A Partnership of Increasing Significance

The role of psychiatry in primary care is an area of rapid expansion and increasing significance. Given the fact that inadequate diagnosis and treatment of psychiatric disorders (including addictive disorders) are major public health problems (Katon and Gonzales), it is essential to integrate psychiatrists into multi-disciplinary primary care teams. In addition, since primary care physicians are increasingly called upon to act as "gatekeepers" in managed care programs, they will have to meet the important and growing need for broader psychiatric diagnostic and referral skills. Successfully integrating the fields of primary care and psychiatry to face these challenges will allow patients with psychiatric disorders to be more effectively recognized and treated.

The Institute of Medicine defines primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (Donaldson and Colleagues). Psychiatrists can and should establish their value within primary care teams as clinicians, consultants and educators. They can then play a significant role in the overall clinical enterprise. Moreover, by working as part of the comprehensive care team, improved continuity of care and greater accessibility to care are offered to the patient.

Detection of patients with psychiatric disorders is an area of great importance in primary care. While studies suggest that the prevalence of psychiatric disorders in the primary care setting is 20% to 30%, only a fraction of that number is properly detected and referred to psychiatrists (Carr and Donovan). Three models have been proposed to improve detection and referral of such patients.

The replacement model substitutes the psychiatrist for the primary care physician as the physician of first contact. Such an approach requires an increased number of psychiatrists to meet demand, and also displaces primary care providers from their gatekeeper status. This model may lead to a higher degree of recognition of psychiatric disorders, but at the cost of potentially significant amounts of limited resources. A second approach has been termed increased throughput. In this model, primary care physicians are encouraged to refer a greater number of patients for psychiatric evaluations, in the hope that an increased number of referrals will lead to better detection. However, this model does not allow primary care providers to improve their own diagnostic skills.

The model that has received the most attention, liaison-attachment, had its origins in Great Britain in the 1950s (Carr and Donovan). In the liaison-attachment model, psychiatrists work within the primary care setting and are a functioning part of the multidisciplinary care team. This approach allows for potential joint assessment and treatment of patients. It can also lead to decreased patient resistance, since patients often find the familiar primary care setting to be more acceptable and less anxiety-provoking. In addition, since the psychiatrist is working in the primary care setting, medical and psychiatric appointments can be easily correlated (an added convenience for the patient), feedback between primary care provider and psychiatrist is enhanced and "curbside" consultations are readily accessible.

While efficient and comprehensive psychiatric consultation is important to the treatment team, it is also crucial to emphasize the psychiatrist's liaison role. Psychiatric liaison work is largely collaborative and educational, and can be of great benefit to other health care providers who may have had limited training in the detection and treatment of mental illness.

Psychiatrists can and should emphasize the importance of biological, psychological and social issues (including spiritual and cultural aspects) in the assessment and treatment of patients. By incorporating the biopsycho- social model into primary care, health care providers will more fully appreciate that patients are complex beings and much more than simply chief complaints. Educational approaches to help attain this goal include lectures, handouts, screening tools such as the PRIME-MD (PT February), attendance at rounds, and aiding in the comanagement of patients with medical and psychiatric illnesses.

Excellent communication skills are crucial to the psychiatrists' value to a treatment team. Within the team itself, clear and effective communication is critical; and when working with patients, the psychiatrist can help primary care physicians appreciate the power of communication and empathic listening. In addition, psychiatrists must continue to ensure that the significance of patient-physician communication as a therapeutic modality itself is not overlooked in the ever-changing health environment.