When it comes to psychiatry, primary care could use the help

In Pierce County, Washington, where I work, it is difficult to find a psychiatrist to care for psychiatric cases that are outside the scope of practice of a primary care physician.  Our community is not unusual in this situation.  There is a nationwide shortage of physicians specializing in psychiatry.

According to Tom Insel, MD, the director of the Institute of Mental Health in 2011 both the number of psychiatry residency programs and the fill rates of the available training slots is declining. In addition 55% of psychiatrists are over age 55, compared to 38% of all practicing physicians.  The difficulty in finding available psychiatric care for patients with difficult psychiatric disorders is likely to get worse in the near term.

This is made worse by the shortage of primary care physicians.  Family practice physicians in particular have at least moderate training in the diagnosis and care of psychiatric disorders.  Over the last 10-20 years we have been left simply doing the best we can to diagnose and treat these patients because they simply cannot find a psychiatrist to assist with their care.  We often lean heavily on psychologists to help with counseling and psychotherapy.

Unfortunately we also have to rely on these psychologists more than is ideal for diagnostic assistance.  Many psychotherapists are pretty good at diagnosis, but they are simply not trained in the complex pharmacotherapy decisions that are involved in the care of these patients.  Oftentimes psychiatric nurse practitioners can help with these decisions, but they too are in short supply.  Too often I just have to do the best I can to make therapeutic decisions without a psychiatrist consultation or ongoing management.

The options for pharmacologic treatment of the major psychoses like bipolar disorder, schizophrenia, schizoaffective disorder, and major depression have become much more varied and intricate than they were not many years ago.  In addition many of the medications used in treatment are used off label, meaning that their use for treatment of these psychiatric disorders is not FDA approved.

The newer or off-label drugs are often better tolerated with lower chances of intolerable side effects than those seen with  many of the earlier antipsychotic medications which is a mixed blessing.  It can make a primary care physicians less reluctant to try treatment sometimes without rigorous diagnostic evaluation when a patient does not have access to a psychiatrist to help with coming to that diagnosis.

These illnesses are diagnoses almost entirely clinical, meaning there are no lab, imaging, or other quantifiable tests to confirm or add certainty to the diagnosis.  In addition, symptoms can vary considerably over time, modified by social circumstances, life stage and the patient’s overall circumstances.  Having a skilled psychiatrist is crucial to high quality care for many of these patients.  Often times it is simply not available, and primary care physicians just have to do the best we can.

What will it take to recruit and train more psychiatrists?  I really have no idea, though Dr. Insel gives hope that there is a movement in the focus of psychiatric training away from psychotherapy to more intense focus on the rapidly evolving field of clinical neuroscience as well as looking at novel ways to reach patients in need of care.  Hopefully he is correct in his hope that this change in focus will attract larger numbers of medical students into psychiatry, because we can sure use the help.

Edward Pullen is a family physician who blogs at DrPullen.com.

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  • Deceased MD

    BeforE you need a psychiatrist, you need to fix a broken mental health system. The number of psychiatric hospitals has shrunk.( As written by a previous article by Dr. Frances, there are a million less hospital beds and those have now been transferred to prisons.)
    If you see a psychotic pt, in outpt you need the back up of a psychiatric hospital in cases where they need hospitalization. And one that can hold them long enough to get treatment.

    • edpullenmd

      Agreed. We also have great difficulty finding any type of inpatient care. On another topic the difficulty in our state of getting inpatient help for young adults who need care but don’t fit criterion for involuntary hospitalization is another crisis in its own right. DrP

      • Deceased MD

        yes and that is nation wide problem as well, The laws are really inadequate. Do you get that feeling as well?

        • guest

          If you change the laws to make it easier to commit people (and/or keep them longer) you will make patients even more afraid to seek help.

          • Deceased MD

            This is only for pts that are a danger to themselves or others.

          • guest

            We already have laws which allow for involuntary admissions for danger to self or others. Loughner could have been picked up under the laws that existed, but that wasn’t done. The laws don’t mean much if people don’t use them.

  • MabelMabel

    We have the same situation with a psychiatrist shortage in my area. Thus, a local insurance company’s new mandate that ALL patients being treated by a psychologist for depression (the most common diagnostic condition) MUST have an evaluation with a psychiatrist, NOT a primary care physician, BEFORE being treated with talk therapy for depression, seems more like a crafty move to save money by not paying for treatment of depression given the lack of psychiatrists. I can hardly contain my disgust!

    • querywoman

      Tell the patient about the insurance company’s nutty policy. Try $4 meds first and suggest the patient pays out of pocket.

      • MabelMabel

        Thank you.