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

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