MDD Care Across Primary and Specialty Settings: Referral, Triage, and Safety

This episode, "MDD Care Across Primary and Specialty Settings: Referral, Triage, and Safety," features the psychiatry panel examining who is actually delivering depression care.

Dr. Alva observes that most major depressive disorder in this country is not managed by clinicians who would call themselves psychiatrists. He asks Dr. DeBattista which parts of the journey belong in primary care and which genuinely require a specialist.

Dr. DeBattista notes that primary care clinicians see the vast majority of these patients, while only a small percentage reach psychiatry. Some patients are actively resistant to seeing a specialist at all. On screening, he argues primary care does a fairly good job. The real constraints are structural. Primary care has minutes per visit, while his clinic has the luxury of an hour. He credits improved training in medical school. In his view, only the more serious end of the spectrum truly requires a specialist, including catatonia, suicidality, emerging bipolarity, or multiple failed trials. Asked where handoffs break down, he points to access and to the loop that never closes. Most counties do not have a psychiatrist, and even in the Bay Area, with its high concentration of mental health professionals, referrals are hard to place. He calls the problem structural but surmountable, requiring oversight from the primary care physician and an educated patient.

Dr. Alva then asks Dr. Oyedeji how severity and urgency shape whether she treats, monitors, or refers. She puts safety at the forefront and says risk to the patient or to others trumps everything else. That may mean a crisis team, a referral to a hospital, or an admission. After safety, she takes stock of current medications and what her toolkit allows. She notes that patients often arrive frustrated, urgently wanting their work, relationships, and families back.

In "Tricyclics, MAOIs, and Psychotherapy: Legacy Options in MDD Treatment," Dr. Clayton will revisit the agents that a generation of prescribers has largely stopped using.