The initial interaction for a distressed individual seeking care in a community mental health center will either be with a nonprofessional community worker or possibly a social worker. If they determine that the mentally ill individual needs further assistance or assessment, they will make the essential arrangements. This could include enrollment into a day program, a detoxification program, hospitalization or referral for medication. The psychiatrist in these settings is usually not the patient's initial contact. The psychiatrist may be asked for assistance in diagnosis, but the usual psychiatric intervention is to provide medications for another mental health care worker's client. Follow-up to the physician will usually be only to assess and provide medications. Responsibility for oversight of a patient's care is by a treatment team, which may or may not include a psychiatrist.
Various arguments are used to support this system: because psychiatrists do not want to work with individuals with severe mental illness, other mental health care professionals have to assume responsibility for patient care; psychiatrists are expensive and not cost-effective; medical training interferes with a physician's ability to understand the special issues that seriously or chronically mentally ill individuals face. For whatever reason, psychiatrists are not the key players or the captains of the treatment team, and they may not even be on the treatment team in some treatment centers.
The community hospital emergency department follows this model. Even though initial patient interactions are with medical staff, the ED has demedicalized mental health care at the point of the patient's critical psychiatric assessment. Although a psychiatrist supervises the on-call mental health care worker who actually sees the patient, the psychiatrist will seldom see or know the patient and will usually defer decisions to the non-M.D. mental health care worker.
It might be argued that this is only a model of care provided by community mental health centers, community hospitals or community hospital EDs at night. Yet variations of this model exist in various teaching hospitals and HMOs. New outpatients are seen by nurses, social workers, psychologists, and psychiatrists or other physicians. A nurse or social worker, in combination with a psychiatrist, may also see a patient where they take the psychosocial history. The patient is assessed by the physician, who confirms the diagnosis and prescribes medications, if necessary, while the other members of the team provide psychosocial treatments.
In situations where a joint assessment is not built into the evaluation, follow-up care may be provided by an array of practitioners that might not include a psychiatrist. Furthermore, there might not be any input from the psychiatrist in the disposition.
For individuals who are not members of an organized health care system, the choice of which mental health care provider to select is not clear. They may not know the differences in training between psychiatrists, psychologists, counselors and social workers. Individuals who speak to their primary care doctors first are as likely to be referred to a social worker as a psychiatrist. If the social worker feels that the individual might benefit from medication in addition to psychotherapy, the internist might be asked to provide it. Frequently, HMOs steer patients to nonpsychiatrists and use psychiatrists only to provide medication. The individual seeking care is not likely to obtain an explanation for why they were seen by a particular mental health care provider. In some group practices headed by psychiatrists, most of the professionals are non-psychiatrists, and the psychiatrists essentially function to provide medication treatment and assist in diagnosis if asked by other professionals.
One might argue that this process of non-M.D.s providing key services in psychiatry is not significantly different from what physician extenders or nurse practitioners do in other areas of medicine. Yet I believe it is. Laws regulate the relationship of other providers to physicians, and usually an oversight relationship exists with the physicians. In psychiatry, it would seem that the non-M.D. frequently determines treatment. In some community settings, bachelor's degree-level or community workers can override the judgment of psychiatrists or other mental health care professionals with advanced training. In addressing psychiatric disorders, we have large numbers of individuals with varied educational and training experiences making critical health care decisions.
Psychiatry has not made it clear to patient groups, potential patients or various medical professionals (including other mental health care professions) what the essential criteria are for seeing one mental health care professional rather than another. Furthering this confusion are the diverse names given to psychiatric clinics; psychiatric clinics, mental health clinics, behavioral health clinics or neurobehavioral health clinics may all see the same patients and be staffed by individuals with similar training. In some universities, even the name of the department of psychiatry has been altered, which reduces the focus on psychiatry. I might note that I have not heard of surgical clinics changing their names to "Invasive Health Care Centers" because they feel some individuals are afraid of surgery. Yet all of these actions occur in psychiatry.