On the surface, the cases appear an obvious contrast. Patient A was a collegiate athlete suffering from mysterious and debilitating fatigue that threatened to derail his future. Patient B was a young man with autism spectrum disorder whose increasingly erratic behavior had led to his hospitalization and sedation. Underneath, however, the two cases — one seemingly medical, the other psychiatric — had significant similarities. In both instances, the conditions resisted easy diagnosis and failed to respond to standards of care, leaving providers puzzled and the patients and their families searching for answers.

When it comes to diagnosing conditions that blur the line between psychiatric and physical health, modern medicine, with its emphasis on speed and specialization, can fall short. Michael Mufson, MD, director of the Psychiatric Complex Diagnostic Service (CDS) — a one-of-a-kind consultation clinic at Brigham and Women’s Hospital — likens these situations to the ancient parable of the four blind men and the elephant.

“We might have an immunologist on the tail, a rheumatologist on the leg, and an internist on the tusk — they are all looking at something different and not seeing the patient as an integrated whole,” Dr. Mufson says. “It’s not a failure of clinical skill or a deficit in medical excellence; it’s how you put your eyes on the case.”

From hard-to-define psychiatric conditions, like mood and trauma-related disorders, to illnesses such as chronic pain and long COVID, where physical and psychiatric symptoms are often interwoven, Dr. Mufson and the CDS team have earned a reputation for helping patients with mysterious and unresolved illnesses find the proper diagnosis and get the treatment they need. Their secret? In terms of the parable, they specialize in seeing the whole elephant.

Time is of the essence

Founded in 2012 by Dr. Mufson and former Brigham and Women’s Chair of Psychiatry David Silbersweig, MD, the CDS began as an experiment in addition by subtraction. Complex medical psychiatry cases were on the rise, but the department’s capacity to diagnose and treat them was limited. Patients often waited months to be seen. By forgoing treatment and focusing solely on diagnosis for other providers, the CDS could see patients sooner, devote more time to individual evaluations, and help more people. For Dr. Mufson — who began his career at the Brigham in 1980 and had decades of experience treating complex sleep disorders, chronic pain, and trauma — the extended evaluation time was essential.

“If I can sit with a patient four or five hours, I have a much better chance of making an accurate diagnostic assessment than if I see them for 20 minutes,” he says.

The typical CDS consultation consists of two or three 90-minute sessions with Dr. Mufson and one of his colleagues. The conversations explore the patient’s history, their symptoms, the psychosocial context of when those symptoms occur, and more. In between sessions, there may be additional tests, such as a sleep study or blood work, conversations with the referring physician and care team, or consultations with specialists outside of psychiatry. When all the information is gathered, the CDS team meets to determine the diagnosis, formulate a treatment plan, and arrange next steps.

“Each patient gets a comprehensive evaluation to take to their clinicians,” says Dr. Mufson. “It’s a very hands-on process. The personal touch sets our clinic apart.”

After thorough evaluations and assessments of patients A and B, Dr. Mufson and his team were able to tie patient A’s fatigue to a combination of depression, anxiety, and physical distress triggered by the death of a teammate. Patient B’s erratic behavior was caused not by psychosis, but by a small, benign tumor in his pituitary. In both cases, the diagnoses allowed the patients to get the help they needed to return to their normal lives.

Careful, comprehensive curriculum

Although originally designed to meet the needs of the Mass General Brigham psychiatric community, today the CDS attracts patients from around the world. As demand for consultations has grown, the program has expanded to include distinct subspecialized services, such as ophthalmology, dermatology, and immuno-psychiatry. It’s also become an important teaching tool for resident psychiatrists and specialists who regularly join Dr. Mufson for his evaluations.

“This is such an educationally rich model,” says Nomi Levy-Carrick, MD, MPhil, vice chair of clinical services for Mass General Brigham’s Department of Psychiatry, who recently joined the CDS as associate medical director. “We’re showing the next generation the value and privilege that comes from assessing these complex cases in a careful, comprehensive way.”

As successful as the CDS has proven to be, there is a reason it hasn’t been widely replicated. To maintain this highly specialized, time-intensive service, the clinic depends on institutional and philanthropic support.

“When patients have had first-, second-, or third-line interventions fail, this is a place where they can find understanding, regain a sense of control and hope, and feel seen,” Levy-Carrick says. “Clinical revenue alone could never support this kind of deeply transformative work. This is academic medicine at its best, and it could only happen at a place like Mass General Brigham.”

To learn more about the Psychiatric Complex Diagnostic Service and other innovative programs at Mass General Brigham, contact Alex Dippold at adippold@mgb.org.