How to get help for your troubled patients

Millions of patients with mental health problems go undiagnosed and untreated—and primary care physicians often don't know when or where it's best to refer them. Experts offer guidance.

Of every 10 patients you see, chances are one may suffer from depression serious enough to warrant professional intervention—although it may not be apparent. According to the National Institute of Mental Health, nearly 19 million adults, or about 9.5 percent of the US population aged 18 or older, have a depressive disorder in any given year. And depression is merely one of a bewildering array of emotional and behavioral problems—ranging from anorexia to substance abuse to panic to stress—that may have physical repercussions.

Yet, due to lack of training or to prejudice, discomfort, or ignorance about mental illness and the professionals who specialize in treating it, many primary doctors don't give these patients the help they need.

How do you know, for instance, whether a patient who says she feels sad is suffering from a temporary spell of the blues, or a clinical depression that might call for medication, a referral to a specialist, or both? If a referral is the way to go, should it be to a psychiatrist, a psychologist, a clinical social worker, or a mental health counselor? For answers, read on.

Diagnosing depression can be tricky. Here are some clues

By Michael F. Myers, MD
Psychiatrist/Vancouver

Because we tend to associate depression with sadness, and it's easy to tell when someone is sad, many doctors presume—incorrectly—that depression is easy to diagnose. Depression may be hidden not only from a primary care physician, but from the patient's spouse and even from the patient himself. That's because the symptoms are often subtle. While some patients will come right out and say, "I'm feeling blue," others offer vaguer clues: "I'm not feeling well," "I'm having trouble sleeping," or "I've been losing weight."

Other symptoms might include fatigue, aches and pains, or hypochondria. The patient may have a drinking or substance abuse problem—a sine qua non of depression—which he typically will minimize. Or he may have a problem with anger, which often masks depression. Anger isn't likely to be the patient's chief complaint, but if the spouse is present or subsequently questioned, it often comes out.

Because depressed elderly patients might have cognitive difficulties, primary care physicians may assume they're demented. But the memory impairment may be due to depression. Even in cases of Alzheimer's disease, antidepressant medication may improve cognitive functioning. Become familiar with the range of symptoms that may indicate depression, and don't be afraid to ask probing questions in order to build a differential diagnosis.

Primary physicians are often reluctant to address potential mental health problems. Addiction medicine specialists, for example, feel that the average physician—including the average psychiatrist—doesn't do a very good job of recognizing and evaluating patients who are alcohol or drug abusers, because the doctors don't have a high enough index of suspicion to take a thorough history. Or primary physicians miss the main diagnosis because asking about mental illness makes them uncomfortable.

Depressed patients may also go untreated because of a doctor's misconception about what's normal. This is especially true with elderly patients. I had an 89-year-old aunt who confessed to her primary physician that she felt depressed. "What do you expect?" he replied. "You're old." While depression is common among the elderly, it's not fate. In my aunt's case, I began to suspect that something was wrong because she'd become uncharacteristically hypercritical. "Do you feel depressed?" I asked her. "Yes," she said, "I just want to die." Alarmed, I told her physician about my concerns and suggested that he prescribe an antidepressant. Soon after starting the medication, she perked up.

Knowing when to intervene is a judgment call. One way to gauge the severity of a patient's depression is to ask her to answer a series of subjective questions—like those in the Beck Depression Inventory—to discern the nature of her mood. A high enough score may indicate that she needs medication from you, a referral to a specialist, or both. Some primary care physicians monitoring depressed patients for whom they've prescribed medication have them retake the Beck Inventory on follow-up visits to see whether their scores have improved. Patients who aren't doing better are then referred out.

While chronic depression involves a biochemical shift that no amount of talking will change, the imbalance may be exacerbated by a lifetime of negative self-perceptions that should be addressed with talk therapy. For a patient with low-level depression, simply being supportive—letting the patient talk, with you providing reassurance that things will get better—may be sufficient.

However, if you allot 10 to 20 minutes for most patient visits, even the most basic talk therapy is apt to create a backlog in your waiting room. And for patients with chronic or severe depression, talk therapy is an ongoing process, not a one-shot deal. Psychotherapists—who may be psychiatrists, psychologists, clinical social workers, or mental health counselors—usually see such patients at least once a week for 50-minute sessions. The therapy may continue for months. Few primary physicians have that sort of time to spare. Moreover, effective talk therapy generally requires extensive training. If it sounds beyond your ken, hand off to, or at least work with, a specialist.

Who's who among mental health care providers

How do psychiatrists, psychologists, clinical social workers, and mental health counselors differ, and when should you seek a consult or refer a patient? Representatives of their national organizations clear up the confusion.

Psychiatrists: the only mental health professionals who are physicians

As physicians, psychiatrists are the only mental health providers licensed to prescribe medication. They're also trained to recognize and treat with psychotherapy a range of mental disorders. As with other medical disciplines, psychiatry offers board certification requiring rigorous written and oral exams.

In treating patients, psychiatrists often partner with other types of mental health professionals and have comfortable working relationships with them. A psychiatrist may administer drug therapy while a psychologist or clinical social worker performs psychotherapy, although many psychiatrists prefer to do both.

Regardless of who conducts psychotherapy, though, it's often preferable to at least get a psychiatric diagnosis for the patient, since a psychiatrist is trained to understand the effects of various medications on a wide variety of mental illnesses. For instance, a patient with panic disorder may seem a good candidate for cognitive-behavior therapy rather than drug therapy. And yet, with psychotropic medication, the complete remission rate for patients with panic disorder ranges from 80 to 90 percent.

The same may be true of psychiatric problems associated with physical illness. Ailments such as thyroid disease and diabetes may cause depression, anxiety, and other behavioral problems that proper medication will greatly alleviate. If a psychological problem relates to pregnancy (as in postpartum depression) or to pain or trauma, the fact that a psychiatrist is a physician may better enable him or her to determine an effective course of treatment, sometimes with the patient's primary doctor administering the medication.

—Michael Blumenfield, MD, chairman, Joint Commission on Public Affairs, American Psychiatric Association

Psychologists: seeking to partner in patient care

In most states, to be eligible for licensure to practice independently, psychologists must earn a doctoral degree. This typically requires seven years of didactic course work, practical experience, and internship training, plus at least one year of postdoctoral supervised experience.

Many patients referred to a mental health professional never make the appointment. One reason is the stigma associated with mental illness. Research conducted by the American Psychological Association and other organizations, showed that patients feel this stigma most acutely when referred to a psychiatrist, because they tend to view psychiatrists as treating the most serious mental disorders, and doing it primarily with drugs.

The stigma notwithstanding, evidence suggests that the public recognizes the benefits of integrating physical and psychological care. In a 1996 survey, 80 percent of respondents said they were more inclined to see a primary care physician who works collaboratively with a psychologist.

But establishing such partnerships isn't always easy, as the APA discovered when it studied the care given by 10 pairs of Texas and Wyoming FPs and psychologists in rural communities with limited access to psychiatrists. Obstacles to collaboration included the doctors' different ways of describing the same disorders, patient confidentiality issues, and FP time constraints on treatment. When a psychologist and an FP planned how and when they would communicate, however, it promoted a good working relationship. By the end of the project, each of the 10 pairs of doctors agreed that the collaboration had enhanced the effectiveness of their respective treatments.

The way a physician handles a mental health referral is crucial to patient compliance. If you can describe a psychologist with a certain degree of familiarity and respect, the patient is less apt to feel he's being dumped onto another professional because he has a distasteful problem you'd rather not deal with. It's the difference between telling the patient, "I know a very good specialist I'd like to involve in your treatment," and "I can't figure out what's wrong with you. It must be in your head. So I'm sending you to a psychologist." Or, "Here's a list of local community mental health centers. Give one a call." The patient is much less likely to comply with approaches 2 and 3.

Because many physical problems have psychological components, primary care doctors often collaborate with psychologists on different aspects of the same problem. For example, patients with cardiovascular, gastrointestinal, immunological, and skin disorders have benefited from psychological services, as have patients with cancer, in which there's often related depression, anxiety, and stress.

—Russ Newman, PhD, JD, executive director of professional practice, American Psychological Association

Clinical social workers: the nation's major providers of mental health services

Clinical social workers hold an MSW (master of social work), or a PhD with a focus on clinical social work. A minimum of two years of postgraduate training in a supervised clinical setting is also mandatory. Most states require that clinical social workers be licensed, enabling them to diagnose and treat mental illness. Many clinical social workers hold additional certifications, such as that of the Academy of Certified Social Workers (ACSW).

Sixty percent of people who are treated for a mental health problem are seen by clinical social workers, who generally charge less than psychiatrists and psychologists. Most managed care organizations reimburse social workers, as do Medicare, Medicaid, and Champus. Social workers can be found in solo and group practices, hospitals, mental health centers, and municipal agencies.

Unlike psychiatrists, clinical social workers don't prescribe medication, but they treat patients much the same way that psychiatrists do. Indeed, social workers often train other professionals including psychiatric residents, in psychotherapy techniques.

A 1994 Consumer Reports survey found that patient's were as satisfied with social workers' mental health services as they were with services provided by psychologists and psychiatrists.

—Miriam Coleman, senior staff associate for clinical social work, National Association of Social Workers

Mental health counselors: filling a need in underserved areas

A mental health counselor has a master's or doctoral degree in counseling. In addition, a minimum of two years or 3,000 hours of supervised postgraduate clinical counseling experience is required for licensure as a professional counselor (LPC) in 45 states and Washington, DC. In the remaining five states—California, Hawaii, Minnesota, Nevada, and New York—counselors are either licensed as marriage and family therapists or practice without being formally licensed. Several thousand counselors also hold a national certification: certified clinical mental health counselor (CCMHC).

As practitioners in a discipline that's about 25 years old, mental health counselors may be the newest mental health professionals. But there are already 75,000 licensed counselors in the ranks, and they receive reimbursement from 85 percent of managed care organizations and Medicaid—though not Medicare, which our organization is lobbying to change.

In mental health counseling, the principles of psychotherapy, human development, learning theory, group dynamics, and the etiology of mental illness and dysfunctional behavior are used to treat individuals, couples, families, and groups. As with master's-level clinical social workers and doctoral-level psychologists, counselors diagnose and treat all forms of mental and emotional disorders.

More than 25 percent of mental health counselors practice in rural areas where mental health professionals are in short supply. In the 20 most rural states, more than 55 percent of mental health providers are counselors. Referrals often come from primary care physicians. I work in Sedalia, MO, where one resident psychiatrist serves a population of 20,000. We all work closely with primary care physicians, who might administer drug therapy to patients while we provide psychotherapy.

—Glenna C. Wentworth, MA, LPC, CCMHC, president, American Mental Health Counselors Association

The best mental health resources on the Web

What questions should you ask a patient whom you suspect has a mental illness? How do you learn more about diagnosis and treatment of behavioral health problems? Where do you find a licensed mental health professional locally? Where can patients learn more about mental illness? These Web sites will help.

American Mental Health Counselors Association 800-326-2642www.amhca.org
Phone or e-mail AMHCA to receive local referrals. The sites offers links to 15 state chapters, related organizations (including the Canadian Counselling Association), and resources, such as the Eating Disorder Referral and Information Center.

American Psychiatric Association 888-357-7924www.psych.org
Phone or e-mail APA to receive local referrals. The site offers links to state chapters, psychiatric medications, and resources for patients, and includes information on choosing a psychiatrist and other useful topics.

American Psychological Association 800-964-2000www.helping.apa.org
Phone APA to receive local referrals. The site offers information on how psychology can help with problems such as stress, depression, and serious physical illness; when and how to access psychological services; and more. A free brochure, "Talk to someone who can help," is available in quantity for distribution to patients.

National Association of Social Workers 800-638-8799www.naswdc.orgorwww.socialworkers.org
Phone or e-mail NASW to receive local referrals. The site offers links to state chapters.

National Institute of Mental Health 301-443-4513www.nimh.nih.gov
This site offers patient education materials, detailed information on the most prevalent mental illnesses, and links to sites providing referral information.

www.find-a-therapist.com
Claims to be the Web's largest referral database, including more than 6,800 psychiatrists, psychologists, clinical social workers, marriage and family therapists, and pastoral counselors in 50 states, Washington, DC, Puerto Rico, and Guam. The site also pairs patients with therapists offering help by phone or e-mail.

www.mentalhealth.org
The Center for Mental Health Services Knowledge Exchange Network offers extensive links to mental health sites on the Web in 62 topic categories. The Mental Health Services Locator is an interactive map. Click on your state for a listing of local resources.

mentalhelp.net
Contains a vast number of links in more than 150 alphabetically indexed categories, from abuse (physical, sexual, substance) to trigeminal neuralgia. A Clinician Yellow Pages, searchable by state, directs you to more than 1,500 mental health specialists nationwide.

www.helphorizons.com
Assists patients in finding a local or online therapist, and offers links to information on mental health disorders and problems associated with grief and loss, relationships, sexuality, and more.

www.mentalhealth.com
Internet Mental Health covers 54 common mental disorders (description, diagnosis, treatment, and research findings) and 72 common psychiatric medications (indications, contraindications, etc.). Especially useful is an online tool that helps you—or a patient—diagnose anxiety, mood, eating, personality, substance abuse, and other disorders. Extensive links to related sites are grouped by topic.

www.1-800-therapist.com
Phone to receive referrals nationwide, or click on links to state resources. The site offers useful tools to help patients evaluate their symptoms and overcome their resistance to getting help.

 

Neil Chesanow. How to get help for your troubled patients. Medical Economics 2001;7:87.