When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?
However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.
Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.
Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.
A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.
The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.
The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.
Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.
Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.
Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?
The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).