A Partnership of Increasing Significance

The role of psychiatry in primary care is an area of rapid expansion and increasing significance. Given the fact that inadequate diagnosis and treatment of psychiatric disorders (including addictive disorders) are major public health problems (Katon and Gonzales), it is essential to integrate psychiatrists into multi-disciplinary primary care teams. In addition, since primary care physicians are increasingly called upon to act as "gatekeepers" in managed care programs, they will have to meet the important and growing need for broader psychiatric diagnostic and referral skills. Successfully integrating the fields of primary care and psychiatry to face these challenges will allow patients with psychiatric disorders to be more effectively recognized and treated.

The Institute of Medicine defines primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (Donaldson and Colleagues). Psychiatrists can and should establish their value within primary care teams as clinicians, consultants and educators. They can then play a significant role in the overall clinical enterprise. Moreover, by working as part of the comprehensive care team, improved continuity of care and greater accessibility to care are offered to the patient.

Diagnostic/Treatment Models

Detection of patients with psychiatric disorders is an area of great importance in primary care. While studies suggest that the prevalence of psychiatric disorders in the primary care setting is 20% to 30%, only a fraction of that number is properly detected and referred to psychiatrists (Carr and Donovan). Three models have been proposed to improve detection and referral of such patients.

The replacement model substitutes the psychiatrist for the primary care physician as the physician of first contact. Such an approach requires an increased number of psychiatrists to meet demand, and also displaces primary care providers from their gatekeeper status. This model may lead to a higher degree of recognition of psychiatric disorders, but at the cost of potentially significant amounts of limited resources.A second approach has been termed increased throughput. In this model, primary care physicians are encouraged to refer a greater number of patients for psychiatric evaluations, in the hope that an increased number of referrals will lead to better detection. However, this model does not allow primary care providers to improve their own diagnostic skills.

The model that has received the most attention, liaison-attachment, had its origins in Great Britain in the 1950s (Carr and Donovan). In the liaison-attachment model, psychiatrists work within the primary care setting and are a functioning part of the multidisciplinary care team. This approach allows for potential joint assessment and treatment of patients. It can also lead to decreased patient resistance, since patients often find the familiar primary care setting to be more acceptable and less anxiety-provoking. In addition, since the psychiatrist is working in the primary care setting, medical and psychiatric appointments can be easily correlated (an added convenience for the patient), feedback between primary care provider and psychiatrist is enhanced and "curbside" consultations are readily accessible.

Liaison/Communications Roles

While efficient and comprehensive psychiatric consultation is important to the treatment team, it is also crucial to emphasize the psychiatrist's liaison role. Psychiatric liaison work is largely collaborative and educational, and can be of great benefit to other health care providers who may have had limited training in the detection and treatment of mental illness.

Psychiatrists can and should emphasize the importance of biological, psychological and social issues (including spiritual and cultural aspects) in the assessment and treatment of patients. By incorporating the biopsycho- social model into primary care, health care providers will more fully appreciate that patients are complex beings and much more than simply chief complaints. Educational approaches to help attain this goal include lectures, handouts, screening tools such as the PRIME-MD (PT February), attendance at rounds, and aiding in the comanagement of patients with medical and psychiatric illnesses.

Excellent communication skills are crucial to the psychiatrists' value to a treatment team. Within the team itself, clear and effective communication is critical; and when working with patients, the psychiatrist can help primary care physicians appreciate the power of communication and empathic listening. In addition, psychiatrists must continue to ensure that the significance of patient-physician communication as a therapeutic modality itself is not overlooked in the ever-changing health environment.

Barriers to Effective Care

There are three barriers to effective recognition and treatment of psychiatric disorders (Pincus). The first is a reluctance or resistance on the part of the patient to discuss psychosocial issues or to be seen by a mental health professional. A second barrier is the health care system itself, which sometimes provides insufficient time and/or inadequate reimbursement policies for proper psychosocial evaluation and psychiatric treatment by primary care providers. A third potential barrier is the primary care providers themselves, who may have had negative experiences with psychiatric consultants, or who may hesitate to consult psychiatrists secondary to their own feelings of inadequacy when diagnosing mental illness. It is to be hoped that, with collaboration, the partnership between psychiatry and primary care can progress in a mutually educational fashion. This will help to overcome some of these barriers and enhance the overall quality of patient care.

Provider and Patient Education

Treatment options are a major concern for primary care providers. While it is not reasonable to expect primary care physicians to become experts in the field of psychiatry, they should have some familiarity with basic psychiatric treatment options. Any psychiatrist working with a multidisciplinary team should place emphasis on educating the team's other health care providers (which may include nurses, social workers and case managers in addition to physicians). These providers need to have a basic knowledge of diagnostic criteria, psychiatric medications, appropriate doses, major adverse effects and potential drug interactions. They must also be aware of lab abnormalities and medical conditions which may mimic mental illness (e.g., hypothyroidism, urinary tract infections and the psychological components of medical conditions such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome). Moreover, primary care physicians should have some appreciation of the significance of psychotherapy, and realize that empathic listening and reflection are important to the patient-physician relationship.

Improved knowledge of available referral sources is also important when designing comprehensive treatment plans. Psychiatrists should make primary care providers more aware of appropriate referral options within their own health care systems. Potential referral options include mental health clinics, substance abuse treatment programs, day hospitals and community support or bereavement groups.Patient education is an important factor in improving patient compliance and is a crucial element in all treatment plans, leading to increased patient satisfaction and decreased morbidity.

Over time, the psychiatrist can also focus on other topics such as the effects of mental illness on family members, risk factors in suicide, approaches to working with psychotic patients and psychological issues related to terminally ill patients. Further education in these areas will help primary care personnel to have a more thorough appreciation for the biopsychosocial approach to illness. Such appreciation can help improve physicians' understanding of their patients, and reflects the view of Sir William Osler that "[i]t is better to know the patient that has the disease, than the disease that has the patient (Dacher)."

Conclusion

Overall, the relationship between psychiatry and primary care should be an ongoing, mutually educational collaboration. A partnership of this sort is beneficial to the health care provider, and more importantly, to the patient. By working closely on multidisciplinary teams, physicians can better address the mental health problems of their patients and better support their patients in solving them. In the long run, primary care physicians encountering patients with psychiatric disorders will be better equipped for effective detection, referral and treatment. This, in turn, can lead to improved care, decreased morbidity, decreased health care costs, and much-enhanced patient satisfaction and compliance.

References:

References

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Dacher ES. Reinventing primary care. Alternative Therapies. 1995;1(5):29-31.

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Donaldson MS, Youdy KD, Lohr KN, Vanselow NA, eds Primary Care: America's Health in a New Era. Washington: Institute of Medicine, 1996.

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Katon W, Gonzales J. A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics. 1994;35(3):268-278.

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Pincus HA, Vettorello NE, McQueen LE, et al. Bridging the gap between psychiatry and primary care. Psychosomatics. 1995;36(4):328-335.