Neuropsychiatric patients rarely have a single medical diagnosis. Even when they do, their disease may cause functional impairments that require adaptation and/or rehabilitation or entail a complex and demanding treatment regimen. The illness is likely to impact the patient’s family and/or significant others, especially if it involves cognitive or sensory impairment; aggressive, self-injurious, psychotic, or otherwise risky or socially inappropriate behavior; or expensive treatment or care not covered by insurance. Consistent delivery of treatment to a patient might be difficult because of the patient’s functional impairments or social and environmental issues, including challenges accessing health care and/or paying for treatments, and environmental hazards with disproportionate impact on patient’s specific problems. Treatments for neuropsychiatric disorders sometimes have neuropsychiatric or general medical side effects. Finally, there often are illness-related educational, occupational, financial, and/or legal issues, which may be complicated by family conflicts about how best to deal with them.
Ideally, patients with neuropsychiatric disorders and accompanying comorbidities will receive treatment from a physician serving as a subspecialist in neuropsychiatry. The role might be filled by neuropsychiatrist, behavioral neurologist, or a general neurologist or psychiatrist with a one or more neuropsychiatric conditions as a focus of his/her practice. Geriatric and pediatric neurologists and psychiatrists often function as “brain/mind medicine” practitioners for a specific set of conditions, as do specialists in neurotrauma and stroke. For simplicity, any physician who works at the interface of psychiatry and neurology in their care for a patient with brain dysfunction will be referred to in this chapter as a neuropsychiatrist, with the understanding that most neuropsychiatric care is delivered by physicians who do not have neuropsychiatry as their primary specialty.
In approaching the care of complex patients, it is useful to acknowledge that clinical care is not delivered by physicians alone. Chronic neuropsychiatric conditions also frequently involve nonphysician health care professionals including physical, occupational, and speech therapists, social workers, and psychologists. However, even straightforward outpatient care of chronic conditions requires the involvement of pharmacists to fill prescriptions and answer patient’s questions about medications, office staff to schedule appointments, technical and professional staff involved with diagnostic imaging and clinical laboratory tests, and people who handle coding of diagnoses and procedures, billing, claims processing, and payment. These individuals can facilitate and enable physicians’ work, making it more efficient and more financially sustainable.
The neuropsychiatrist’s role varies among cases, in a way that can be conceptualized in terms of his/her position on an organizational chart. A chief executive officer (CEO) has overall responsibility for deciding on strategy, assigning duties to others, evaluating results, and representing the team externally. A chief operating officer (COO) is responsible for organizing and overseeing the implementation of the strategic plan decided upon by the CEO. A chief strategy officer (CSO) is responsible for creating a strategic plan to be adopted in some form by the CEO and implemented by people who report to the CEO or COO. A ...