A report in the May/June 2009 issue of Health Affairs reveals that at least two-thirds of 6600 primary care physicians (PCPs) were unable to obtain mental health care for their patients.1 The reasons cited include “manpower shortage” and “inadequate insurance coverage.” This extraordinary figure almost certainly includes problems with the referral process itself. Other factors may include the type of practice (solo vs group) and its location (rural vs urban).
Psychiatrists helping nonpsychiatrists refer their patients has a long but not always illustrious history. Patients admitted to a general hospital with emotional disorders are said to account for 25% of all admissions, yet referrals to consultation-liaison services rarely exceed 10%.2,3 And studies that have examined the detection and/or management of depression and other affective conditions in primary medical practice report a disappointing 50% failure rate.4 PCPs, as de facto mental health providers, are generally the first contact for individuals with emotional disorders; as such, it would be reasonable to expect a more robust referral rate.5
It is unlikely that much can readily be done to remedy manpower or reimbursement factors, but reexamination and possible modification of referral practices may enhance the availability and use of mental health services. The education and training model endorsed and promoted for decades by professional organizations such as the AMA, the American Psychiatric Association, the NIMH, the Institute of Medicine, and others has been a startling failure.6-8 Psychiatrists helping PCPs facilitate appropriate psychiatric referral may be a place to begin.
Barriers to effective referral present a challenge to both PCP and psychiatrist. Awareness of these impediments will help show the PCP how to minimize failure and disappointment. Some of these factors were identified at least 30 years ago, but a reevaluation in the context of today’s health care system is warranted.9 A partial list of barriers to successful referral appears in Table 1.
. . . not all evidence of psychosis requires referral; burned-out schizophrenia, for example, is readily managed and maintained by the PCP, with psychiatric backup.
Differences in tolerance of affect as well as training will influence awareness of psychosocial problems; medical education that emphasizes the biomedical model does not readily shift to a biopsychosocial one. Styles of interviewing and listening as well as beliefs affect the nature of physician-patient relationships. Stigma still prevails and fosters fear, apprehension, and distorted views of mental illness and psychiatry. Various specialties differ in their reliance on interviewing, technology, and laboratory results. Ultimately, funding and reimbursement are profound incentives (or disincentives) for both physician and patient to use available services.
Given these obstacles to incorporating a psychiatric dimension in primary care, psychiatrists must not expect PCPs to become “junior psychiatrists.” Psychiatrists learn skills of interviewing and working with patients in a time- and labor-intensive multiyear process of supervision and clinical experience that cannot be transferred to nonpsychiatrist physicians in brief courses, workshops, lectures, and seminars.
How can psychiatrists help?
How, then, might psychiatrists help their nonpsychiatric colleagues recognize the need for and successfully execute psychiatric referral? Effective referral begins with a good consultee-consultant relationship that includes familiarity with each other’s needs and idiosyncracies. While not routinely easy to initiate, occasional encounters may occur in institutional settings, as well as other settings. Helping PCPs familiarize themselves with mental health services and competent psychiatrists is a helpful beginning. Effective referral will, in part, hinge on expectations and knowledge each has of the other.
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