maker in your psychiatric care. Your opinions and conclusions matter and your psychiatrist should actively seek your input on your care.
How fast should medications be changed?
It can be a warning sign if a psychiatrist wants to start or change two or more medications at the same time. This is understandable if you are on an inpatient psychiatric unit, but if you are being treated on an outpatient basis, the standard approach is to change one medication at a time or switch from one medication to another. If you changed two medications at once and you got better, which medication was the cause of the improvement? The answer is: you don’t know. What if you change two medications at the same time and you have side effects? Which of the changes is causing your side effects? The answer is: you don’t know. Sometimes it can be frustrating if it seems like your psychiatrist is going very slowly in making changes, especially if you are suffering, however, a methodical approach in your treatment will give you better answers regarding how effective or ineffective each strategy is.
How to get your questions answered in a psychiatric visit
The best way to get your questions answered in a psychiatric visit is to bring up your questions and concerns at the beginning of the visit, no matter how the visit starts. For example, if the psychiatrist asks, “How is your day?” or “How have you been?”, it is okay to answer, “Fine, but I wanted you to know that I have several concerns that I want to make sure that we address in today’s visit.” A lot of people try to be patient and respectful to their psychiatrist and wait until their psychiatrist is done asking all their questions and it is their “turn” to ask their own, only to find that the appointment is over. It is perfectly fine for you to be bold and bring up your concerns at the very beginning of any appointment. It is not advised to bring up something important at the very end of the visit.
Timeliness of Follow Up
When medication changes are being made or you have continued symptoms or side effects, it’s really not okay for your psychiatrist to end the visit by saying, “I’ll see you in six months.” Visits should be often enough to assess the results of interventions and should only become less frequent after you are doing well.
Psychiatrist Red Flags
Your psychiatrist has the local nickname of “Candy Man.”
Your psychiatrist routinely cuts you off when you bring up critical issues and says, “I don’t want to hear about that issue” or “That’s something for you to talk about with your therapist, not me.”
Your first visit only lasts 15-20 minutes. Your follow-up visits last 5-10 minutes.
Your psychiatrist calls themselves a “psychopharmacologist” or “neuropsychopharmacologist”.
Your psychiatrist continues to refill your meds without requiring you to schedule an appointment.
Your psychiatrist moves to a new job or a new city every 1-2 years.
You have no reliable way of calling or talking to your psychiatrist between scheduled appointments or knowing when they will get back to you.
You have consistent trouble getting your prescriptions renewed.
Your psychiatrist’s only solution for any of your urgent needs between appointments is to call 911 or visit your local emergency room.
Your psychiatrist talks about a certain “cocktail” or combination of psychiatric medications that they “really like.”
Your psychiatrist has a prescription suggestion for every problem you bring up.
Your psychiatrist strongly encourages you to “smoke more weed.”
Your psychiatrist does a lot of independent insurance reviews to generate extra revenue.
Your psychiatrist has a picture of themselves on their website in casual clothing with their shirt unbuttoned halfway down their chest and a prominent gold chain around their neck.
Your psychiatrist invites you to their basement to watch the movie, The Silence of the Lambs.
Decent vs. exceptional care
There is a wonderful article titled “The Secrets of Super Shrinks” by an exceptional researcher and teacher, Dr. Scott D. Miller, who has looked at quality and exceptional care in mental health. He has studied what separates average or mediocre treatment from exceptional treatment and it appears to boil down to two distinct issues. To achieve superior outcomes, a person should be able to confidently say that:
“My psychiatrist listens to me. We have a good connection/fit.”
“I believe my psychiatrist can/is helping me.”
Both of these elements are needed to make good progress in treatment. If one of these areas is missing, a person is unlikely to achieve superior outcomes. Therefore, it is important for a person to have confidence in and a good interpersonal relationship (or a sense of connectedness) with their psychiatrist.
Why is it that the good psychiatrists don’t have room for new patients?
There is a reality that once a person finds a good psychiatrist, they never want to give them up, even when they are doing much better because their goal is to stay better! Having a psychiatrist who listens to you and is constantly seeking to help you can be inspiring and confidence building. Knowing that your doctor will return your phone calls and that your shrink has got your back if you run into difficulties can make all the difference in the world. You are paying for your medical care and you should expect the best. Spend time finding out who can give you the care that you need so that you can thrive, no matter what condition you face. You deserve the best and if you are patient and careful in your selection of doctors, you can receive exceptional care. A word to the wise: once you find the right doctor, don’t let go!
For further reading, check out:
My article “Finding Quality Psychotherapy – Moving Beyond Talk Therapy”
My article “Does a Psychiatric Diagnosis Even Matter?”
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the APA (See Len’s Book Review)
Shrink Rap: Three Psychiatrists Explain Their Work by Drs. Miller, Hanson and Daviss (See Len’s Book Review)