A Systemic Cause for Mental Health Care Woes?

December 31, 2006

In his article, “The Primary Care Physician’s Role in Treating Mental Illness”(CONSULTANT supplement, April 15, 2003, page 24), Dr Joseph Lieberman correctlyasserts that “more and more primary care physicians are prescribing psychotropicmedications.”

In his article, "The Primary Care Physician's Role in Treating Mental Illness"(CONSULTANT supplement, April 15, 2003, page 24), Dr Joseph Lieberman correctlyasserts that "more and more primary care physicians are prescribing psychotropicmedications." He proposes 2 possible explanations for this phenomenon:A growing recognition by primary care physicians of psychodynamic dysfunctionthat is amenable to psychopharmacologic treatment.The fact that it is simply easier to write a prescription than to listen to a patient.I propose a third explanation: that access to the mental health system--in particular to psychiatrists who can prescribe--is made cumbersome, if not impossible,by mental health "carve-outs" and the incongruence between benefitsfor mental ailments and those for physical problems. Consequently, primary carephysicians attempt to fill the void by providing care and medication as best theycan. The lack of concordance between diagnoses and medications prescribed mayreflect unfortunate inadequacies in the mental health training of some of thesepractitioners.Sadly, I don't see much sitting and listening to the patient on the part of mypsychiatrist peers either. Many of them have been relegated to the role of "medicationmanagers" who see patients with mental health problems for 5 to 10 minutesmonthly, while social workers provide psychotherapy.This system is badly in need of repair. In the interim, however, we familyphysicians will continue to care for our patients with mental illness to the best ofour ability.
---- Bruce Blumenthal, MD
Baltimore

I am most indebted to Dr Blumenthal for pointing out the "elephant in theliving room"--that is, the fundamental dysfunctionality of the Americanhealth care system. His insightful comments help to complete my argument,and I appreciate his contribution.
---- Joseph A. Lieberman III, MD, MPH
Professor of Family Medicine
Jefferson Medical College
Thomas Jefferson University
Philadelphia
Dr Blumenthal has it right. There is something fundamentally wrongwith the way the delivery of mental health services is currently structured.Access to psychiatrists is a problem; low fees and administrativehassles resulting from behavioral health carve-outs have causedmany of my colleagues in psychiatry to retire early or limit their practiceto privately paying patients. Of necessity, primary care physicians are tryingto fill in, but the treatment of major mental illness is far more difficult than theprescription of SSRIs for mild depression. How things will turn out is anyone'sguess. In the meantime, patients with serious mental illnesses, such as schizophreniaand bipolar disorder, are often not able to find the expert medical care(including psychotherapy and medication) they deserve.
---- Jay M. Pomerantz, MD
Assistant Clinical Professor of Psychiatry
Harvard Medical School
Boston