Psychiatric teaching and consultation in a primary care clinic

A historical review of outpatient consultation-liaison psychiatry

Outpatient consultation-liaison psychiatry evolved from the application of clinical principles learned in inpatient work. The author reviews reports of outpatient C-L psychiatry and categorizes them into four groups: 1) Comprehensive Medicine Clinics; 2) Consultation to Other Outpatient Settings; 3) Psychiatric Consultation Clinics; and 4) Behavioral Medicine Clinics. Advantages and disadvantages of each are postulated, and evolution of these clinics to the present time as well as suggested future research directions are discussed.

Psychiatric consultation and referral

Over half of patients with psychiatric problems are seen by primary care physicians. Many of these patients will benefit from psychiatric consultation when the diagnosis is unclear or when the patient is not responding to treatment. Good communication between referring physician, consulting physician, and patient are essential to ensure a good result. Specific problems that should lead to consultation include: patient's request, unclear diagnosis, poor results from treatment, and crisis situations such as suicide attempts. Consultation-liaison psychiatry services in the primary care setting are becoming more popular and are an excellent way of improving communication between primary care physicians and psychiatrists. Further development of this role of the psychiatrist in the primary care setting has great potential of improving the quality of care delivered patients with psychiatric problems who seek care from their primary care physician. It appears that the majority of patients continue to seek care for their psychiatric symptoms from their primary care physician. Open communication and ease of consultation with psychiatrists can make the care of these patients even more rewarding to the primary care physician.

The effectiveness of mental health consultation and referral in ambulatory primary care: a research lacuna

This article reviews the research literature on referral to and consultation with mental health specialists for patients in ambulatory medical settings. Very few controlled trials measuring the efficacy of such liaison could be located. They were mainly from the British literature, usually involved psychologists, and (with the exception of one study) tested only the model of referral to the mental health specialist for treatment. More research needs to be done in this important area. Methodologic issues and topics for further study are discussed.

The role of psychiatry in the training of primary care physicians

The question of psychiatry's role in medicine, and in particular its role in the training of primary care physicians (PCPs), is heightened by the knowledge that 60% of the 15% of patients who have DSM-III diagnosable alcohol, drug abuse, and mental health (ADM) disorders are seen exclusively in the general health sector. In addition, although PCPs have a low recognition rate of ADM disorders and are pessimistic about their outcome even with treatment, they prescribe the majority of tricyclic and anxiolytic medications. Models of mental health training for PC residents in training are examined, with particular emphasis on competencies taught, pedagogic vehicles, disciplines of the mental health teacher, and the relationship to departments of psychiatry. A computerized approach to assist the mental health training of primary care physicians developed at the Mount Sinai School of Medicine and Northwestern is presented. Finally, critical policy issues with regard to psychiatry's future role in training is described.

Teaching psychiatry to primary care internists

Many patients who seek the care of primary care physicians are suffering from a wide variety of psychiatric disorders. Primary care physicians should become skilled in interviewing techniques and basic psychiatric differential diagnosis, management, and treatment approaches for some types of psychiatric disorders and learn to regularly consult with and make referrals to psychiatrists when appropriate. Psychiatrists should play a very active role in the education of primary care specialists. This should include observation of the physician interviewing patients with different types of psychiatric disorders in addition to didactic teaching and supervision on topics such as psychopharmacology. With mutual collaboration between primary care interests and psychiatrists the patients of both groups of physicians should receive better care and continuing education of both may occur through an ongoing dialogue.

Psychiatric consultation in a medical clinic: what do medical providers want?

A participant observation needs assessment of the use of a psychiatrist in a primary care medical setting was undertaken to quantify details of the interaction between a psychiatrist and primary care providers. Two hundred seventeen encounters involving 63 providers were recorded over a five and one-half month period. Utilization of the psychiatrist was widespread but skewed, with only 17% of the sample using 50% of the services. The mean number of encounters for all providers was 3.44. Consultation occurred mainly in a private area of the clinic, usually in an unplanned fashion. Only 21% of encounters involved seeing a patient. The range and content of these interactions was broad. Initial reasons for consultation were often redefined as the consultation ensued. The kinds of help most frequently requested involved discussing nonpsychopharmacologic treatments (35%), assisting providers with evaluations (31%), and exploring unresolved feelings about patients or patient care issues (29%). Slightly more than 50% of encounters required some type of follow-up. The findings suggest that psychiatrists who wish to work in primary care settings must have expertise in a multitude of areas and must be flexible in adapting themselves to the setting in which the primary care providers work.

Behavioral medicine. Broadening the interface between medicine and behavioral science

The work of psychotherapists who have a cognitive-behavioral orientation and are trained in time-limited, focused psychotherapy has proved to be beneficial in the setting of a comprehensive medical and health maintenance organization. Group interventions that deal with relaxation, social skills, depression, agoraphobia, smoking cessation, problem drinking, weight modification, and Type A behavior, to mention a few, are conducted on an ongoing basis, allowing staff to treat large numbers of people in a time-efficient and cost-effective way. These groups also help the staff to provide a coordinated set of therapeutic and training experiences for patients through their participation in appropriate group treatment during the course of their individual treatment.