Expanding roles for primary care providers in mental health care.
Posted Dec 05, 2018
by Eugene Rubin MD, PhD and Charles Zorumski MD.
Psychiatric disorders are common medical conditions that can lead to disability and death. Symptoms involve changes in cognition, emotion, and motivation, and are often accompanied by a variety of physical symptoms. Depression is considered one of the most disabling of all medical conditions. Substance use disorders, including opiate use disorders, can be fatal and are receiving well-deserved national attention. Psychotic disorders such as schizophrenia are associated with substantially diminished life expectancy. Autism has life-long medical and social consequences. Cognitive illnesses such as Alzheimer disease are devastating conditions that typically affect the elderly.
Suicide is now the tenth leading cause of death in the United States and the second leading cause of death in individuals 15-to-34-years-old. Over the last 15 years, the suicide rate has increased about 27 percent, and it is believed that the reported suicide rate underestimates the magnitude of the problem. In this country, a suicide occurs about every 12 minutes.
Suicidal thoughts are almost always associated with a psychiatric disorder. Almost all individuals with suicidal thoughts are suffering from depression, substance use disorders, and/or personality disorders. Almost half of those dying from suicide saw their primary care providers during the month prior to their deaths, and primary care doctors are often the conduit to the mental health system for patients. Primary care doctors are familiar with treating common medical illnesses such as hypertension, high cholesterol, and diabetes, but they have less familiarity with handling serious psychiatric illnesses. Nonetheless, primary care doctors and their teams are increasingly being expected to recognize and treat common psychiatric disorders.
The National Action Alliance for Suicide Prevention was established in 2010. Part of this organization’s strategy to reduce suicides involves encouraging changes in the healthcare system to identify, assess, and treat persons at risk for suicidal behavior. This group recently released a report recommending standards of care designed to increase recognition of suicidality as well as pragmatic steps to help decrease the risk of an individual completing suicide.
The group suggests specific approaches for various health care settings, including primary care offices, outpatient mental health offices, emergency departments, and inpatient psychiatric and addiction units. They discuss five elements of standard care in each setting: the emphasis of care that each setting should provide, identification and assessment of suicidal risk, safety planning, means reduction, and institution of caring contacts. The overall approaches suggested in this report are pragmatic. Their intent is to aid in the recognition of suicidality, provide supportive measures including close follow-up, and help each individual reach the appropriate care setting.
Until recently, many physicians in medical settings, including primary care settings, have shied away from evaluating and treating psychiatric disorders. Many non-psychiatric physicians have not been adequately trained, both clinically and attitudinally, to deal with depression, suicidal thoughts, psychotic symptoms, substance use disorders, and symptoms of personality disorders. Until recently, there has been an unwritten tendency to separate care for psychiatric disorders and "real" medical disorders.
With increased recognition that psychiatric disorders are common and associated with significant disability and mortality, primary care and emergency room doctors are being expected to play major roles in recognizing and initiating treatment of individuals with such conditions. This movement is enhanced by an emphasis on integrative medical care.
There are many models of integrative care, but all involve increased interactions between a patient’s physical health and mental health care providers. Such models of integrated care are extremely important because our country does not have, and will not have in the foreseeable future, enough well-trained, high quality mental health care providers, particularly psychiatrists and those with expertise in handling suicidality. Integrative care models are designed to increase access of mental health expertise to a larger population through coordination with the primary care system.
The need to improve training in psychiatry for non-psychiatric physicians is increasingly recognized. Reports such as the one from the National Action Alliance for Suicide Prevention addressing suicidality in primary care and emergency room settings reinforce the urgency of this increased training. Changes in physician education will be one important step in dealing with the problem of suicide, but steps to implement cost-effective integrative care will be equally important.
This is an important and necessary evolution of the health care system.
National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. (2018). Recommended standard care for people with suicide risk: making health care suicide safe. Washington, DC: Education Development Center, Inc.