November 20, 1998

Primary care physicians provide care for more patients with mental disorders than the specialty mental health sector, according to former APA president John McIntyre, M.D.

And while many psychiatrists may find this fact disconcerting, effective collaboration with primary care physicians can ultimately benefit patients, psychiatrists, and primary care physicians, McIntyre said in a lecture last month at APA's Institute on Psychiatric Services in Los Angeles.

During his tenure as APA president, McIntyre stressed the importance of facilitating the interaction of primary care physicians and psychiatrists, and he has continued to do so. The relationship between primary care and psychiatry will determine whether people with mental illness are properly diagnosed and have access to care, he noted.

"Psychiatric disorders are very prevalent, serious, life-threatening conditions in primary care," said McIntyre, who is a clinical professor of psychiatry at the University of Rochester and chair of the department of psychiatry and behavioral health at Unity Health System in Rochester, N.Y. If psychiatrists and primary care physicians collaborate well, "our patients will be well served. If not, their care will be inadequate."

Sixty percent of referrals from other physicians to psychiatrists come from internists and family practice physicians, McIntyre noted. Efforts to better educate primary care physicians about when to refer patients to psychiatrists have not been very successful, he observed. A special version of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM) for primary care physicians "has not caught on" and may need to be made "more user friendly," he commented.

Given that nearly 30 percent of people ages 15 to 54 had at least one psychiatric disorder in the past 12 months, it is not surprising that many of these people receive psychiatric care from primary care physicians. Estimates are that 11 percent to 36 percent of primary care patients suffer from some psychiatric disorder.

Often physical complaints are what bring patients with a psychiatric problem to their primary care physician, observed McIntyre.

Compared with patients suffering from other disorders including hypertension, diabetes, heart disease, arthritis, and pulmonary problems, patients with depression score lower in most categories of physical and social functioning. The World Health Organization's Global Burden of Disease project identified unipolar major depression as the number one cause of disability worldwide in a report published in 1996 (Psychiatric News, November 1, 1996). The fourth greatest cause of disability was alcohol use, sixth greatest was bipolar disorder, ninth greatest was schizophrenia, and 10th greatest was obsessive-compulsive disorder.

Depression goes unrecognized in two-thirds of primary care outpatients, McIntyre noted. One in three patients who go to the emergency room with acute chest pain is suffering from either panic disorder or depression.

Among the top 10 percent of "heavy utilizers" of primary care, who average 15 medical visits and 15 phone calls in a given year, more than 68 percent suffer from major depression during their lifetime, and more than 40 percent suffer from generalized anxiety disorder.

One study of 119 high utilizers found that 45 percent needed antidepressant medication, but that only 11 percent received the correct dosage and appropriate length of treatment.

A survey for the Robert Wood Johnson Foundation published last year found that about 70 percent of primary care physicians report they have difficulty finding high-quality inpatient or outpatient mental health services for their patients (Psychiatric News, November 7, 1997).

Given that primary care physicians have trouble finding good mental health services for their patients, is there a solution? McIntyre thinks so and is starting to put his ideas into action as the chair of the Psychiatric Education for Primary Care Alliance (PEPCA). The alliance has won endorsements from a number of major psychiatric organizations including APA, the Society of General Internal Medicine, and the American Academy of Physicians and Patients. PEPCA aims to enhance the psychiatric education of medical students, particularly those who plan to enter primary care.

"Medical students need experience with common clinical problems and settings [including] the treatment of psychiatric disorders in primary care settings," he remarked. But at present, most medical students receive little such exposure.

Other solutions to closing the communication gap between psychiatrists and primary care physicians are less complex, for example, simplification of patient information forms exchanged by psychiatrists and other physicians. McIntyre recalled his own experience with a dermatologist who had developed a one-page form describing diagnosis and treatment and indicating whether a return visit was needed. The dermatologist had faxed the form to McIntyre's primary care physician before McIntyre left the dermatologist's office.

Primary care physicians "don't want pages and pages of information," McIntyre commented. "They don't read it."

Collaboration and integration are the keys, according to McIntyre. The goals are better communication, integrated planning, and continuity of care. Logically, the relationship between psychiatry and primary care is an ideal place to employ a biopsychosocial model, McIntyre noted, yet that "often is not the case." Primary care physicians often "emphasize the biologic and minimize the psychosocial," he added. True collaboration means "working together and drawing on [one another's] individual skills." But that goal will be reached only by active efforts to enrich the psychiatric component of basic medical education and by psychiatry's continuing to reach out to primary care in the spirit of alliance rather than competition.