Primary Care Practitioners and Psychotherapy: Time to Talk

As someone who has been involved in health care education for 40 years and whowas a counselor in a private mental health practice for 24 years, I appreciated DrJoseph Lieberman's article on the role of the primary care physician (PCP) in thetreatment of mental illness (CONSULTANT supplement, April 15, 2003, page 24).Psychology and nutrition have historically been something of a veneer on theoverall education of both physicians and physician assistants. Dr Lieberman is ontarget when he suggests that the training of PCPs needs to give more emphasis tothe recognition of mental disorders in patients who generally present with physicalcomplaints. If the PCP can recognize an emotional disturbance and deal with it,management of the physical problem is often enhanced.However, Dr Lieberman's discussion left me with the impression that he believedthe goal was to help PCPs learn to diagnose an emotional problem andthen prescribe the correct medication. While it is true that some emotional disturbancescan be treated with medication initially--and at times solely--PCPs mustlearn to recognize those disturbances that are better treated by a mental healththerapist, so that the effectiveness of a medication can be maximized throughgroup or individual therapy. In many emotional disturbances, the personal attentiona patient receives in therapy sessions is often an integral aspect of treatment.We are not yet at the point where PCPs are able--or want--to devote thekind of time and energy to patients that effective therapy requires. At our institution,we train physician assistants in the same basic philosophy and approach thatDr Lieberman describes (including use of the BATHE protocol [background, affect,trouble, handling, empathy]). However, we also teach students the limitationsof the primary care provider with regard to psychotherapy, as well as techniquesfor referring patients to a psychotherapist with whom they will be comfortable.---- Robert C. Grosz, EdD
Professor and Course Director
Physician Assistant Program
Nova Southeastern University
Fort Lauderdale, Fla
I appreciate and agree with most of your comments. However, you state thatthe objective of my article was that PCPs "learn to diagnose an emotionalproblem and then prescribe the correct medication." I apologize if what Iwrote would lead one to conclude that my goal was to get physicians to employonly pharmacologic interventions for their patients with mental healthproblems--for this was not my intention. I firmly believe that in most cases,a joint "talk therapy"/pharmacotherapy approach has the best chance of success.However, in order for any intervention to succeed, the diagnosis must bemade! Hence my emphasis on that aspect of primary care practice.---- Joseph A. Lieberman III, MD, MPH
Professor of Family Medicine
Jefferson Medical College
Philadelphia