Last month I was invited to give a lecture at an annual conference for Physician Assistants. The title of my talk was, “Treating Depression in Primary Care.”
Physician Assistants typically work in a primary care setting, which is where many mental health disorders are diagnosed and treated. Roughly 60% of psychotropic medications in the United States are prescribed by a primary care provider.
Despite these statistics, many primary care providers receive a limited amount of formal education in mental health/psychiatry related conditions during their training. This issue was recently highlighted in a New York Times article that described the lengths a psychiatrist and ADHD expert is taking in order to ensure that primary care providers, who diagnose and treat the majority of cases of ADHD, are better equipped to do provide such care.
Training and education aside, the problems with accessing mental healthcare in a timely and sustained fashion leave many primary care providers with no choice but to treat mental illness themselves, especially those who serve in rural and underserved communities of our country. (I previously blogged about issues surrounding access to mental healthcare here.)
For these reasons, I was excited to have the opportunity to talk to and interface with this group of professionals and to disseminate up-to-date information on treating clinical depression in primary care.
As I prepared the PowerPoint slides, I was overwhelmed by urges to emphasize the fundamentals of good psychiatric practice to my audience. I felt a need to do this, in part, because of my observation that in our fragmented healthcare system, where we are all being required to do more with less, these fundamentals are increasingly getting pushed aside.
So I decided to spend a good portion of my talk on the fundamentals that have proven to be essential to me during my 15 years of psychiatric practice. Over these years I have treated thousands and thousands of patients, seen pretty much every psychiatric diagnosis, and treated people of all genders, ethnicities, religions, and ages. I have treated patients in two different continents and two different U.S. states. I have treated patients in a variety of settings: emergency room, inpatient, outpatient, residential and day programs, private clinics, academic medical centers, county hospitals, the VA, and the British National Health Service.
This immersion and clinical experience has led me to the following observation: When things go awry in the care of treating a person with mental illness, the majority of the time it is because one or more of these fundamental principles was neglected or overlooked.
It dawned on me that I have become a fundamentalist when it comes to my psychiatric practice.
For the researchers amongst you, it is akin to the assumptions we make about data before we use a particular statistical test. If these assumptions are incorrect, then the test and subsequent results mean very little and, worse, can mislead us about what is actually going on.
These fundamentals (which, at their core, are a tribute to the biopsychosocial model that was propagated by Engel) are separate from the fundamental principles of care that should be employed when diagnosing mental health disorders and advising patients regarding specific medical treatment decisions – those are whole other topics for a whole other blog.
In case you are starting to think that this blog is just me waxing lyrical on my personal viewpoints, I would refer you to the American Psychiatric Association guidelines for the treatment of mental health disorders. Each guideline devotes several pages to these very principles and, again, emphasizes the importance of providing psychiatric care within these fundamental parameters.
My fear is that the current medical climate is encouraging the practice of skipping right to the “treatment part” of such guidelines and just glossing over these fundamentals.
So here are the principles that I shared with my audience during the lecture, described as Ten Commandments and listed in no particular order of importance. Some of the language is specific to the treatment of depression, but the principles are applicable to all mental health disorders.
Perhaps one the biggest challenges to physicians practicing in a 21st century medical environment is preserving relationships with our patients. Many of us operate in settings where we are pushed for time, have to do more with less, and are bombarded by a constant stream of interruptions that have us focusing more on computer screens, pagers, voicemails, and instant messages than on the patient that sits in front of us.
This is not only frustrating for us (most people I know became healthcare professionals because of a capacity to care deeply for the plight of other human beings, not because of a desire to be stuck in front of a screen, or phone, or to do paperwork) but it is wrong for our patients. Such an environment inhibits trust, rapport building, and the development of what, in my field, we call alliance.
Therapeutic alliance is a crucial fundamental of good psychiatric practice; it promotes collaboration, trust, and mutual respect. It can take years to build with false starts and setbacks, but the provider’s commitment to maintaining it must be unwavering. Any factors or situations that interfere with our ability to maintain an alliance with our patients interferes with our patients’ inclination to fully disclose what is on their minds, share their fears and darkest thoughts freely, and to be truthful in their communication with us.
Our job as the treating clinician is to preserve the sanctity of the relationship between doctor and patient and push back on external factors that impinge on it. More than just touchy-feely medicine, it is the very foundation upon which good psychiatric care is practiced.
#2. Thou Shalt Always Do A Complete Psychiatric Assessment
Anyone treating a mental health disorder can only do so after they have done a thorough psychiatric assessment; when time is of the essence this can be the first thing that gets short thrift. At minimum the following areas have to be touched on (and can be done in an efficient way with practice):
- History of the present illness and current symptoms
- Past psychiatric history
- Substance use
- Relevant social, occupational, and family history
- Physical examination and appropriate diagnostic tests to rule out physical causes for depressive symptoms
#3. Thou Shalt Always Do A Thorough Evaluation For Safety
Any clinician who treats patients living with mental illness has do the following, not only on the initial evaluation but on an ongoing basis:
- Make specific inquiries about suicidal thoughts, intent, plans, means, and behaviors
- Identify psychiatric symptoms or general medical conditions that might increase the likelihood of acting on suicidal ideas
- Assess past and, particularly, recent suicidal behavior
- Assess for potential protective factors that can serve to decrease the chances that the patient will harm themselves or others
- Identify any family history of suicide or mental illness
- Have a good sense of the patient’s level of self-care, hydration, and nutrition
- Evaluate the patient’s level of impulsivity and potential risk to others, including any history of violence
- Assess the impact of depression on the patient’s ability to care for their dependents
#4. Thou Shalt Always Identify the Appropriate Treatment Setting
The patient’s treatment needs and symptom severity should determine what setting they are treated in, from outpatient care with a primary care physician to hospitalization in a specialized psychiatric unit.
Measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others. Unfortunately, because of mental health parity and inadequate access to mental healthcare for many, health care professionals are often put in the very difficult position of caring for those with mental illness in a setting that is not optimal for comprehensive care. Whilst this is inevitable at times, the clinician has to remain watchful that these circumstances do not interfere with the patient’s clinical progress.
Mental illness impacts many spheres of a person’s life, including work, school, family, and social relationships. Any treatment interventions should be aimed at maximizing the patient’s level of functioning within these spheres and focus on enhancing their quality of life.
#6. Thou Shalt Coordinate The Patient’s Care With Other Clinicians
American healthcare is famous for being fragmented. With so many different providers, healthcare systems, and insurance providers involved, talking to each can become a low priority for clinicians involved in a patient’s care. This lack of communication, however, can have disastrous consequences for patient outcomes.
The patient’s response to treatment should be carefully monitored. Patients who are on psychiatric medication need ongoing assessment for adherence, symptom control, and side effects. This is even more important if a patient is new to medication, this is their first episode of mental illness, they have clinical factors that place them at high risk for suicide, or they are not improving clinically. Ongoing care can be spaced out once the patient is stable, but until that time comes they need to be monitored with sufficient regularity.
An invaluable option for the busy clinician is to integrate clinician and/or patient-administered questionnaires into initial and ongoing evaluations of patients with mental health disorders.
Assume and acknowledge that the patient will have potential barriers to treatment adherence, and collaborate with the patient (and if possible, the family) to minimize the impact of such barriers.
The clinician should encourage patients to articulate any fears or concerns about treatment or its side effects and offer patients a realistic notion of what can be expected during different phases of treatment.
Education! Education! Education! The clinician has to spend time clarifying common misperceptions about antidepressants; emphasizing the need for a full course of treatment; and promoting the benefits of healthy behaviors like exercise, sleep hygiene, and nutrition on mental health. Family and others involved in the patient’s day-to-day life may also benefit from education about mental illness and its effects on functioning and treatment.
I believe each of us should be a fundamentalist when it comes to providing mental health care. No matter the treatment setting or level of training of the provider, we cannot adequately care for our patients when these Ten Commandments are forgotten or ignored.