VANCOUVER, B.C. — Primary care physicians in community health centers say they are practicing “reluctant psychiatry” because mentally ill patients with chronic diseases often have nowhere else to turn for care, Dr. Carol Darr reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.
“They hate it. They're dealing with many, many things beyond the scope of their knowledge,” said Dr. Darr of the Colorado health outcomes program at the University of Colorado Health Science Center in Denver.
Dr. Darr and her associates conducted 71 semistructured interviews with primary care physicians and staff members and observed 198 hours of clinical care and practice processes at seven community health care centers that serve uninsured or underinsured working poor families in the Denver region.
They found that mental health issues significantly complicated the care of chronically ill patients served by the clinics, but that a combination of spending cuts and a shortage of mental health professionals created barriers in referral.
The physicians said they felt they were often “on their own,” either consciously ignoring clues to mental health issues or practicing “reluctant psychiatry” outside of their scope of expertise, said Dr. Darr in an interview at the meeting.
Statements by the respondents illustrated their high level of frustration as their clinics are increasingly forced to manage chronically ill patients with mental health problems. In many cases, specialty clinics have closed or cut back their services because of funding cuts. Other times, families lose access to care through the loss of Medicaid or other insurance programs.
“This is beyond me,” one physician said of a particular patient. “I don't know what to do with the man. I've adjusted his meds as much as I can do [as] a primary care person. But he needs a little bit more than that—he's still hearing voices.”
Another physician described a patient who saw a psychiatrist and received psychotropic medications while hospitalized but did not receive them after her release.
“She's 100% in-house managed now,” the physician said. “And this woman truly does need to see a psychiatrist … somebody who understands psychosis and … all the antipsychotics and all the medications that she's on. As family practitioners, we do the best we can, but we're not psychiatrists. She's pretty poorly controlled.”
Yet another physician said, “If you feel you don't have a lot of tools at hand to deal with the mental health side of things, that tends to be the last thing you get to … why open that can of worms if you don't know [how] to solve the problem?”
Respondents described trying to obtain more psychiatric training “on their own or on the job” and said they sometimes have to “curb side” a psychiatrist to obtain an informal consultation about some of these cases, said Dr. Darr.
One physician recalled getting a telephone consultation with a psychiatrist who vowed never to speak to him again after he learned that his name would appear in the patient's chart.
Dr. Darr said the findings suggest that those compiling medical education models and drawing up clinical guidelines may need to rethink their assumptions that primary care physicians have the option of referring patients with serious mental health disorders to psychiatrists. Risks and liability issues are elevated whether primary care physicians ignore mental health issues or treat complex disorders outside of their scope of practice, she added.
“Reluctant psychiatry exacts a toll on the individuals forced to practice it, on the patients whose care is compromised for lack of appropriate specialty care, and on the society that absorbs the cost of supporting increasing numbers of individuals whose physical and mental health are poorly controlled,” she concluded.