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When to Refer to Psychiatry: Practical consideration for the primary care provider

10/5/2020

6 Comments

 
In the practice of medicine, there are clear moments where a specialist is needed. Seizures require a neurologist. Leukemia requires a hematologist. In mental health, there are similar lines in the sand. Acute mania requires psychiatry, commonly on an inpatient unit. Management with clozapine requires a psychiatrist. Electro-convulsive therapy requires a psychiatrist. 

However for less severe/complicated conditions, the potential to refer is often less clear. The following considerations may help extend care in the primary care setting or lead to a need for a referral:
  1. Comfort with psychotropic medications: Many primary care providers have comfort with an SSRI/SNRI or two, one methylphenidate medication and one amphetamine. This is quite appropriate and can lead to substantial healing for patients. In PAL trainings, we stress the need to build comfort with a few meds including an ability to reach therapeutic dosing. Referrals often come when those initial trials do not work or cause side effects. Calls to PAL can assist in setting up an appropriate second or third trial. Additionally, tapers and cross titrations are often stress points that lead to referral. Please call for coaching based around half lives of medications. The need for a mood stabilizer or anti-psychotic medication can also often lead to referrals. Consider a call to PAL to assist in safe initiation to avoid care delays if patient is waiting for psychiatric care.
  2. Access to psychiatry: In urban settings, referral may be easier with less obstacles to access. In rural settings, waitlist time can be substantial. Notably, the current pandemic and the easing of virtual health policy has decreased geographic access issues. Consider using fasttrackermn.org as a method to find specific care. When psychiatry is needed, especially for diagnostic needs, consider calling PAL to start appropriate care and referrals.
  3. Safety: Frustratingly, when safety rapidly becomes a concern, a patient is more likely to see an inpatient psychiatrist or emergency room physician before they see a psychiatrist. Self-injury remains common, and when it's not a normal part of day to day practice, this can lead to concern and rapid care escalation. Once this begins, consider engagement with psychiatry for assistance and ability to clarify needs of the patient. For chronically suicidal patients, psychiatry is warranted and should not be delayed unless care for those with mental illness has become the mainstay of your day to day practice.
  4. Support from additional service lines: Correct psychiatric diagnoses are needed to provide correct treatment. Information from therapists, teachers, case managers, occupational therapists, nursing home aids etc, can help inform diagnostics and benefits/side effects of medication. Collaboration with the these care modalities can bolster confidence in correct treatment and lead to early effective care and delay psychiatric referral.
  5. Practical mentorship availability: Mentorship and support can lead to increased comfort with psychiatric diagnoses in the primary care setting. Curbside consults, PAL calls or touching base with those who have longitudinally worked with mental health patients, may support each step in care leading to an extension of primary care services.
  6. Specific medication needs: Certain medications warrant psychiatric treatment. This list is extensive but includes: lithium, clozapine, antipsychotics, MAOI class antidepressants and clomipramine, to name a few. Often, primary care providers may need support in managing the medical needs of patients on these medications. It is appropriate to call the psychiatrist prescribing or PAL if questions/concerns arise.

The list above displays some of the considerations when referring to psychiatry. Access delays are not uncommon. If you are questioning a referral it would be appropriate to immediately refer to avoid morbidity while waiting for an appointment. Again, PAL can assist in bridging care in the meantime when needed.

​- Dr. Joshua Stein

6 Comments
Adam Golightly link
8/3/2021 01:55:11 pm

My cousin has been thinking about getting the right kind of primary care because it will allow her to be safer. Getting care from a professional could allow her to be a lot safer. I liked what you said about how they shouldn't have fewer obstacles to access the care that they need in order to be better.

Reply
Mia Evans link
10/19/2021 07:45:32 pm

Thanks for pointing out that it would be best to call the professionals and ask for referrals or for the appropriate care that you need if you might need psychiatrist services. I will share this tip with my sister now that she hasn't been at her best lately. It might have been caused by her toxic relationship of three years that ended just this year.

Reply
Millie Hue link
10/7/2022 03:18:06 am

It's great to know that it is easy to access psychiatric services in urban areas through referrals. I will tell this my sister because she already needs help with her anxiety which started when the pandemic happened. We are starting to have a normal life again, but she still has this crippling fear of going out.

Reply
child psychologist near me link
11/6/2022 04:33:49 am

The purpose of this study was to determine the factors that affect primary care practitioners' judgments about depression referrals. This study involved 40 primary care providers, including 15 general internists, 10 nurse practitioners, and 15 family practice doctors. The medical professionals took part in semi-structured interviews and finished two quantitative tests (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis showed that several factors, including the patient's resources, the clinician's comfort with prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment, influence the clinician's choice to refer a depressed patient to a mental health specialist.

Reply
Jessie Holloway link
11/22/2022 03:47:50 pm

I love how you point out the importance of consistent checkups with a psychiatrist. My partner has been struggling with seasonal affective disorder and we've been thinking about maybe trying a medication to help. We'll have to look into finding a psychiatrist we can go to get help.

Reply
Abby Littler link
1/30/2023 06:08:06 pm

Thank you for sharing this very informative content. It helps a lot especially to those who are seeking knowledge about this.

Reply



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    Dr. Adam Klapperich
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    ​Dr. Joshua Stein

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