National Ambulatory Medical Care Surveys (NAMCS) persistently indicate that problems diagnosed as “mental and behavior disorders” account for at least 20% of visits in primary care practice.
One of the most difficult tasks for primary care physicians has been the discussion with patients and families about disorders whose resulting behaviors either make patients unhappy or make people they interact with unhappy. Despite several Federal laws requiring employers, health insurers, and health care providers to treat “mental and behavioral disorders” like any other illness or injury, there is still substantially more fear and loathing connected to a diagnosis of one of these disorders. Ironically, many patients are more willing to accept a diagnosis or treatment for these disorders from a primary care provider than from a “mental health professional”. This makes it all the more necessary for us to manage these disorders for our patients through consultation or coordination with other professionals. Unfortunately, the third party environment has divided disease into “physical and mental”; only recently have primary care providers been paid by insurers for providing anything other than prescription medication for any disorder defined by the International Classification of Diseases (ICD) or American Psychiatric Association’s Diagnostic and Statistical Manual (DSM).
The traditional “mind-body” dichotomy has become increasingly blurred as scientific evidence accumulates of significant brain changes in function and structure in most, if not all, of these disorders. Although the anatomic and functional pathology of most mental and behavioral disorders are not well defined, compared to other primary care practice areas, there are standardized clinical criteria for their diagnosis and evidence-based treatments. I have found that most patients are more willing to accept diagnosis or therapy for disorders which fit the “medical model”, so I emphasize neuroscience in my explanations. Most of us in primary care practice are not trained in counseling or psychotherapy, but we are expected to screen for many of these disorders in our patients, as well as, coordinate referral to other professionals, and manage uncomplicated mood and anxiety disorders. That is no different than the primary care of other illnesses that may require consultation when complication or crisis arise.
The “medical model” is not the only approach to emotional distress and maladaptive behavior. I often encourage patients to consider complementary approaches, like self-help and faith-based healing, but emphasize that my own training is limited to the “medical model” which relies on evidence published in biological and behavioral science. Sources of patient and family education in the “medical model” include websites of many professional organizations that specialize in treating and researching these disorders.
The primary information source for most Americans today is the internet with searches on health and disease ranking at the top. As a family physician, my first sources of patient education are the online collections curated by the staffs of the American Academy of Family Physicians and the National Institutes of Health. Both of these “generalist” sources have good introductory material on almost any disorder likely to be seen in primary care practice with references linking to more detailed information. The articles are carefully written for anyone with basic adult literacy in English or Spanish to understand.
For more detailed information about mental and behavioral disorders, especially those whose management is primarily outside the purview of primary care, the websites of the various “mental health professional” organizations are good sources not only of evidence-based scientific information, but the therapeutic techniques of that profession.
The American Psychiatric Association (APA) represents the specialty of medicine which limits itself to diagnosing and treating mental and behavioral disorders. Their website is oriented around the association’s Diagnostic and Statistical Manual, whose 5th edition (DSM-5) was released in 2014 and is the “bible” of medical diagnosis in psychiatry. For patients managed primarily by psychiatrists or those who see psychiatrists in consultation, the APA has a newly published guide “Understanding Mental Disorders: Your Guide to DSM-5”. Some of the topics are also covered on the APA website or the APA blog.The full publication is sold by the APA Press for $25 in both softcover and electronic book format.
The American Psychological Association’s website has a section for the public onpsychology topics. I find this particularly helpful because there is information on support for improving mental health, as well as, dealing with mental disorders.
For the latest in research The National Institute of Mental Health also has excellent public information at their website and the director, currently Dr. Tom Insel, has a wonderful blogMy Blog-Tom Insel, M.D.
The website of Mental Health America (formerly known as the National Mental Health Association) has a listing and explanation of recognized mental health professions. Each state independently decides on licensure and how they recognize professional qualification. There is also no uniformity of third party reimbursement for the services of mental health professionals. Some medical insurers will reimburse for therapeutic counseling or other activities by some professionals, but will not for others, so patients and families may face more than just the burden of a disorder itself when they seek treatment. The one consistent rule in treatment is that psychoactive medications must be prescribed by either a physician or other health professional with a prescribing license. Primary care providers are often called upon to prescribe and monitor psychoactive medications in conjunction with non-medical therapies provided by other professionals for our patients. This is a topic outside the scope of this article, but one which creates significant coordination and communication challenges for us!