The delicate relationship between patient and doctor, based on trust, may change when the diagnosis is a mental disorder.
Yes. Primary-care physicians screen for and treat all types of illnesses. It makes perfect sense that they diagnose and treat psychiatric disorders that respond to medication, such as depression and panic disorder.
In most primary-care practices, 25 percent of the patients suffer from mood or anxiety disorders. There aren't enough psychiatrists to treat all these people. Even if there were, most patients prefer to be treated by their primary-care physicians. Patients are often reluctant to acknowledge symptoms' psychological component. Because of these feelings and the expense, most are reluctant to seek psychotherapy.
Unlike the patients psychiatrists treat, the ones we see with mood disorders don't come to us suffering or suicidal. They have physical complaints such as chronic fatigue and pain, headaches and abdominal symptoms. It is only after examination that the symptoms are seen to be caused by an underlying psychiatric disorder.
Primary-care physicians need to be trained in the recognition of depression and anxiety. These illnesses have specific and recognizable criteria permitting sound diagnosis and treatment.
Physicians in primary care are not opposed to psychotherapy. We encourage patients to go, even though experience has shown most won't. For those who don't respond to treatment, referral to a psychiatrist is essential.
Fortunately, most patients respond to medication. But that's not enough. The key to successful treatment lies not in medication alone but in the committed, caring, ongoing relationships that primary-care physicians have with their patients. -- Dale Matthews, MD Assistant professor of medicine, University of Connecticut No. Primary-care physicians should not make final psychiatric diagnoses. They should recognize potential problems and make appropriate referrals.
Psychiatry has become too complex and the medications too varied and powerful for non-psychiatrists to make the treatment plans. Psychiatrists see many patients other physicians have misdiagnosed or underdiagnosed.
Often, by the time patients come to see us, they've been on several psychiatric medications, none of which has worked. This leads them to doubt the ability of these medications to help them. Patients whose proper treatment has been delayed experience not only additional suffering and expense but also potential deterioration.
Most physicians don't have enough training in diagnosis. They don't know how -- or don't take the time -- to look at various cyclic phenomena that can mimic drug-treatable disorders. They lack experience with the full range of medications and are not knowledgeable about dose ranges and fine-tuning.
When they do prescribe, internists tend to turn to the Physicians' Desk Reference (PDR) for guidance rather than the psychiatric literature. Many are afraid to bring patients up to therapeutic levels of drugs such as alprazolam (Xanax) out of fear of making them dependent. Often, doctors don't hear about or understand the older drugs that may be more appropriate for particular patients.
Patients don't want their doctors telling them they have psychiatric problems. But that's not a one-way street. Many doctors are reluctant or embarrassed to tell patients they should see a psychiatrist. Few want to deal with the anger patients or their families often show when the subject is brought up. But this isn't a valid reason not to refer. -- Abbey Strauss, MD Attending psychiatrist, Boca Raton (Fla.) Community Hospital
1990, Physician's Weekly, a Whittle Communications Publication; reprinted with permission