Primary care doctors carrying heavier mental health load
■ More than a third of patients rely solely on them to treat psychiatric conditions as the number of psychiatrists fails to keep pace with demand.
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As an internist, Charles Cutler, MD, was trained primarily to detect and treat physical problems. But he sees many patients for mental health issues at his practice in Norristown, Pa.
Because psychiatrists in the area frequently do not have openings for new patients, Dr. Cutler often provides mental health treatment.
He is among a growing number of primary care physicians who say they are handling a greater load of mental health care. A report from the Center for American Progress, a public policy and advocacy organization, shows that more than a third of patients who receive treatment for mental health disorders rely solely on primary care physicians.
"A key part of primary care is an awareness of the need to provide mental health services to your patients. If you're doing primary care and you're not aware of that, you're in the wrong field," Dr. Cutler said.
Although treating psychiatric conditions in primary care is not new, the amount of cases physicians are seeing is increasing, said Thomas Wise, MD, medical director of behavioral health services at Inova Health System in Falls Church, Va.
One reason for the trend is that there are too few psychiatrists to meet the nation's mental health needs, doctors say. In the past decade, the number of practicing psychiatrists has grown from 39,494 to 40,904 -- an uptick of only 1,410, according to 2010 data from the American Medical Association's Physician Characteristics and Distribution in the U.S. The figure does not include specialists in child and adolescent psychiatry.
Although the number of psychiatrists has increased, the supply is not keeping pace with the demand for such specialists, said Steven Schlozman, MD, an assistant professor of psychiatry at Harvard Medical School in Boston. Too few students pursue psychiatry, in part, because the specialty typically requires four additional years of training after medical school -- more if doctors pursue child and adolescent psychiatry, he said.
In addition, psychiatrists often are disproportionately spread across the country, with a majority practicing in urban areas. And there is a stigma attached to psychiatry by some patients who may feel more comfortable seeing a primary care doctor for mental health issues.
Prevalence of mental illness
Nearly one in 10 Americans 18 and older is depressed, according to a Centers for Disease Control and Prevention study in the Oct. 1 Morbidity and Mortality Weekly Report. One in four adults has a diagnosable mental disorder in any given year, according to the National Institute of Mental Health.
When a psychiatric issue is identified, primary care doctors have limited options for referring patients to specialists due to the shortage of mental health professionals, particularly child and adolescent psychiatrists, Dr. Schlozman said.
Additionally, many health insurers contract out psychiatric benefits to different companies. Unlike most referrals from physicians, this approach often requires patients to find an available psychiatrist by making calls from a list provided by their insurer.
"This makes it immensely more difficult for patients to get care," Dr. Schlozman said.
Another problem is that some primary care physicians lack the training and appropriate amount of time to successfully treat mental problems, experts said. The result is that some mental disorders are going undiagnosed.
With mental illness affecting all ages and experienced by many with chronic conditions, the impact is great. "This is not something we can ignore," said Lesley Russell, PhD, a visiting fellow at the Center for American Progress.
In October, the center issued a report on mental health care services in primary care. The report said more primary care doctors are treating mental health problems, but the quality of treatment is uneven, because many conditions are going unrecognized and untreated. Only a third of cases seen by primary care doctors received minimally adequate care, the report said.
Improving mental health care
To ensure that patients with mental health issues do not go untreated, the U.S. Preventive Services Task Force in 2009 recommended that physicians screen adults for depression when there is a support system in place to ensure "accurate diagnosis, effective treatment and follow-up."
Physician organizations, such as the American College of Preventive Medicine, also have issued depression guidelines for doctors to use. In 2009, the college recommended that primary care doctors screen all adult patients for depression.
In October, the American Psychiatric Assn. issued new clinical guidelines for patients with major depressive disorder, updating its 2000 guidelines. The guidance includes new evidence-based recommendations on antidepressants, depression-focused psychotherapies and strategies for treatment-resistant depression.
In the primary care setting, physicians should look for signs of mental health problems, such as trouble sleeping and eating, experts say. In children, doctors should look for atypical behavior that begins suddenly, such as irritability or a drop in grades with a good student, said Ulrick Vieux, DO, medical director of Children's Community Mental Health Services at St. Luke's and Roosevelt Hospitals in New York.
Daniel Yohanna, MD, vice chair of the Dept. of Psychiatry and Behavioral Neuroscience at the University of Chicago Medical Center, encourages physicians to attend mental health lectures at medical conferences. He also recommends that primary care doctors modify their practices so staff members can consult mental health specialists easily when they identify patients with psychiatric issues.
Russell, of the Center for American Progress, said some barriers to receiving mental health care will be reduced by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. The law, which took effect Jan. 1, prohibits group insurance plans from restricting access to mental health care by limiting benefits and requiring higher patient costs than for general medical or surgical benefits.
Dr. Yohanna said telemedicine, such as video conferencing, might help physicians connect with child psychiatrists to evaluate a patient. Despite the benefits of the health parity law, challenges will remain for primary care physicians, he said.
"It's true that most of the people with psychiatric disorders are seen in primary care," Dr. Yohanna said. "It's up to [psychiatrists] to figure out ways to assist them, because we're not going to put a psychiatrist in every county."