Psychiatric Therapy – Whose Responsibility Is It?

Mrs. Smith comes into the office of the family practitioner (or the office of an internal medicine practitioner) presenting with the following symptoms: congestive breathing; sore throat; head ache; malaise; some joint aches.

Mr. Jones comes into the office of his osteopathic physician (or his orthopedic physician) complaining about his shoulder that began to ache after the fifth set of tennis.

The Johnsons bring their teenage son into the dermatologist’s office because he suddenly is breaking out with some nasty rashes.

Mr. French comes into the urologist’s office to get his periodic PSA test.

These scenarios could present to just about any physician, physician assistant, or nurse practitioner. Predictably each patient draws the attention of the clinician to the presenting symptoms or complaints for which he/she initially came into the office. As the clinician talks with the patient, and observes the patient, the clinician may become aware or may suspect that there is more to this patient than just the obvious reason(s) for coming to the office. The clinician may sense or see evidence of a behavioral or psychiatric problem. If the clinician hasn’t already employed the MSE (Mental Status Exam), he/she might consider doing so. The clinician might want to take it a step further and employ the MMSE (Mini Mental Status Exam). Whatever the clinician might feel comfortable with, such as gut level instinct, measurable tests, definable observations, they might see fit to be open and up front and try to determine if there is a psychiatric concern. The patient may become receptive to some tactful probing or may take advantage of an opportune opening and volunteer his/her concerns/feelings.

Most clinicians are not extensively nor specifically trained to be psychiatric consultants. However, most have had some exposure to recognizing potential behavioral characteristics of someone who is depressed or shows signs of extreme anxiety. The reasoning being that these behavioral patterns generally are the hallmarks of potential suicidal ideation. When there is a suspected psychiatric concern, there frequently is a comorbid issue. In addition, it is difficult for one not trained in psychiatric medicine to engage in differential diagnoses in order to identify dominant and/or comorbid psychiatric conditions. However, most medical training nowadays (MD, DO, PA, NP) does offer enough psychiatric training so that the non-psychiatric clinician can treat, let alone detect a severely depressed individual or a high anxiety person. It would not be out of the question for the clinician to write a prescription for immediate needs and offer a referral to a psychiatrist or psychotherapist for further treatment. It probably would not be as beneficial for the patient if the clinician would attempt treating the patient for the psychiatric condition assuming that the medication is all that is needed and therefore will suffice.

More and more practicing psychiatrists are finding that they cannot spend the time necessary for more complete therapy programming, other than seeing the patient periodically for the need to update medications. In psychiatric care, medicines do not necessarily cure or resolve a behavioral problem. They often go a long way towards making the patient more comfortable and vulnerable to engaging in therapy that might identify and or relieve the cause of the psychiatric problem. "Talk therapy”, (such as psychoanalysis, cognitive and/or behavioral therapy, group or single therapy, etc.) is often the key to helping those with psychiatric problems.

Unlike physical medicine, the parameters of psychiatric medicine are not as clearly defined. Medicines usually do not cure psychiatric illness. An antibiotic can destroy the "bugs” thus ending the cause of the problem and of the need for that medication. Zoloft can possibly make the patient more comfortable and thus possibly create the conditions for further treatment, but the cause of the disorder still exists.

So with many psychiatric illnesses we come to a fork in the road. Because of the medications, the patient can continue down one path for treatment of the symptoms or take the other path and along with the medications the patient can explore the possibility of a cure. The second path will require "talk therapy.”

With today’s science and medicine, we have at our disposal more evaluation tools (technical, quantitative, qualitative).

Who will have the training and be able to afford the time for the patient to take that second bend in the road? It certainly seems as if we will need more clinicians (physicians, nurses, physician assistants, psychiatric social workers) exposed to more training, wanting and able to devote more time, to more "talk therapy”.

So for those patients who require more time to be able to talk to a qualified practitioner, whose responsibility will it be?


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