The role of the primary care physician in mental health care
Interview with Piedmont Family Practice providers Dr. Steven Von Elten, Dr. Christopher Ward, Dr. Ash Diwan, and Annie Pratt, PA-C.
Of course, the first place you go if you have a sore throat or fever is your family doctor. You also go there for regular check ups, vaccinations, and other health care advice. But they have another important role in your life that you may not have thought of: that of mental health care provider. With the insufficient numbers of psychologists and psychiatrists in this country today, your primary care physician is the first line of defense when things begin to go wrong. Lifestyle had the opportunity to interview three primary care physicians and a nurse practitioner from Piedmont Family Practice about their role in mental health care of their patients.
Dr. Von Elten said, “Primary care physicians are very adept at helping people. We help most of our patients with the majority of their mental health problems. We can also guide them through the healthcare system as needed for problems that are more complicated.”
And are family care doctors qualified to handle most mental health issues? Yes, they are. “The training for family practices is very good in psychiatry,” said Dr. Von Elten. “That’s one of the reasons I chose to be a general practitioner forty-some years ago. It’s a large part of what we do, and pharmacology for mental illness has been well embedded in our training.” He added, “I keep an eye on all my patients, even those that come in for another health reason. My first question to patients is always, ‘How are you doing?’ And I listen carefully to their response. If they hesitate, I know that at some point during the appointment I have to circle back and try to figure out what’s going on and if they need help.”
So what are the red flags in mental illness? When is it time to mention any problems to your doctor? Dr. Von Elten cited two indicators: “When you’re depressed or anxious to the degree that is out of the ordinary and the symptoms don’t really go away as they should, or if your mood is affecting day-to-day function, those are the two things that warrant a visit to the doctor.” He also advised, “Don’t wait until things get to be a monumental problem, just come in and we can talk about it.”
Dr. Diwan added, “It’s very important to realize that depression and anxiety, like other diseases such as hypertension or diabetes, have long-term consequences if left untreated or under-treated. They can manifest into more severe disorders, which is why we stress that it’s so important to talk to your doctor. The worst thing you can do is not address the problem at all.”
Then what happens? Dr. Von Elten explained, “We would then sit down and define what the problem is, whether it’s depression, anxiety, or something else. Then we look at the dynamic in the family and the stressors in the patient’s life and we start to develop a treatment plan incorporating available therapies and medication. We have to see what a patient is willing to do. Some people are totally medication resistant.”
So what is the role of medication in treating mental illness? It can be a very important part of recovery. Dr. Diwan said, “Although treatment of depression has in the past too commonly been relegated to a provider giving patients a prescription with not enough emphasis on long term counseling, it should be noted that today’s antidepressants are more targeted and effective with far fewer side effects than ever before. By increasing serotonin, dopamine, or norepinephrine in the brain, antidepressants can be very helpful by relatively quickly improving mood, energy, and motivation and getting people to the point that they are willing to engage in activities that then get their depression under control through counseling and other treatments.”
Ms. Pratt said, “But I also think there’s a lot of misunderstanding, sometimes people expect medication to simply fix the problem, to make them feel everything is sunshine and rainbows 100 percent of the time, and I have to clarify that that isn’t what medication does. Part of the visit is helping them understand that there are limitations to what medications can do. Our goal with medication is to get you to the point where you can handle day to day stress and accomplish your goals of daily living without closing yourself up in your house and crying. But patients need to understand that they will still feel sad when sad things happen, and feel stressed when there are stressors, medication doesn’t remove that.” Dr. Diwan agreed: “I think medication can help get people out of a low mood, but at some point they have to move on and address the underlying psychological causes of their depression and learn how to deal with their emotions and stressful situations without medication. In this case, the non-pharmaceutical therapies can be really helpful.”
Medication can be a part of treating mental illness, often an important part. But other treatments are also available and appropriate. Dr. Ward explained: “We have medication that we can use, and it doesn’t take us very long to write that prescription and move on, but that’s really only a small part of an effective treatment regimen. Cognitive behavioral therapy, counseling, relaxation, mindfulness and meditation, diet, all these methods have been shown statistically to improve mood and they don’t have side effects. Some also have additional benefits like lowered blood pressure. But some of these things take time and can be expensive.”
But there are bigger cases, such as treatment-resistant depression, schizophrenia, and bipolar disorder that do need further treatment out of the sphere of the primary care doctors. So what then? Your primary care physician can help patients navigate to further treatment, and continue to help you through the journey to health.
Dr. Von Elten said, “Sometimes I have patients who I’ve tried to help, but everything we have tried has not worked. So at that point, I tell them that they really need to see a psychiatrist. Many of them don’t want to, sometimes it’s challenging to convince them. Some are afraid of the stigma of seeing a psychiatrist, sometimes it’s financial issues, sometimes the providers are far away and travel time is an issue, or maybe they’ve tried before and failed to develop a comfortable relationship. So I have to encourage them, and I tell them ‘Go have one visit and I will consult with the psychiatrist afterward and see if there are other medication regimens out there that might help you.’ Sometimes there are medications that I’m not as familiar with that I wouldn’t like to prescribe without a higher level of training. A psychiatrist can guide us with that.” Dr. Diwan agreed: “If people can’t afford to visit a psychiatrist regularly, I just encourage patients to go once or twice so they can help guide me in treating them. I tell my patient that I’m not deserting them, I’m just looking for more input so I can manage their case more effectively.”
There can be challenges in seeing a psychiatrist, and the lack of providers is only one problem. Insurance coverage can also play a big role in how patients pursue treatment. Ms. Pratt said, “Therapy is expensive. The first thing I do is have the patient call their insurance to see what their benefits are and where the closest in-network provider is. I have them call that day to make an appointment. Usually it’s a 4-6 month wait to get in to see a psychiatrist, and I tell them to expect that. I reassure them that I am not giving up on them, that I’m going to keep managing their case in the meantime, that they’re not alone. After all, the appointment can always be cancelled if it’s not needed when the time comes, but I tell people to go ahead and make that appointment right away.”
Of course, in the case of an actively suicidal person, the best thing is to take them right away to the Emergency Room, where they will be safe and may be admitted. Once the active crisis has passed, follow up with the family care provider, who will help get the patient the needed treatment. Ms. Pratt said, “It’s usually not possible to get a quick appointment with a psychiatrist, unless you are a regular patient. It’s easy to get an appointment with your primary care provider; in most cases we can see you within a few days. And we can follow the patient regularly, as often as necessary. Our receptionists know to schedule longer appointments for people coming in with depression or a serious mood problem.” Dr. Diwan also added, “One of the benefits of being a primary care provider is that we build relationships with patients over time, so in a crisis they are much more apt to open up and be honest with us than perhaps a new provider they’ve just met.”
It is particularly important to follow suicidal patients carefully and often when they begin treatment. Dr. Diwan explained, “Most people who commit suicide aren’t doing so when they’re at rock-bottom, they’re doing it as they start to feel better, and get the energy to actually carry out their plans to end their life. The point is, we really have to follow closely, especially when they’re starting to feel a little better.” Dr. Von Elten agreed: “When I put someone on medication I see them back often, at least initially, for that reason.”
The doctors and Ms. Pratt agree that the stigma of mental illness is diminishing, but also concur that some people still shy away from treatment or mentioning the problem to their doctor. Dr. Von Elten explained, “I think there’s a perception among patients that mental illness is a sign of weakness, that they’ve got some personality flaw, but I try to tell them that in reality it’s quite common. I think particularly among people who are getting anxious or depressed, they feel that they’re the only one, and they’re not. Coming in and talking about it is not an indication of a character flaw.”
Dr. Ward elaborated: “I stress the evolutionary psychology. Humans were designed to be anxious as a defense mechanism. Our genetic makeup wants us primarily to survive and pass on our genes to the next generation, it doesn’t particularly care if we are happy or not. After all, the first person to climb up a tree when the saber tooth tiger jumped out survived to pass along his genetic information.” He continued, “Humans are just designed this way, there should be no shame in it, we just need to be aware how these internal algorithms produce emotion. This is where mindfulness meditation is very helpful, it allows you to take a step back and see these emotions coming out because of how we’re wired as human beings and not because you’ve sinned, or you’re a failure, or you don’t have enough willpower. It’s much more mechanistic than that. That’s really helps some of my patients to see that this is just kind of like a car problem, you just need to figure out how to address things, it’s not a moral failing.”
Feeling down? Talk to your doctor and try these suggestions.
Don’t isolate yourself
The three doctors and Ms. Pratt concurred that isolation can be a cause or exacerbate the symptoms of depression. Dr. Von Elten said, “I find a lot of people who are depressed are very isolated, and don’t have a lot of family or friends in their lives. I try to get them to develop or rekindle relationships with people they might be able to talk to. If family or friends aren’t an option, there are also other options in the community such as religious leaders and counselors.”
Join an interest group
Don’t underestimate the importance of socializing and interacting with people who have the same interests, whether online or in person. Dr. Diwan said, “I’ve had patients who have had remarkable success with joining a book club or a social club. They feel so much less isolated and happier when they have people with common interests that they can talk to.”
Take a break from social media
People who spend a lot of time online in general have lower happiness scores than those who don’t. Dr. Ward said, “People do a lot of curating of their online personas, trying to put the best parts of their lives on display and omitting the less-than-perfect aspects. Some people think that their lives can’t compare to their peers…they dwell on it and they become much more unhappy because they’ve been exposed to a lot of stimuli that would make anyone feel anxious and dissatisfied.”