Over
the last few decades, primary care physicians have been treating more and more
patients with psychiatric illness. Many factors have contributed to this change
of role. Some of the factors may include: stigma, physical symptoms of
depression, increase in physician comfort, insurance coverage, shortage of
mental health providers, and increase use of antidepressants while decreasing
referral for psychotherapy.
Stigma
The
increase in treatment of psychiatric illness in the primary care setting may be
due to several factors. Social
stigma may have also had an impact. Studies have found that patients are more
comfortable seeking care for depression from their primary care physicians
rather than psychiatrists because it reduces the stigma associated (Olfson,
Marcus & Druss, 2002). In addition, primary care physicians are more likely
to add diagnostic symptoms, such as chronic fatigue, which patients feel reduces
stigma (Chizobam, Bazargan, Hindman, 2009).
Physical
Symptoms of Depression
The physical symptoms of depression are
often first addressed by family care physicians. This is another reason why so
many patients with depression are seen in the primary care setting. Some of the
physical symptoms include: lack of energy, fatigue, weakness, slow movements,
agitation, insomnia, loss of concentration, and pain. While it is possible that
these symptoms are in fact solely caused by depression, they may also be
comorbid; medically, psychiatrically, or both. Interconnections between
depression and medical comorbidities should, and have the potential to be
considered with treatment in the primary care setting, however, is not always
done. Among many of the medical illnesses that can be associated with these
physical symptoms include: hypothyroidism, hypogonadism, diabetes, and
dementia. In addition, studies have found people with mood disorders are at an
increased risk of physical illness comorbidity (Zimmerman, 2008).
Physician Comfort
Another
factor of the expanding role is that primary care physicians feel more
comfortable prescribing antidepressants since seemingly safer treatment options
have been available (Olfson,
Marcus & Druss, 2002).
Toxicity
and addictive properties of medications treating mental illness symptoms have
improved, however, although psychotropic medications are often thought to be
safer than they actually are (Olfson,
Marcus & Druss, 2002). This may be contributed by lack of education, lack
of awareness, and manipulation by pharmaceutical companies.
In
addition, physicians may be more comfortable with prescribing psychotropic
medications because patients are more knowledgeable and accepting of using
psychotropic medications (Kravits,
Epstein, & Feldman, 2005). Furthermore, physicians are more likely to
prescribe patients with antidepressants when they either ask for a certain
brand or for antidepressants in general (Kravits, Epstein, & Feldman,
2005).
Insurance Coverage Limitations
Prior to the Affordable Care Act
(ACA), many individuals did not have mental health care, or their coverage was
limited. Treatment under a primary care physician are more affordable than a
psychiatrist, and even with insurance coverage, often require higher copayments
and out-of-pocket costs (Olfson, Marcus & Druss, 2002). In addition, insurance premiums
could increase once mental health care treatment was documented, therefore
going through a primary care doctor, psychiatric diagnoses could be hidden by
medical diagnoses (Olfson, Marcus & Druss, 2002.
Other Factors
Other factors
may have contribute to the dramatic increase of treatment of depressive
disorders in the primary care setting. The shortage of mental health providers,
including psychiatrists could contribute to increase of psychiatric care in the
primary care setting. Another possible factor is that primary care physicians
have turned to treating depression with psychotropic medications rather than
referring to mental health specialists, which may appeal to certain
populations.
Advantages of the Expanding Role
The expanding role of primary care
physicians with psychiatric care has many advantages. They have the ability and
potential to deliver quality care for treatment of mental health illnesses.
Individuals are more likely to reach out to their primary care physician than
with any other type of professional, which means these physicians have the ability
to treat or coordinate care and can be helpful if done so appropriately. Their ability
to facilitate care for patients to see other professionals, such as for psychotherapy,
nutrition management, or holistic therapies, may provide the patient with the
best possible outcome.
Rule out Medical Illness
Primary care physicians have ability to
rule out medical illness that may be the explanation behind the symptoms of depression.
Physicians that order lab work, such as screening for thyroid dysfunctions or
vitamin deficiencies prior to prescribing psychotropic medications can provide
a safer treatment for their patients.
Integrate Medical History
In addition, primary care physicians can
integrate their patients’ medical history which may help to choose the most
appropriate psychotropic treatment, depending on the patients’ other diagnoses,
such as heart disease or diabetes which can result in larger or worsening
problems when inadequately monitored or poorly considered. They are also able
to keep their patients’ conditions under control by monitoring lab work and
make changes to psychotropic medications when needed based on the results,
rather than waiting for the problem to arise. Furthermore, since primary care
physicians often see several members of a family, physicians are able to
consider predisposition and environmental influences and if applicable, what
treatments have been successful for their relatives in the past.
Other Advantages
Primary
care physicians also have ability to recognize depression through screenings
performed during physical exams that may have been otherwise ignored without
preventative care. When used correctly, psychopharmacologic treatment can
reduce symptoms of depression and prevent relapse. These advantages of
providing mental health treatment in primary care settings can significantly increase
the patients overall quality of care, in turn, greatly improving their quality
of life.
No comments:
Post a Comment