mental health referral question for fam med docs

[bmedclinic]

Hey All,
I'm a clinical psychologist that has experience in family medicine in the past and am in a new location, but looking to be in an integrated primary care situation again, this time most likely outside of a family medicine residency (but maybe not).

I was involved in a conversation yesterday that really got me thinking- when family medicine physicians want a mental health referral, what do they (you) specifically want? Do you want a psychiatrist to consult with about meds? Do you want a psychologist in your office that you can hand off your patient to for behavioral/somatic concerns? Do you just want to know your patient's mental health needs are being taken care of? Help me, as a psychologist, understand what a pcp is looking for, and how I can best work with them to manage mental health needs of their patients.

I really appreciate whatever you got.

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[cabinbuilder]

I don't prescribe initial any psych medications so I look for the mental health folks to assess and initiate pharm therapy. Once that has been established then I have no problem doing refills. My experience with psych issues is very minimal and I'm not comfortable making diagnosis. I also don't Rx ADHD medication. Also, when the patient doesn't seem to be doing well on established regimen, it's nice to have them re-evaluated by the mental health folks for any medication adjustments.

 

[saudades]

We've got a psychologist in our office and it's a great asset. A lot of times I'd like to send patients to psychiatry for help with meds, but we have a large indigent population so it's not always possible, so we sometimes end up managing bipolar or ADHD ourselves. I take care of quite a few psych patients because I'm pretty comfortable with it and I find that a lot of times (not always) I can start a simple regimen and send the patients to our psychologist and they get what they need. Of course sometimes you have to just do the best you can within your scope of practice and just make sure they understand that their condition could be managed optimally by a specialist, then do your best to get them in. Really I just want to make sure they're getting whatever psych needs they have taken care of, like you said. I'm sure there are many residencies and offices that would jump at the chance to have someone on hand for counseling!

 

[saudades]

Edit: sorry if that double posted.

 

[JustPlainBill]

I don't prescribe initial any psych medications so I look for the mental health folks to assess and initiate pharm therapy. Once that has been established then I have no problem doing refills. My experience with psych issues is very minimal and I'm not comfortable making diagnosis. I also don't Rx ADHD medication. Also, when the patient doesn't seem to be doing well on established regimen, it's nice to have them re-evaluated by the mental health folks for any medication adjustments.

Agree 100% -- my approach is that if I get a new patient requesting psych meds, if they're completely out, I give them one month and then refer to psychiatry. If they're an established patient and stable on meds, I have no trouble refilling. I DO NOT do new diagnosis of ADHD/ADD peds or adult, period. Too easy to read up and fake the symptoms.

I've had cases where a parent wanted me to dx the teenager with ADHD and start meds (which they had looked up on Dr. Google) -- I declined and referred to psychiatry. A month or so later, they present again having seen a psychologist who had charged them several hundreds of dollars an hour to dx and had made some general suggestions for therapeutic medications but said they would need to have their PCP begin and titrate those medicines. They became somewhat miffed when I informed them I had recommended/referred a psychiatrist who could start meds and stabilize the dose after which I would be happy to refill as long as the patient was stable. One of the parents tried to intimidate me with the old,"Well, we could just take them somewhere else...." to which I responded, "Yes, you surely could"....

As far as a psychologist goes -- to my knowledge this is more of a counseling sans medications field, so if my patients require that sort of therapy, that's where I'll send them.

 

[deleted87716]

I'll utilize psychology for psychotherapy (e.g., CBT, etc.) I'll refer to psychiatry for med management for conditions that I'm not comfortable with (e.g., bipolar d/o, schizophrenia, atypical depression, anxiety/depression not responding to first-line medications, etc.) I'm pretty comfortable treating ADD/ADHD, monopolar depression, generalized anxiety disorders, etc.

 

[styphon]

I'll utilize psychology for psychotherapy (e.g., CBT, etc.) I'll refer to psychiatry for med management for conditions that I'm not comfortable with (e.g., bipolar d/o, schizophrenia, atypical depression, anxiety/depression not responding to first-line medications, etc.) I'm pretty comfortable treating ADD/ADHD, monopolar depression, generalized anxiety disorders, etc.

I am like the above, I feel comfortable treating Anxiety, depression, and even BPDII. What I want in a PSYCHIATRIST is someone to see Schizophrenics, severe bipolars, treatment resistant depression. I also do not start people on ADD meds, I like a psychiatrist to make this decision, but I will do the follow up if needed.

I would like a PSYCHOLOGIST to do CBT, Dialectic therapy for borderlines, trauma/PTSD counseling, grief counseling..

 

[Bacchus]

There's a fantastic AAFP review article on ADHD diagnosis in the adult population. We are doing our patients a HUGE disservice by not restarting meds or managing already diagnosed patients. I haven't had any patients request evaluation for diagnosis, but I have restarted several patients medications after lapse in treatment or insurance. If they are new to the office and they provide appropriate documentation I have no problem.

http://www.aafp.org/afp/2012/0501/p890.html

As far as depression, I'll do SSRIs and adjuncts such as remeron, trazadone or abilify.

Anxiety I'll do the SSRIs and judicious BZDs.

Uncomplicated bipolar disorder I'm OK with.

Our system's psych department doesn't service very many Medicaid patients which are the most vulnerable so someone has to do it

 

[deleted87716]

Uncomplicated bipolar disorder I'm OK with.

Yeah, I've yet to run across that (the "uncomplicated" kind).

 

[Bacchus]

Yeah, I've yet to run across that (the "uncomplicated" kind).

Meh. We throw lithium and depakote around here like an 8yo just smashed open a piñata. In our county I think our mental health provider ratio is about 1 in 750. In my parents' county it's 1 in 2500. I do think I have a psych-light qualification by the end of residency. I never dreamt I'd be using so many of these drugs. You'll cover most our office patients if you throw them an ACEI, statin, metformin, insulin and TCAs/SSRIs.

 

[deleted87716]

I'm busy enough. I'll leave the lithium and Depakote to the shrinkologists.

 

[Doctor4Life1769]

There's a fantastic AAFP review article on ADHD diagnosis in the adult population. We are doing our patients a HUGE disservice by not restarting meds or managing already diagnosed patients. I haven't had any patients request evaluation for diagnosis, but I have restarted several patients medications after lapse in treatment or insurance. If they are new to the office and they provide appropriate documentation I have no problem.

http://www.aafp.org/afp/2012/0501/p890.html

As far as depression, I'll do SSRIs and adjuncts such as remeron, trazadone or abilify.

Anxiety I'll do the SSRIs and judicious BZDs.

Uncomplicated bipolar disorder I'm OK with.

Our system's psych department doesn't service very many Medicaid patients which are the most vulnerable so someone has to do it

You actually write for abilify and other anti-psychotics/mood stabilizers to augment anti-depressant effect in those who seemingly have "complicated" depression?

What's exactly is considered "uncomplicated" bipolar disorder?

I have no problems providing refills, especially in ADHD pts, provided they are still seeing a psychologist/psychiatrist and there is good effect, etc. if there needs to be a dose adjustment, back to psych office you go.

Even if I assume a pt is depressed - I don't like starting SSRIs, TCAs, etc in the off-chance the person could be hypo manic and starting such med could lead to a manic episode. I will give mirtazapine only if someone has insomnia, reduced appetite, and mild depression and then taper off. Trazodone for sleep but normal appetite/weight etc.

I do not write for benzos.

 

[bmedclinic]

Wow. Thanks for the responses. To follow up, basically, you want

1. Access to psychiatrists for the complex (Serious Mental Illness, or SMI) cases.
2. Access to psychologists in a secondary sense, for referrals for therapy.

Seem like a fair synopsis, then?
To follow up to point 2, how do you feel about the referral process, and what would you like psychologists to do to fix it, considering patient confidentiality, time constraints, etc?
What about patients that you really want to see a psychologist who you suspect wont go? Obviously you cant walk them to my office, so what would you like to see happen?

 

[FrustratedFamDoc]

I do a lot of psychiatry for my patients. I enjoy it and the community resources are really lacking. I manage BPD and monopolar depression, anxiety and ADD. I'll initiate mood stabilizers, SSRIs, SNRIs and have close follow-up until improvement is seen. My residency training was super heavy on psych so I'm pretty comfortable with it.

I'll utilize psychology for ADD assessment, counseling and CBT. I'll refer on to psychiatry for the cases that I'm clearly just not making any progress on. Unfortunately, those usually come with a lot of secondary gain problems.

 

[deleted87716]

To follow up to point 2, how do you feel about the referral process, and what would you like psychologists to do to fix it, considering patient confidentiality, time constraints, etc?

I'm not aware of any insurance plans that actually require a referral for mental health services. In most cases, there's a mental health carve-out. Plus, most psychiatry practices won't allow PCP offices to schedule appointments for patients. They want the patient to make the appointment themselves. I guess this has something to do with no-show rates. Anyway, all I can do is recommend to a patient that they see psychology/psychiatry, give them a list of local practices, and the rest is up to them (assuming they aren't suicidal). I will not treat conditions that I'm not comfortable with.

What about patients that you really want to see a psychologist who you suspect wont go? Obviously you cant walk them to my office, so what would you like to see happen?

I actually have walked a patient to a psychiatrist once (they're right next door to us, and the patient was suicidal). I called first and told them the situation, and they said "bring him over." If not for that, I'd have had to call EMS to have him transported to the ED for a psych assessment.

 

[Bacchus]

You actually write for abilify and other anti-psychotics/mood stabilizers to augment anti-depressant effect in those who seemingly have "complicated" depression?

What's exactly is considered "uncomplicated" bipolar disorder?

I have no problems providing refills, especially in ADHD pts, provided they are still seeing a psychologist/psychiatrist and there is good effect, etc. if there needs to be a dose adjustment, back to psych office you go.

Even if I assume a pt is depressed - I don't like starting SSRIs, TCAs, etc in the off-chance the person could be hypo manic and starting such med could lead to a manic episode. I will give mirtazapine only if someone has insomnia, reduced appetite, and mild depression and then taper off. Trazodone for sleep but normal appetite/weight etc.

I do not write for benzos.

You don't prescribe SSRIs...?

 

[Doctor4Life1769]

You don't prescribe SSRIs...?

Only if it's clear cut depression or anxiety. It takes 4-6 weeks for effect anyways. Usually an urgent referral. If they need something stat then they earn a 72hr inpt hold.

 

[Bacchus]

Only if it's clear cut depression or anxiety. It takes 4-6 weeks for effect anyways. Usually an urgent referral. If they need something stat then they earn a 72hr inpt hold.

Are there that many psychiatrists available where you are? I can't imagine making my patients wait 3-6 months here until they can get in.

 

[Doctor4Life1769]

Are there that many psychiatrists available where you are? I can't imagine making my patients wait 3-6 months here until they can get in.

There's plenty of mental health facilities and providers in my area. I'm not averse to SSRIs but not every "depression" is truly depression and you could potentially lead to a manic episode or worse, SSRIs can also lead to worsening depression and suicidal tendencies. They are not some benign medication and mental health is trickier than DM/HTN/HLD etc.

I do understand that frequent follow up is recommended with ED precautions, but CBT should always be number 1 option. Plenty of psychologists around.

You will be held to the same standards as that of a psychiatrist

 

[deleted87716]

It's not that difficult to correctly diagnose depression and GAD with a decent history and screening instruments like the PHQ-9 and GAD-7. Starting an SSRI is pretty elementary. You're not likely to miss bipolar disorder unless your history is really lacking. If you're that worried about suicidality, bring them back or call them in a week or two to make sure they're OK. As for the 4-6 week thing, that's what I tell patients to expect, but most are improving noticeably within a couple of weeks (especially with Lexapro).

The psychiatrists in my area kinda suck, too, which doesn't help.

 

[Bacchus]

It's not that difficult to correctly diagnose depression and GAD with a decent history and screening instruments like the PHQ-9 and GAD-7. Starting an SSRI is pretty elementary. You're not likely to miss bipolar disorder unless your history is really lacking. If you're that worried about suicidality, bring them back or call them in a week or two to make sure they're OK. As for the 4-6 week thing, that's what I tell patients to expect, but most are improving noticeably within a couple of weeks (especially with Lexapro).

The psychiatrists in my area kinda suck, too, which doesn't help.

Agree. Anyone I start comes back in two weeks, then 2-4 weeks after that follow up to see if dosing adjustment is needed. Anyone I think is depressed gets a PHQ-9 survey which is validated and sufficient. I use the GAD and BPD questionnaires as well. I have yet to uncover someone's mania by giving them an SSRI secondary to doing a thorough history. Everyone goes home with their visit summary which clearly states the black box warning associated with SSRIs and is given strict return precautions.

Patients deserve to feel well mentally. For my population of patients during residency training if I didn't prescribe SSRIs I'd be failing my patients. I'd liken it to using only metformin to treat T2DM and anything more needs to see endocrinology. I mean, insulin is dangerous and so are the sulfonylureas.

I have had too many people thank me for significantly improving their lives to not use them.

 

[Doctor4Life1769]

You don't need an SSRI to feel better. I have personal experience in this.

I have also had pts thank me for getting them off SSRIs or not starting them on it and they feel better without it.

I believe PCPs jump straight to SSRIs like its candy.

There is a major difference between insulin or other agents and SSRIs. Depression is not a serotonin deficiency or resistance issue.

 

[deleted87716]

You don't need an SSRI to feel better. I have personal experience in this.

Just be careful you don't let your personal experience (N=1, as they say) cloud your judgement.

Besides, if you're just going to send everybody to psych, what do you think psych is going to do? Most likely, they're going to put them on an SSRI.

 

[Doctor4Life1769]

Just be careful you don't let your personal experience (N=1, as they say) cloud your judgement.

Besides, if you're just going to send everybody to psych, what do you think psych is going to do? Most likely, they're going to put them on an SSRI.

If they do, they are doing it in conjunction with psychological evaluation and treatment in the form of some sort of therapy.

I don't allow it to cloud my judgement. I do use PHQ-9 etc. and I have continued SSRIs and at times started an SSRI. However, a lot of times we treat depression chemically more times than we should. The issues that lead to their depression need to be dealt with and resolved and not simply a medication being thrown at them as a band-aid. There are real side effects to these medications - weight gain, sexual dysfunction, sleep issues, further depression/suicidal thoughts, etc.

I do believe there is an "imbalance" but I do not believe medication is the primary treatment. Management of stress, anxiety, depression can be dealt with using a multi-disciplinary approach that does not mean starting an SSRI as the first line. If despite all options being explored, and there are still issues, then sure go ahead and start one. However, we are more likely treating dysthymia or acute/subacute/acute on chronic stress disorders rather than actual depression. Getting a good history is key, but a lot of times it is difficult getting that "good history." Patients aren't always open to revealing everything, as you know well.

 

[deleted87716]

I have no problems providing refills, especially in ADHD pts, provided they are still seeing a psychologist/psychiatrist and there is good effect, etc. if there needs to be a dose adjustment, back to psych office you go.

Why would you refill medications prescribed by somebody else, especially if they aren't drugs you're comfortable using...? You're definitely assuming liability in that situation, no question about it. It's your name on the prescription, after all.

If the patient is still following up with psychiatry, they should be getting refills from them.

And while we're on the subject of "refills," I'm going to draw a distinction between a "refill" and a "new prescription." It may seem like nitpicking, but it's important. A "new prescription" is what you give a patient (either in written form or electronically), based on your own evaluation (or re-evaluation) that said medication is appropriately indicated, safe, and effective for the patient to take (or continue taking). You may put "refills" on said prescription (generally up to one year's worth), which allow the patient to get a new supply of medication from their pharmacy without seeing you again. However, once said refills are gone, the patient needs to be re-evaluated for ongoing indication, safety, and efficacy (which usually means an office visit, or at least some type of contact with the prescriber). At that time, you may (or may not) give them another "new prescription" for the same medication, with or without "refills" on it.

So, technically, we never "refill" a prescription. That's what a pharmacist does. As prescribers, we "initiate" or "continue" therapy, based on our clinical judgement as to the appropriateness of ongoing treatment with regard to indication, safety, and efficacy. So, when you put your name on a new prescription (even if the original prescription was written by somebody else), that's exactly what you're doing.

 

[surrender903]

You actually write for abilify and other anti-psychotics/mood stabilizers to augment anti-depressant effect in those who seemingly have "complicated" depression?

What's exactly is considered "uncomplicated" bipolar disorder?

I have no problems providing refills, especially in ADHD pts, provided they are still seeing a psychologist/psychiatrist and there is good effect, etc. if there needs to be a dose adjustment, back to psych office you go.

Even if I assume a pt is depressed - I don't like starting SSRIs, TCAs, etc in the off-chance the person could be hypo manic and starting such med could lead to a manic episode. I will give mirtazapine only if someone has insomnia, reduced appetite, and mild depression and then taper off. Trazodone for sleep but normal appetite/weight etc.

I do not write for benzos.

if you re providing the refill why would the patient go see the other provider?

giving someone an SSRI is not a death sentence, you can treat an episode, and say you know what your mood has improved, lets montior it off, continue doing talk therapy, lets check in a few weeks/months. if you re that concerned about misdiagnosis of GAD/MDD vs Bipolar talk to a colleague, attend webinars, read afp, watch online CME, as your colleagues on *this* forum, private message if need be (my point is try to educate yourself the most you can)

in no way am i perfect, but deferring to a psychiatrist is going to end up giving your patients the short end of the stick especially with the volume of patients we see as primary care providers and the paucity of mental health providers.

as BD suggested, interacting with the patient doesn't end at the time of the visit, or when you get your labs back, or when you see a consultants note with the patients name on it. *CALL them* if you re concerned about their well being because you started them on a new medication.

"Hey you were on my mind this weekend, how are you feeling on this, do you want to come back in sooner?"

 

[Doctor4Life1769]

I provide refills knowing they are seeing a psychologist. I continue to monitor for side effects and discuss drug holidays or tapering doses as needed, or increased dose requirements. I don't need a psychiatrist to continue providing refills for a stable condition. I have documentation from the specialist as well. I did not realize I had to go in detail with that post.

I do make calls off hrs but I am not going to call every pt just to check in. Sorry, for the number of supposedly depressed pts y'all see it would take up my off time. If I'm running a DPC or concierge practice that's different.

It's not that I'm not comfortable treating depression, but my point is not every patient needs medication. I personally have been working on improving my comfort level with psychotic type disorders but we as PCPs should not be managing those or bipolar disorders and to those who feel like they can more power to y'all.

My recommendations start with dietary changes, sleep hygiene, vitamin d, folate, b12 checks, thyroid, diabetes screening (if appropriate), eval of work and home or school, stressors, personal and family, social hx and make changes accordingly. This fixes/improves most of the so-called depression without an SSRI in my brief experience.

Currently doing an urgent care shift so This was a quick post on my cell.

Of note, I don't touch anti-psychotics/mood stabilizers period

 

[styphon]

Even if I assume a pt is depressed - I don't like starting SSRIs, TCAs, etc in the off-chance the person could be hypo manic and starting such med could lead to a manic episode. I will give mirtazapine only if someone has insomnia, reduced appetite, and mild depression and then taper off. Trazodone for sleep but normal appetite/weight etc.

Although I love TCAs, I would also be very cautious about using TCAs on someone who presents with depression, it is like handing the person a loaded gun. Instead, I use TCA for neuropathic pain, fibro, migraine prophylaxis.

I actually have walked a patient to a psychiatrist once (they're right next door to us, and the patient was suicidal). I called first and told them the situation, and they said "bring him over." If not for that, I'd have had to call EMS to have him transported to the ED for a psych assessment.

I am lucky enough to be in the same complex as a group of BH/SA counselors. When I have a patient who I think is suicidal, I have the nurses escort them to the counselors who then do a lethality assessment. This is great, as my former office we would have to call EMS, who sometimes demand a police escort.

 

[Doctor4Life1769]

Although I love TCAs, I would also be very cautious about using TCAs on someone who presents with depression, it is like handing the person a loaded gun. Instead, I use TCA for neuropathic pain, fibro, migraine prophylaxis.



I am lucky enough to be in the same complex as a group of BH/SA counselors. When I have a patient who I think is suicidal, I have the nurses escort them to the counselors who then do a lethality assessment. This is great, as my former office we would have to call EMS, who sometimes demand a police escort.

Agree about the TCA and depression part. Seen too many people in ICU for intentional TCA o/d in that pop.

 

[bmedclinic]

So what keeps you guys from recruiting a psychologist to join your practice? Seems like everyone has a fairly positive attitude towards it. In theory, it would be great to get a psychiatrist too, but that seems like a much harder feat.

 

[Doctor4Life1769]

So what keeps you guys from recruiting a psychologist to join your practice? Seems like everyone has a fairly positive attitude towards it. In theory, it would be great to get a psychiatrist too, but that seems like a much harder feat.

A good Social worker is a great cheap option too

 

[deleted87716]

So what keeps you guys from recruiting a psychologist to join your practice? Seems like everyone has a fairly positive attitude towards it. In theory, it would be great to get a psychiatrist too, but that seems like a much harder feat.

We have psych in our group, but their office isn't co-located with mine.

 

[bmedclinic]

A good Social worker is a great cheap option too

and web md = cheaper than seeing a fam med doc. Are those equivalent?
Because psychologists = social workers, same training, same licensure, same competency. I just choose to charge a higher rate.

With no disrespect to social workers, your comment makes me curious if you understand the difference between what different mental health professionals bring to the table. Perhaps this is part of the problem. I've worked with social workers in primary care, and they do okay, but I'd argue we're not interchangeable. It's true, we both do therapy. That's about where the similarity ends. Psychologists tend to have a much deeper knowledge of therapy, working with different populations, medication, and better diagnostic skills. Additionally, most psychologists are research friendly, evidence based, and tend to be more skilled in handling difficult clients such as personality disordered clients. Again, I'm not saying psychologists are superior in every way, I'm saying that perhaps you aren't aware of the differences between how we're trained and what we do.

 

[bmedclinic]

A good Social worker is a great cheap option too

and aside from my above post, do you have a social worker integrated into your practice?

 

[FrustratedFamDoc]

My patients that I've referred to psychology to augment their medical therapy, or hopefully to develop internal mechanisms have all expressed great satisfaction with the experience. For some of my harder cases, it has significantly cut down on the follow-up frequency where "this drug isn't working, we need to change."

 

[Doctor4Life1769]

and aside from my above post, do you have a social worker integrated into your practice?

Actually, we do in our residency program. I say they are great options because a lot of them are trained to provide same day evaluations and also coping mechanisms in preparation for that psychology referral. I do not use social workers in place of a psychologist. It is just not often feasible to hire a psychologist in every practice setting. However, a social worker may also be helpful for patients who have multiple needs due to comorbidities, insurance issues, or just want someone to talk to without having to pay a co-pay and keep it confidential. I do not see psychologists out there with half the knowledge of available resources in the community for patients like I've seen a good social worker be able to provide to many of my patients.

Yes, feel free to accuse me of not understanding the complexity of mental health disorders. You are the one talking to someone who feels that patients should have complex mental health issues being evaluated by and managed by a psychologist/psychiatrist.

 

[styphon]

and aside from my above post, do you have a social worker integrated into your practice?

My facility has two social workers integrated into the facility, but they do not do counseling. Instead they help schedule apts, transport, keep medications straight, go to specialist apt's with pts....
We also have about 5 counselors (non social workers) who do BH and SA counseling.
We have a part-time psychiatric nurse practitioner who does med management only, no counseling.

 

[Doctor4Life1769]

My facility has two social workers integrated into the facility, but they do not do counseling. Instead they help schedule apts, transport, keep medications straight, go to specialist apt's with pts....
We also have about 5 counselors (non social workers) who do BH and SA counseling.
We have a part-time psychiatric nurse practitioner who does med management only, no counseling.

Our social worker does all that too (except actually physically taking patients to their specialists' appts)