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.