As health care continues to shift in the United States from fee-for-service to managed care, and away from specialist-driven care to the primary care gatekeeper, it is necessary to re-examine psychiatric training and the psychiatric services that are being provided.
Growing numbers of psychiatrists believe that forming strong affiliations with primary care physicians is crucial for their future (Nickels and McIntyre, 1996). Some surveys, however, suggest that only a minority of academic psychiatry departments have shifted substantial resources toward primary care (Wulsin, 1996).
The need for this shift becomes compelling when considering that the great majority of psychotropic medications are prescribed by primary care physicians and medical specialists, and that approximately 25% of patients in the primary care setting have a mood disorder (Pincus et al., 1998; Spitzer et al., 1994).
What is clear is that common psychiatric disorders are not well-diagnosed in this setting, and pharmacotherapy is employed less intensively than is optimal (e.g., Wells et al., 1994). All this must be placed into the following context: Within traditional health settings, most people get their psychiatric care from primary care providers, not from psychiatrists (Regier et al., 1993).
Despite concerns that their patient base and political power may be subsumed by primary care providers, there are enormous opportunities to assert that psychiatrists are pivotal in ensuring quality medical and psychologic health in this country. These opportunities are in the areas of service delivery (Katon et al., 1996), education (Steinberg et al., 1996), research (Barsky, 1993), and health policy formulation (Henk et al., 1996). These opportunities extend from the level of the single provider to national representation in professional and political organizations. Thus, there is a strong case to be made for collaboration between psychiatrists and primary care physicians.Stating the Case for Collaboration
It is important first to note that in order to work with large groups of patients, psychiatrists cannot function without primary care providers. One reason for this is that primary care providers control large percentages of psychiatric referrals. Without a referral from a primary care physician, many patients with managed care cannot have reimbursed access to specialty treatment. This lack of reimbursed access will greatly reduce the number of people who will self-refer to psychiatrists (Forrest and Reid, 1997).
Another equally important reason why psychiatrists need primary care providers is that there are not enough psychiatrists to treat everyone who has a mental illness. This calculation can be based on the National Comorbidity Survey (Kessler et al., 1994): If all Americans who needed psychiatric care were diagnosed and treated, each psychiatrist annually would see roughly 250 new people with mood disorders and about 1,000 new people with any mental disorder. In contrast, the 1996 National Survey of Psychiatric Practice, a study of 970 American Psychiatric Association members, indicates that psychiatrists treat 39 patients per week and receive 16 referrals per month, on average (Peterson et al., 1998).
There are many reasons why psychiatrists are not inundated with patients to the degree that the National Comorbidity Survey implies: 1) many people who would agree to psychiatric treatment are not being diagnosed; 2) many people have cultural or personal distrust of psychiatry or Western medicine; 3) many people form extremely close relationships with their primary care provider, who becomes the only person they will trust with their mental health care; 4) economic barriers to mental health treatment; 5) limitations to how much we can help certain people (e.g., those with antisocial personality disorder); and 6) suboptimal collaboration between psychiatrists and primary care physicians to increase detection and treatment of mental illness.
Again, most people seek out their primary care provider for mental health care and, to further encourage this, the federal government's Health Care Financing Administration has given financial incentives to New York State residency programs as a demonstration project to reduce the number of psychiatry residents they train. This is part of a larger movement to reduce the number of specialists trained and increase the number of generalists.
Conversely, it is crucial to understand that primary care providers will not function optimally without mental health care providers. On one level, they benefit from psychiatric expertise in addressing issues of patient adherence to medical treatment and psychological issues that complicate medical treatment. This is an extension of consultation-liaison psychiatry to the outpatient setting. In addition, many patients will have mental health problems too complex for primary care providers to treat effectively-this calls for psychiatric expertise in diagnosis and treatment, and for facilitated referral pathways. As outpatient consultants and mental health care providers, psychiatrists will relieve the stress or burden primary care practitioners often face when treating patients with mental illness (Taylor and Wilkinson, 1997).
Ultimately, the distinction between psychiatric and medical problems is artificial, an outgrowth of a dualistic division between mind and body. According to one study, for example, depressed patients will have a 100% increased prevalence for coronary heart disease (Ford et al., 1998), and according to another study, depressed patients will have a 400% increased mortality rate six months after a myocardial infarction (Frasure-Smith et al., 1993). Possible causes for these outcomes are that depressed patients have both increased platelet activity and decreased heart rate variability. Studies underway will address whether treatment of depression will improve cardiac outcome.
There is some good evidence that mental health treatment can improve medical outcomes in some kinds of cancer (McDaniel et al., 1995). For example, women with metastatic breast cancer live 18 months longer if, in addition to treatment as usual, they also receive group therapy (Spiegel et al., 1989). Along with the direct benefits to patient well-being and the expansion of psychiatrists' roles as physician-healers, these consultants may decrease health care costs as well. Primary care providers need psychiatrists. Therefore, patients with mental illness or psychological stress should not feel that they must choose between a primary care provider or a mental health care provider. Many patients will have optimal health, medical and mental, with care from both sectors.
Perspectives About Service Delivery
The barriers to more effective mental health treatment on a population level are difficult to address, but psychiatrists can make significant contributions toward solutions by examining models that lead to increased collaboration between themselves and primary care providers.
At the simplest organizational level, a psychiatrist working as an individual practitioner, who has a strong relationship with several referring primary care providers, either directly or through a patient's managed care organization, will ensure a steady stream of patients. According to the 1996 National Survey of Psychiatric Practice (Peterson et al., 1998), only 16% of referrals to psychiatrists came from nonpsychiatrist physicians. If primary care providers are going to continue to control a significant percentage of specialist referrals, it makes sense for psychiatrists to affiliate in ways that will appropriately increase mental health care referrals from them. It is important to understand the needs of primary care providers in order to know how to form tight relationships with them and how to best serve both them and the interpro-fessional patient base. Common sense dictates the individual characteristics primary care physicians value: reliability, availability, an impression of a good work ethic, timely communication without psychiatric jargon and a feeling that they are not being analyzed. As an example, a primary care physician may call to complain, "I am disgusted with this patient who keeps showing up every week with dizziness, and nothing is wrong with him. I gave him a million-dollar workup. He is somatisizing! Can you see him?"
It is well-advised at this point to refrain from questioning the doctor about his or her aggression toward the patient, or to wonder how the disgust that has entered the medical relationship may be exacerbating the patient's dizziness. Good responses may include showing genuine support ("That is a difficult person to treat. How can I help you out?") combined with education ("Sometimes dizziness can be a manifestation of anxiety. I would be happy to see the person.")
This may sound simplistic or condescending, but as Mack Lipkin, M.D., illustrates, both primary care physicians and psychiatrists sometimes stereotype the personal attributes of one another. There are, in other words, some cultural differences in the training received and the different languages used by each specialist that become distorted into pejorative mythologies. It is important to be sensitive to these differences as interspecialty relationships develop, in order to dispel myths that some physicians may have about psychiatrists: that they are unavailable, ineffective, not knowledgeable about medicine, not particularly hard-working and condescending of other specialties. A psychiatric consul-tant can be viewed as an outsider who is being given access to a social group by a high-status member (Karasu and Hertzman, 1974). To garner respect, the psychiatric consultant must meet the expectations of the primary care physician.
In addition, the specialized knowledge that consultants bring to the situation may arouse competitiveness from one or both parties (Perry and Viederman, 1981). This competitiveness can be healthy, as it may spur both clinicians to work at a high level, but when it is excessive it could be destructive. This is a point to stress, because as gatekeepers, primary care physicians are placed in a position of power and may be perceived by the psychiatric consultant as threatening.
Collaborating with primary care physicians is partly outpatient consultation-liaison psychiatry, and it carries with it the same rewards-keeping up-to-date about medicine, feeling like part of a team, and bridging the interface between the mind and body. Ultimately, patients get better care with collaborative models. Much excellent work has shown that having psychiatric services on-site in a primary care setting can improve psychiatric outcomes (for example, Katon et al., 1996), and many medicine departments are eagerly embracing this model of collaborative care.