4062F Patient referral for psychotherapy documented (MDD, MDD ADOL)

Name of the Procedure:

Patient Referral for Psychotherapy (MDD, MDD ADOL)
Common Name(s): Therapy Referral, Counseling Referral
Technical/Medical Terms: Psychotherapy Referral for Major Depressive Disorder (MDD)

Summary

This procedure involves a healthcare provider referring a patient to a mental health specialist for psychotherapy. It is commonly used for patients diagnosed with Major Depressive Disorder (MDD), including adolescents (MDD ADOL).

Purpose

This referral aims to provide the patient with specialized mental health support to manage and treat Major Depressive Disorder. Expected outcomes include improved mood, coping mechanisms, and overall mental health.

Indications

• Persistent feelings of sadness or depression lasting more than two weeks.
• Loss of interest in activities once enjoyed.
• Significant change in weight or appetite.
• Difficulty sleeping or oversleeping.
• Fatigue or lack of energy.
• Patients diagnosed with MDD who have not responded to initial treatments.

Preparation

• No specific preparation is required for the referral itself.
• Patients may need to complete a mental health assessment questionnaire.
• It is helpful for patients to have a list of current medications and previous mental health history available.

Procedure Description

1. Initial Consultation: The primary care provider or specialist conducts a thorough evaluation to confirm the diagnosis of MDD.
2. Referral Decision: Based on the evaluation, the provider decides that psychotherapy would benefit the patient.
3. Referral Documentation: The provider fills out a referral form, which includes details about the patient’s condition, symptoms, and previous treatment history.
4. Coordination: The referral is sent to the chosen mental health specialist (psychologist, psychiatrist, or counselor). Administrative staff coordinate the appointment.
5. First Appointment: The patient meets with the mental health specialist for an initial evaluation and to develop a treatment plan.

Duration

The referral process typically takes 1-2 weeks from the initial consultation to the first appointment with a mental health specialist.

Setting

The referral is usually initiated in a primary care setting, outpatient clinic, or hospital. Psychotherapy sessions are conducted in an outpatient mental health clinic or private practice.

Personnel

• Primary Care Provider (PCP) or Specialist
• Mental Health Specialist (Psychologist, Psychiatrist, or Counselor)
• Administrative staff for coordination

Risks and Complications

• Risks are minimal for the referral process itself.
• Potential delays in getting an appointment with a mental health specialist.
• Initial sessions may take time to build rapport and trust with the therapist.

Benefits

• Improved management of depressive symptoms.
• Enhanced coping strategies and emotional regulation.
• Long-term improvement in mental health and quality of life.
• Patients might start noticing improvement within a few sessions, although it varies.

Recovery

• No physical recovery is needed.
• Regular attendance at sessions is crucial for the best outcome.
• Follow-up appointments with the referring provider to monitor progress.

Alternatives

• Medication management (antidepressants).
• Lifestyle modifications (exercise, diet changes).
• Support groups.
• Each alternative has its own set of pros and cons. For example, medication can provide quicker symptom relief but may have side effects, while psychotherapy focuses on long-term coping strategies.

Patient Experience

• Patients may feel anxious or apprehensive about starting therapy.
• Initial sessions focus on building a therapeutic relationship and assessing needs.
• Pain relief is not an issue, but emotional discomfort might occur as patients discuss difficult topics.
• Comfort measures include a supportive environment and a skilled therapist.