Identifying severe behavioral problems is not the strong suit of primary care, and nonpsychiatric physicians generally feel uncomfortable dealing with these extreme symptoms. Moreover, were the PCP to detect such behaviors, he likely would not know what resources to turn to nor would he have the time to follow through appropriately. As a result, the physician often chooses not to ferret out these behaviors lest they render him helpless to intervene. This leaves the patient, the physician, and the community in a serious and potentially dangerous situation, because the patient with extreme symptoms should be immediately transferred to a far more intensively monitored level of behavioral treatment.
None of this is meant to disparage PCPs. To the contrary; theirs is a demanding role that is under-recognized, underfunded, and significantly overtaxed for time. I have great respect for their work and their burdens. Still, many patients are not receiving optimal care when they fail to see a behavioral or psychiatric specialist. Unfortunately, there currently exists a dearth of psychiatrists to handle the vast demand for behavioral care. More important, the appropriate systems to effectively integrate behavioral health and primary care are only in their infancy at this time, and little or no attention is being paid to the cost-effective funding of such programs.
PCPs who wish to make a referral all too often cannot find a psychiatrist to evaluate the patient soon enough. A wait of many months before a psychiatric appointment is available is not uncommon, and many psychiatric practices no longer accept new patients. To this may be added the many other barriers to appropriate behavioral care, such as transportation problems, inadequate insurance, and patient nonadherence to treatment and the stigma that is still attached to treatment.
The solution may lie in the creation of new systems of medical-behavioral integration alluded to earlier. These systems are placing the psychiatrist, nurse, social worker, and/or case manager in the same clinic with their primary care peers. Patients are routinely screened for behavioral symptoms using standard paper and pencil screening tools. Mildly symptomatic patients are treated by the PCP, and those with more severe symptoms are treated by the behavioral health team, through some combination of psychiatrist, psychotherapist, nurse, nurse practitioner, social worker, and care manager. Patients are followed up telephonically to foster adherence to both their behavioral and their medical treatments. The psychiatrist is always available, in “real time,” to consult with and to support the PCP on difficult cases and also serves as a formal educator to help his team and medical peers identify, correctly diagnose, and appropriately treat behavioral health problems.
In this way, psychiatric resources will be best leveraged for maximal impact on patients with highly common co-occurring medical and psychiatric problems. For this system to make the psychiatrist accessible to many more patients, it will require new funding mechanisms to cover the costs of services such as consultation between doctors and follow-up outreach to patients. However, these costs will be well offset by improved patient care in both the primary and behavioral care settings, as well as by reduced medical costs for emergency room visits, medical hospitalizations, and unnecessary laboratory testing.
The time has come to treat the whole patient. The time has come to make psychiatry part and parcel of primary care.
Dr Fischbach is a child and adolescent psychiatrist in private practice in Pittsburgh, Pennsylvania.
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