FAQ

FAQ responses from Scott P Hoopes MD & Associates:

Psychiatric Assessment

Psychiatric Treatment

Medication Questions

Therapy and Therapists

Office Policies (including payment)

Contacting the on-call doctor

Psychiatric Assessment

Q. I am already being treated by someone else. When should I consider seeing Scott P. Hoopes, M.D. & Associates for my problems?
A. If your treatment has not been effective or you are experiencing significant side effects from your medications, we may be able to help you. Most medication regimens should work to some extent within weeks to several months. We often see patients who have been treated for months or even years with mediations that have never really enabled them to feel well. We may be able to help you. If your medications seem less and less effective with time, we may be able to help you. If you are not clear what you are being treated for, we are able to help you (see below, "It seems that different doctors come to different conclusions about psychiatric diagnoses" and "What are symptoms and how do they relate to diagnoses?"). If you do not know the objectives of your treatment or your treatment seems haphazard rather than systematic, we are able to help you. If you do not know what each of your medications is supposed to be doing, we are able to help you. If your medications cause you to gain weight, make it hard to think, or make you unsteady on your feet, we may be able to help you. If you have never been informed of the possible, serious side effects of your mediations, we are able to help you. If you are taking medications that should be medically monitored (blood work, etc), and they have not been, we can help you (see below, "What is the Metabolic Clinic?"). top

Q. What should I expect when I come to my first appointment?
A. First, you will be asked to complete forms that help us collect social, medical and psychiatric history. Then you will be invited into an office by one of our professional staff to review and expand your answers and to complete an interactive interview structured around an instrument designed to describe and record your lifetime emotional experiences. Once that has been completed, the appropriate diagnoses will be assigned and explained and the initial treatment plan will be formulated. top

Q. Do I need to come early to my initial appointment?
A. Yes. There is a number of forms and rating scales to be completed before the initial interview that require about 30 minutes for most people to complete. (Please come even earlier if you have a condition that will make it difficult to complete these forms.) top

Q. It seems that different doctors come to different conclusions about psychiatric diagnoses. Why is this?
A. Psychiatric diagnoses are established by comparing a person's lifetime history of symptoms to established diagnostic criteria. These criteria have been formulated by careful clinical study of particular illnesses by academicians and they are published by the American Psychiatric Association as The Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-IV, tr). These lists of symptoms are cumbersome, and consequently many clinicians do not systematically apply the criteria and rely more on personal impressions, or simply collapse the difference between symptoms and diagnoses (see below on the difference between symptoms and diagnoses). At Scott P. Hoopes, M.D., & Associates we rely on standardized instruments that were developed for use in psychiatric research to establish reliable diagnoses. These criteria are summarized in our report of your assessment and allow any trained mental health professional to compare the symptoms a person has experienced to established criteria and to understand the basis for our diagnostic conclusions. top

Q. What are symptoms and how do they relate to diagnoses?
A. This is a very important question. A symptom is a change from normal that suggests the presence of an illness or disease. For example, a sore throat or a cough are symptoms suggesting possible illness or disease of the throat. Unexpected sadness or sudden panic are symptoms that suggest the possibility of psychiatric illness. Note that the presence of a particular symptom of itself does not establish the presence of a particular illness. That is to say, there are many possible causes of a sore throat or a cough. The physician's task is to determine which of the candidate illnesses is present and which are not. The list of candidate illnesses is referred to by physicians as the "differential diagnosis" for that symptom. Similarly, depression or panic are symptoms that can be found in many different psychiatric illnesses, and consequently depression and panic as symptoms have lists of candidate illnesses, or "differential diagnoses", that must be carefully considered before determining the diagnosis responsible for the depression or panic. The differential diagnosis for panic attacks, for example, includes, in addition to Panic Disorder, other Anxiety Disorders including Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder and Social Phobia; Affective (Mood) Disorders including Bipolar Disorder and Major Depression with psychosis; Psychotic Disorders including Schizophrenia and Schizoaffective Disorder; Substance Abuse Disorders including Amphetamine and Alcohol Abuse, and others. The key point here is that the presence of panic attacks does not occur only in Panic Disorder. Similarly, the presence of depression as a symptom does not establish the diagnosis of Major Depression. Prominent anxiety symptoms can occur in Affective (Mood) Disorders and prominent mood symptoms can occur in Anxiety Disorders. Each of these diagnoses has well established and effective treatments that can sometimes make other diagnoses worse. It is imperative, therefore, that we treat diagnoses and not "chase symptoms". For this reason you may come in with symptoms of anxiety but be diagnosed with an Affective (Mood) Disorder or you may come in with symptoms of depression and be diagnosed with an Anxiety Disorder. It is the failure to observe this distinction in practice that often leads to unsuccessful treatments and unnecessary suffering. top

Q. Are medications prescribed to all people who see Dr. Hoopes?
A. No. There are times that our structured interview does not identify a condition for which medications are indicated, in which case the patient is generally encouraged to enter into psychotherapy to address the problem. top

Q How will we decide if I need to take medications?
A. Our structured diagnostic interview yields a catalog of your lifetime psychiatric symptoms. These symptoms are grouped into diagnoses. If professionally established diagnoses are present and they are impairing your ability to function or causing significant distress, medications are proposed that have been shown in scientifically designed clinical research to be able to be helpful. top

Psychiatric Treatment

Q. What happens after the initial appointment?
A. Treatment is divided into three stages. The first, or Acute Stage, includes the initial assessment and consists of designing and implementing a treatment plan to active, distressing symptoms. Patients in this stage of treatment are usually seen every one to three weeks until an effective medication regimen is provisionally identified. In the next, or Stabilization Stage of treatment, we “fine tune” this medication regimen to limit or eliminate the presenting symptoms. People in this stage of treatment are seen every 3 to 6 weeks. Finally, during the Maintenance Stage of treatment, we continue the medication regimen that has been established as helpful in the Stabilization Phase. People in this stage of treatment are generally seen every 3 to 6 months (Please see: What should I expect for my first visit? ). top

Q. How do I know if I need to come in for an urgent appointment?
A. If you decide your medications "are not working", call for an appointment (note, we do not change medications on the phone). Call us right away if you are experiencing suicidal thoughts. If you suffer from a psychotic illness in which the psychosis has emerged again, you should call for an appointment right away. If you suffer from depression, and your depression increases to the point of impairment or marked distress, call for an appointment. If your suffer from bipolar disorder and you suspect mania is emerging or your sleep has deteriorated for 2 or more nights, call for an appointment. If your school or work performance has deteriorated or an important relationship is threatened because of the emergence of symptoms, call for an appointment. top

Q. How long should I have to wait for the medications to work?
A. Most medications work over a period of weeks, so it is important to be patient and to continue your medications for a time. top

Q. What happens if the initial medications don't work?
A. There is no way to predict which particular medication(s) will be effective in a particular person. There is no medication that is helpful for all people with any given diagnosis. We start with a medication regimen that has been shown to be helpful for the diagnosis assigned and learn from each trial of medication more about your personal biology. This allows us to refine our choice of medications over time until we find a regimen that is successful and tolerable. top

Q. If I start feeling well, may I stop the medications?
A. No. We in psychiatry, like virtually every other discipline of Medicine, with the exception of Infectious Disease, manage illnesses, we do not cure them. Consequently, when we find a medication regimen that allows you to feel well and to function fully, it is wise to continue it for a time. How long that time may be depends on the illness itself and how many episodes of the illness have occurred. top

Q. If I take medications now will I have to take medications the rest of my life?
A. That depends on the diagnosis. Many psychiatric illnesses are lifelong, and consequently long term medications may be needed. These include many mood and anxiety disorders. A few conditions, however, are not lifelong, and medications may be needed for limited periods of time. These include eating disorders, impulse control problems and adjustment reactions. top

Q. Can I change or stop my medications myself?
A. Please, please call us before making any change to your medications. The treatment process of psychiatry proceeds most effectively by learning from everything we do, whether a medication has been useful or caused problems. Stopping medications abruptly can sometimes cause uncomfortable or even dangerous symptoms as your body adapts to the withdrawal of the medication(s). So, again, please call before making any changes to your medications. top

Q. Are psychiatric illnesses inherited?
A. Most psychiatric illnesses are a manifestation of subtle or not-so-subtle malfunctions of the brain. The structure of our brains, in turn, is determined by the interaction between the givenness of our biological make up and our life experience. The predisposition to illness is certainly inherited. top

Medication Questions

Q. How do I obtain a refill of my medications?
A. You should have been provided adequate refills to last to your next appointment. If it appears you do not have sufficient medication, first call your pharmacist and have him or her check the original prescription. Transcription errors at the pharmacy are not uncommon. Next, call the office to see if you are due for a follow-up appointment. Finally, if you find you truly do not have enough medication to last until your next scheduled appointment, ask your pharmacist to fax our office for a refill. We process these requests within one working day of receiving them. Note that the state of Idaho does not allow refills of "scheduled medications" (e.g. amphetamines like Adderall, Concerta, Focalin, Daytrana, and others for ADHD) to be called or faxed to the pharmacy. These refills will be prepared on special prescription paper and you may pick them up at the office at your convenience. top

Q. How do I obtain a refill of "scheduled medications" (Adderall, Concerta, Ritalin, Dexedrine, Daytrana, Focalin, Norco, Vidodin, Dilaudid, and others)?
A. These medications cannot have refills associated with them and refills cannot be called or faxed to the pharmacies. Please ask your pharmacist to fax my office a refill request for these medications just like they do for non-scheduled medications. Some pharmacists may not be accostomed to faxing offices requests for these kinds of medications and consequently they may be hesitant to do so. Please reassure them that you know that you must still pick up the written refill from my office. You could also review with him or her the three reasons we ask the pharmacists to fax refill requests for these scheduled medications. First, we can compare the prescription they are dispensing to the prescription we are writing (the hand-written paper script introduces an important source of potential error). In addition, it is important for us to know which pharmacy is dispensing these medications for you. Finally, all refill requests are routed from the fax machine in our office to an internal, electronic, password protected file on our servers to which only clinical staff have access. If your pharmacist is still reluctant to fax the refill request, please have him or her call my office so I can explain to them the reasons for our policy. top

Q. What should I do if I miss a dose of my medications?
A. That depends on the medication. As a general rule it is prudent to take the usual dose of your medications at the next usual time rather than to “make up” doses. One must be careful about Lamictal, however. See the FAQ for Lamictal for details. top

Q. Will I be monitored for side effects?
A. At Scott P. Hoopes, M.D., & Associates we monitor our patients according to current recommendations for significant adverse events through our Metabolic Clinic. top

Q. What is the Metabolic Clinic?
A. There are many effective psychiatric medications that may have medically important adverse effects in a minority of patients. There are guidelines and protocols to follow to watch for the emergence of these side effects. Historically, however, psychiatric offices have not been designed and equipped to provide this important, medical monitoring. At Scott P. Hoopes, M.D. & Associates we have the staff and the appropriate space to provide this monitoring on site. This consists of our examination room staffed by our trained and experienced nurse practioner. If you are prescribed any medication for which monitoring is indicated, you will be referred to our on-site Metabolic Clinic. The items to be monitored are specific to each medication, but they may include laboratory tests as well as clinical measurements like blood pressures, weights and measurements of abdominal girth. We also provide dietary and life-style counseling to help you establish a balanced and healthy life.
Medications that should be monitored for potentially serious medical side effects include but are not limited to the atypical antipsychotics (Abilify, Clozapine, Geodon, Risperdal, Seroquel, and Zyprexa), the typical antipsychotics (Trilafon, Haldol, and others), valproic acid (Depakote, and others), lithium (Eskalith, Lithobid, and others), carbamazepine (Tegretol, and others), oxcarbazepine (Trileptal), some antidepressants (Remeron, tricyclic antidepressants, and others), combination medications (Symbyax), and stimulants (Ritalin, Dexedrine, Adderall, Concerta, and others). top

Q. Will Dr. Hoopes prescribe generic medications?
A. At Scott P. Hoopes, M.D., & Associates we work are mindful of the expense of the medications we prescribe. When possible, we will prescribe generic medications, but we will not do so without discussing with you the advantages and disadvantages for each medication. top

Q. Are there medications without side effects?
A. No. That is to say that any given medication can cause problems, or side effects, in some patients, but few, if any, adverse events occur in every patient. When prescribing any medication there are three questions to be answered: is the medication tolerable for this person; is the medication helpful for the target symptoms; what is the dose that is most beneficial with the fewest side effects. top

Therapy and Therapists

Q. Will Dr. Hoopes want me to see a different therapist?
A. No. We respect your relationship with your therapist and we will do all we can to support that relationship and to collaborate with the therapist of your choice. top

Q. Does Dr. Hoopes work with particular therapists?
A. There are therapists within Scott P. Hoopes, M.D., & Associates and there are therapists in the community with whom Dr. Hoopes often works. If you need a therapist we will be happy to refer you to a therapist skilled in the services you need. top

Q. What is the role of psychotherapy?
A. Medication management and psychotherapy are complementary. An athletic metaphor illustrates this relationship. The prescriber functions as a trainer: the trainer addresses physical problems the athlete may have in order to enable the athlete to return to the game. The therapist is analogous to the coach, he or she works with the athlete to improve their game. top

Office Policies (include payment)

Q. What should I look for when buying health insurance?
A. Before buying health insurance ask the following key questions:

Sources of information to answer these questions include your HR department at work, your insurance salesperson, and the candidate company's customer service department and web site. Obtain answers to all these questions in writing from an authorized source before committing to the policy. top

Q. What if I don't know the mental health benefits of my health insurance?
A. Our office staff, as a courtesy, calls your insurance before your first appointment to obtain the details of your insurance coverage. You will be contacted before your first appointment with this information to allow you to budget your expenses. top

Q. What if my insurance changes after I have been seen in your office?
A. Simply call and inform Tracey of this change and we will update your file accordingly. top

Q. Why are psychiatric insurance benefits different from medical benefits?
A. This is an unfortunate policy of the insurance industry. There is a movement to require the same level of coverage for mental health conditions as is provided for other medical conditions. You can support this movement to require “parity” of coverage by calling and writing your congressional caucus. (The state of Idaho is to be congratulated for adoption, howbeit provisionally, of parity for state of Idaho employees starting July 1, 2006.) top

Q. How can I pay my bill in your office?
A. We use state of the art accounting software so that you are able to know quite accurately what your balance is at the time of service. It is most convenient to pay that balance while at the office. Sometimes, however, insurance companies surprise us by paying less than expected, in which case you are billed by mail for the balance and you may forward your payment by check or you can call in and give us a payment by credit card on the phone. top

Q. What if I miss an appointment?
A. We charge a $50 fee for failure to come to an appointment. Please be mindful that there are many people vying for any given appointment time, and that failure to come to your appointment is a disservice to the people who were not able to use that time themselves. top

Q. Can I set up a payment plan for my bill?
A. We are happy to work out a payment plan, if necessary, for established patients. As a rule, however, we require that the first appointment be paid in full. top

Q. What if I want to see one particular provider? Will I be able to do that?
A. Of course. Simply ask Tracey or Tina to schedule your next appointment with that particular provider. top

Q. What should I expect for my first visit?
A. We have created a page explaining what to expect during your first visit in order to answer this question. top

Contacting the on-call doctor

Q. Am I able to contact any provider I choose after hours?
A. No. The therapists and nurse practitioners are not available after hours. After hours calls are all taken by Dr. Hoopes. top

Q. Are there common problems that can be fixed without paging Dr. Hoopes after hours?
A. Yes. The two most common problems for which Dr. Hoopes is needlessly paged are difficulty sleeping or difficulties after recent medication changes.

Sleep problems can often be substantially improved by following some simple guidelines. Our bodies are generally not able to go to sleep sooner than 15 hours after we have wakened. Often people expect to be able to fall to sleep at, say, 10 pm, when they woke up at 10 am. Your body will not be ready to fall to sleep in this situation until about 2 am the next day. The solution here is to get up earlier if you want to fall to sleep earlier. It is best to keep a very regular sleep schedule, weekdays and weekends. Research has shown that we will not feel rested no matter how much sleep we get if we are in bed more than 9 continuous hours per day. Do not try to “make-up sleep”. Do not drink fluids after dinner to avoid having to get up to use the bathroom at night. Do not drink caffeine after breakfast. Turn off the TV and the computer at least one hour before you want to fall to sleep. Never, ever, use alcohol to help you to fall to sleep. A mild over-the-counter sedative can be used short term to help retrain the body to fall to sleep at a certain time. Try all these maneuvers first and if they are unsuccessful, call the office during working hours to set an appointment to assess further the causes of you sleep problem. Remember, sleeplessness is a symptom, not a diagnosis, and we must always treat a diagnosis.

Medication changes can sometimes be followed the first week or so by new side effects. This is because the medications make immediate changes in brain chemistry that are followed by changes in key structures of the central nervous system known as receptors. The process of the change in receptors takes several weeks, so in the meantime there may be something of a mismatch between the amount of neurotransmitter (more) and the receptors (too many). Usually over the second week these side effects will diminish as the benefits of the medication increase. If your side effects are mild to moderate in intensity, wait for one to two weeks with the expectation that the side effects will resolve. If the side effects do not improve or if they seem to become more intense as time passes, call the office during working hours for an urgent appointment. If the side effects are extreme, then reverse the change of medication to what it was before the change and call the office the next working day to make an urgent appointment.

Many medications can cause rashes, most of which are not serious, but some can be serious indeed. If you have developed an unfamiliar rash call or page immediately. Similarly, if you have developed a fever or swollen lymph nodes call or page immediately.

Dr. Hoopes cannot make medication changes on the phone. In order responsibly to make a medication change Dr. Hoopes must perform a clinical assessment, review the record for past treatments that have or have not been helpful, discuss the various options and educate to the selected change. This cannot be done on the phone. If you feel your medications need to be changed, please call the next working day and make an urgent appointment. top

Q. When should I page Dr. Hoopes after hours?
A. Broadly speaking there are two kinds of calls that we receive after hours. First, a call that poses a particular question and the caller is not personally in crisis. Answers to these questions can almost always be found without paging Dr. Hoopes. Please refer to articles on the web-site on medications and conditions. If you still cannot find your answer, it is best to call during working hours when the receptionists will likely be able to obtain the answer to your question from Dr. Hopes while you are still on the phone. Secondly, we receive calls that involve some kind of personal crisis. These calls are usually from people in two situations. Most commonly these calls are from people who have missed their follow-up appointments and as a result have developed some kind of acute difficulty. It is reasonable to page Dr. Hoopes at these times, but he will likely urge you to be sure to make your appointments to avoid these kinds of situations in the future ("When should I not page Dr. Hoopes?"). Less commonly a recent medication change has led the caller to feel less well or to develop possible side effects. In this situation it is reasonable to reverse the change that has been made and call the next working day for an urgent appointment (see also “Are there common problems that can be fixed without paging Dr. Hoopes”).

Dr. Hoopes cannot make medication changes on the phone. In order responsibly to make a medication change Dr. Hoopes must perform a clinical assessment, review the record for past treatments that have or have not been helpful, discuss the various options and educate to the selected change. This cannot be done on the phone. If you feel your medications need to be changed, please call the next working day and make an urgent appointment.

Many medications can cause rashes, most of which are not serious, but some can be serious indeed. If you have developed an unfamiliar rash call or page immediately. Similarly, if you have developed a fever or swollen lymph nodes call or page immediately.top

Q. When should I not page Dr. Hoopes after hours?
A. Dr. Hoopes cannot address by phone situations in which a person is not safe.

If you yourself feel suicidal, then go to the nearest emergency room where qualified professionals will assess you to determine whether or not you require admission to a psychiatric hospital. If you are having thoughts of suicide, but you are able to be safe, i.e. you are not going to do anything suicidal, call the office the next working day for an urgent appointment.

If you are worried someone close to you cannot be safe, take him or her to the nearest emergency room. If he or she refuses to go, then call 911 and ask for a “welfare check” from the police. The officers will come to interview the person to determine the seriousness of his or her state and, if required, to take the person into “protective custody” and to transport the person to an appropriate facility.

Dr. Hoopes cannot make or change appointments after hours. These calls should be made during working hours.

Dr. Hoopes cannot make medication changes on the phone. In order responsibly to make a medication change Dr. Hoopes must perform a clinical assessment, review the record for past treatments that have or have not been helpful, discuss the various options and educate to the selected change. This cannot be done on the phone. If you feel your medications need to be changed, please call the next working day and make an urgent appointment.top