How does your primary care doctor coordinate with your psychiatrist?

By Pierre
Gingerich-Boberg, Medical Student

Reviewed by Claudia
Reardon, MD



I’m stuck in behaviors
that are making me unhealthy.  My smoking
makes my asthma worse, and I don’t want to end up with emphysema like my dad.  I smoke when I’m anxious, and my finances, my
teenager, my boss, and my increasing weight all make me anxious.  Now to top it off, my chronic headaches are
getting worse.  My problems are physical,
but I know they’re also mental.  But the
idea of seeing a psychiatrist makes me even more anxious!  What should I do?



Patients need primary care doctors who can comprehensively
address the varied aspects of their physical and mental health. Health systems
are starting to recognize that multi-disciplinary teams (sometimes called patient-centered medical homes) can be
an effective way to provide integrated
care.  How might this look for our example
patient?

First, it’s worth noting that traditional primary care doctors
already spend a lot of effort helping patients with a wide spectrum of behavior
issues.  We saw this for our example patient.
 Her anxiety is an example of a classic mental health problem—others
might be depression, panic attacks, and addictions. Primary care docs refer some
of these patients to psychiatrists, but primary care docs are treating the
majority directly.  Our patient’s
headaches are likely a functional
ailment. Like irritable bowel syndrome and general aches and pains,
headaches are real problems that often defy simple solutions.  Standard treatments focus on limiting symptoms
while helping patients cope with the stressors and psychological distress that often
contribute.  Finally, our patient faces
problems with health-related behaviors including
tobacco use, diet, and stress management. 
These and other common behaviors are hugely important for the development
of chronic diseases.  

Our patient’s picture might seem complex, but primary care
doctors face such complexity (and more) every day! Frankly, patients often are
dealing with too much for their doctors to address optimally in a 15-20 minute
time slot. One approach is to triage—to ask what’s treatable and doable, and
what can wait until the next appointment. The limited time
available for counseling tends to push primary care doctors toward relying on
treatment with psych meds. A second approach is to refer the patient to
a psychiatrist.  But psychiatrists in
many communities are spread too thin, so patients often wait weeks or months
for an appointment. Then there’s stigma--our example patient’s anxiety around
psychiatric care is actually pretty typical. 
This helps push up no-show rates for first visits with a psychiatrist to
30 or 40%.  It’s no wonder that careful
studies show that only a fraction of the mental health problems in our
communities are ever diagnosed, and fewer still are adequately treated.

A third option returns us to the medical
home concept.  At the VA and increasingly
in federally qualified health centers (FQHCs), mental health services are being
brought into the primary care setting. 
Here, behavioral health consultants
(BHCs) share space with primary care doctors. 
These are generally psychologists or social workers, that is,
non-physicians. BHCs’ schedules are intentionally left mostly open, so that they’re
available to see patients immediately after a non-threatening ‘warm handoff’
from the primary care doc.  The BHC can offer
expert counseling for the patient, and advise the primary care provider on
diagnosis and treatment.  BHCs arrange
for a small subset of their patients to get a subsequent visit with a psychiatrist
(a specialist physician), who is also in-house. 
 All the BHC patients get
systematic evaluation and follow-up by phone or with visits to make sure their
needs don’t fall through the cracks.

When a behavioral health consultation system is in place,
problems of waiting times, missed appointments, and incomplete records are
eliminated for most behavioral health visits. 
Primary care docs have more time to focus on medical issues, while
getting the expert consultation they need to optimize behavioral health care
for their patients. Finally, because most behavioral issues can be addressed efficiently
by BHCs, specialty psychiatrists are not so swamped, and waiting times can be
greatly shortened for the small group of patients needing psychiatric care beyond
what can be managed in the primary care setting.
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