Tuesday, January 22, 2008

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

  • When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
  • Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
  • For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
  • Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
  • When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
  • Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
  • Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
  • Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
  • If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
  • Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.
Sorry, a little haphazard, maybe Roy can come in and add an addendum....


Anonymous said...

Let's see ... the shrink gets anyone with serious suicidal ideation (their life is at risk), psychotic symptoms, bipolar disorder, failure of one antidepressant, or anything significantly screwing up their life. Well ... what's left? Really mild dysthymia or really mild anxiety? I question whether that kind of thing should even be treated with medication at all.

Aqua said...

This is interesting, because last week on my blog I wrote my story about how it took 18 years for me to be referred to a psychiatrist. Timely post.

I hope referrals are done better now than they were when I was struggling for so long to get the help I need.

The Shrink said...

Completely agree that psychosis and BPD should see us.

I'd also add, simply 'cause we haev the expertise to enhance their care :
- eating disorders
- dementia
- incapacitated adults (i.e. those who lack capacity to make decisions) with neuropsychiatric sequelae to their disorder, where Primary Care doctors are making management decisions acting in their best interests

distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts
I'd swap the "and" for "or" there.
If the patient is quite content with grappling in Primary Care but the Primary Care doctor is feeling at their wits end, I'm keen to see their patients. I may not be able to effect change in the patient's management plan but I can generate a credible management plan for the Primary Care doctor.
Helping support our Primary Care colleagues is a useful role that's valued.

Anonymous said...

That's interesting, aqua, considering I kind of had an opposite experience ... I got forced (um, I mean, encouraged very strongly) to see a psychiatrist and I didn't want to. (But now am VERY glad I did.)

The Shrink said...

Sorrel, partly to show the breadth of what we can do, if I just think of official psychiatric diagnoses (and exclude things like "stress" and "bereavements" and the like that aren't in ICD-10) a lot's still left that Dinah's thinking Primary Care docs can initially have a stab at :
- alcohol misuse
- substance misuse
- a past psychotic episode that's now in remission
- mild mood disorder (that although is called 'mild' as a specific psychiatric diagnostic term ICD-10 F32.0, the psychological impact can be intense)
- chronic low grade mood states such as dysthmia
- phobic disorders
- panic disorders
- generalised anxiety disorders
- obsessive-compulsive disorders
- dissociative/conversion disorders
- depersonalisation/derealisation
- neurasthenia (mental and physical fatigue)
- acute stress reactions
- somatisation disorders
- sleep disorders
- sexual dysfunction
- postnatal depression
- personality disorders
- habit and impulse disorders
- gender identity issues
- mental retardation
- disorders of speech and language development
- specific developmental disorders of scholastic skills, pervasive developmental disorders, childhood autism
- hyperkinetic disorders (e.g. ADHD)
- childhood conduct disorders

Dr. Smak said...

Great post, Dinah -

I personally will go through two SSRI trials before I recommend psychiatry to patients (whom I otherwise think are primary care appropriate.)

In all honesty, my biggest struggle is getting patients who are not primary care appropriate to see psych. They don't want to drive. Their insurance doesn't pay well for it. They don't want to have to go to another appointment. Can't you just refill it while I see you for my diabetes, hyperlipidemia, hypertension, and did I mention my left elbow hurts?

How some primary care doctors do counseling is beyond me. In my visits, I barely get through SIGECAPS.

Conservatively, I'd say at least half of my patients whom I treat for mental health should probably be seeing a psycho and getting counseling/therapy. I'm not holding my breath.

Thanks for your take on who should be referred.

Dr. Smak said...

Oops, that was psych, not psycho.

Freudian slip, anyone?

Dreaming again said...

Someone beat me to the eating disorder suggestion. And that needs to be a team approach, not just psychiatry. Psychiastrist, therapist and nutritionist.

Question about your anti xanax for anxiety ..what about when it's the only drug the insurance covers for anxiety and anxiety is a severe issue?

janemariemd said...

Excellent post and comments.

I'm with Dr Smak--the number of patients in my primary care practice whom I'd like to get to a mental health professional of ANY kind vastly outnumbers that number who eventually go. We have exactly one psychiatrist in town who takes Medicare, the rest require payment up front. We have a list of mental health professionals that I give to most patients with depression, anxiety, or simply life stresses (marital, job, family problems).

Anxiety Disorders said...

my brother has been stable on Lithium for the past 8.5 years. and yes, the psychiatrist said he doesn't need her to prescribe it.

Anonymous said...

wow. i'm kind of appalled. for a lot of those issues a psychiatrist isn't definitely necessary, medication shouldn't be the first course of action for anxiety or depression. psychotherapy can just as well help. we're all way too medicated... although it does feel pretty great.

EastCoaster said...

This is an old thread which I found via a search for "lithium", but when I was in college (93-97), my PCP at University Health Services didn't prescribe an antidepressant. A psychiatrist did at UHS, and it was the social worker who referred me after I pushed hard to explain how poorly I was functioning and that talking to her wasn't enough. SSRIs were new then, and the zoloft I was given came with a prescription for desipramine to counteract any potentially activation from the zoloft. Do PCPs like to prescribe tricyclics? I don't think that mine wanted anything to do with being the prescriber.

I would add another category to the list of people who should be seen by a psychiatrist: anyone who has a family history of serious mental illness (at the very least psychosis, depression that required hospitalization or ECT) or substance abuse. At least for an initial evaluation.