Peter Fifield: Psychiatric Consultation

I spend most of my time doing psychiatric consultations in primary care or crisis service settings, and my consults are primarily addressed to the primary care providers who are asked to prescribe, and in most case already are prescribing psychotropics and somtimes offering brief counseling and substance abuse treatment. I try to make a series of suggestions so that if one thing does not work there are backup suggestions, as well as specific non-medicine suggestions regarding psychotherapy, exercise, smoking, etc.  I know a lot of my consults get lost in the PCP charts, or don't get scanned into EMR's, so commonly I see patients back a year or two later without having tried what I suggested.  It is difficult during my day to get PCP's on the phone after I do a consult unless I have a lot of cancellations, usually they do not call me back till the next day when I have moved on to another job. I write my consults in real time so the PCP gets them the next day or the same day if need be. While I am very interested in integration, my practice is barely collaborative, and particularly when I work in PCP offices I feel very much the odd man out even when I try to engage clinicians when they are not seeing patients.

Because so many patients are treated with medications primarily, despite my skepticism that this is always very effective, I try to be as thorough as possible about what can be tried. Often this means pushing medications through a doseage range, getting levels, trying to do mood charting, while ideally getting some input from psychotherapists about how things are going.  For many primary care settings, as Dr. Fifield indicates, this is a taxing option that requires a lot of regular patient attendance, and patients frequently reject treatment other than medication.

Most of my career I have prescribed in groups, and I may be about to start again now that services are being cut back with the current economic contraction.  Medication groups are a fairly old tradition in community mental health, they can see a lot of people with flexible sheduling and there is always room for other clinicians to participate. Ideally a medication group involves both a psychiatric prescriber and a cotherapist, in this case from the primary care practice, could be a nurse, social worker or some other person.  If enough people are seen in a given period, the cotherapist may be cost effective without billing, but being able to bill is a plus.  I have always billed out this service the same as an individual medication "check" CPT 90862, many others do this, the service is the same regardless who else is in the room, there are some payor limits regarding how many you can bill for in an hour.

Of course, while I am going around the group and prescribing, the possibility of some kind of group therapy is there, whether or not this is stated explicitly. There is a lot of psychoeducation, some support, techniques of cognitive therapy can be tried out, the group process is destigmatizing. Group medical visits are increasing in medicine generally, ideally psychotropic medication groups would be just one flavor of group medical visits in a practice. While the need for confidentiality is addressed regularly, in fact this has rarely been much of an issue in the groups I have run. Groups should always be optional, individual meetings may need to be made as well, but they allow people to be seem much more frequently, there is almost always room for one more person, and often the details of medications adjustment, dealing with side effects and adherance do not take that long for each person. Rating scales can be used to increase the outcome data collected, like the PHQ-9. And most importantly, if a clinician from the primary care practice participates in the group, they get to know the consultant psychiatrist and pick up a lot of prescribing tips.

Ben Crocker, MD

Psychiatrist in Portland, Norway and Augusta Maine.

Eventually when patients get comfortable with the group experience, groups more focused on psychotherapy or psychoed may be budded off. But in the beginning getting the medication is the primary reason people show up. Where things like suboxone or pain meds are the topic, the flexible scheduling of groups can be a way of enticing people resistant to declared psychosocial interventions into participating in them.

Boy, between the original post and Dr. Crocker's comment, there is a lot to discuss here.  In the integrated programs where I've worked the psychiatry service has always had the most fleeting success.  There seem to be a lot of inertia against its success:

   1. The NIMBY that Pete describes among primary care physicians,

   2. The difficulty of coordinating effective chart reviews (that don't digress into 60 minute coffee chats),

   3. The dearth of psychiatrists (much less those with primary-care skills), and

   4.  The lack of effective financial models for sustaining these services.

Just 2 weeks ago I approached an administrator about adding psychiatry services to our clinic and the response was lukewarm at best.  Just as Pete describes, there is a perspective (possibly quite accurate) that "if we build it 'they' will come".  'They' are people with severe and persistent mental health needs.  This fear is exacerbated because community mental health centers are so poorly funded that primary care providers sense an inevitability that they will be forced into the rule of ad-hoc psychiatry.

When I've seen primary care psychiatry most effective it was a model where a psychiatrist came on-site once per week to do one-time consults with patients referred by PCP's.  We limited each patient to one psych consult per year.  The psychiatrist would do a thorough assessment interview and present the PCP with a 1-year management plan (much like described by Dr. Crocker).  In this way, the PCP was empowered to manage the patient's meds by having a plan, a back-up plan, and a back-up back-up plan.  The psychiatrist also needs to identify which patients are too severe to be adequately served in a primary care setting and have the authority to take them to the mental health center.

When it has worked least well is when the psychiatrist sees patients for repeated follow-up visits in the primary-care setting.  When this happens, availability for psych consults quickly becomes limited by the follow-up visits and primary care providers are quickly taken out of the loop in the care of their patients.  The end result is a mini mental health center that functions independently within the primary care setting.

The one place where I disagree with Pete is his statement: "In a perfect world, all patients could have their psychiatric needs met at a specialty mental health clinic."  I believe in a perfect world, we would have primary care systems that can effectively manage the vast majority of psychiatric need.  That is, after all, the goal of collaborative care.  Isn't it?

Randall, well met!  I misstated my “perfect world”.   To restate:  Psychiatrists in specialty mental health settings play a very important role in the treatment of patients living with severe and persistent mental health disorders.  Persons living with less pervasive disorders could be treated in the primary care setting and help unclog community mental health facilities.  At my current place of employment, there has been some past success with using psych nurse practitioners.  What was lacking was integration and collaboration between the players.  Said otherwise, there was no team.  I must admit ultimately, patients would get their mental health needs met at the most appropriate place; In my opinion, for the majority of the population, that would be in the primary care setting. 

Of course, the 800 pound gorilla in the room that no one is talking about is Pete Fifield himself.  Could he look better in that kilt?  Is that a kilt on Finn, too?