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BK: Hi, my name is Brayden Kameg.
SL: And I am Samantha Lau. Today we will be discussing the practice of psychiatry in primary care and how utilizing an integrative care model can help primary care NPs to optimize the care of patients with mental illness.
BK: First, Samantha and I will identify some knowledge gaps in mental health training between primary care providers and specialists and how that can impact patient care. Then we will discuss how specialists can provide important guidance and consultation to primary care providers in managing mental health. Lastly, we will talk about the importance of utilizing an integrative care model that relies on the efforts of a multidisciplinary team to support the needs of different patients.
SL: This topic is an important one, because primary care providers see more patients with mental health conditions than do psychiatrists or psychiatric nurse practitioners. Nearly 20% of adults visiting primary care in urban centers have depression. In addition, nearly 25% of primary care visits involve behavioral and mental health concerns. Primary care providers are therefore the first point of contact for many patients seeking help for these issues.
SL: Most NPs do not receive a lot of training in mental health.
BK: That’s right, Samantha. In contrast, NPs who specialize in psychiatry and mental health complete additional years of education, where they likely learn more about differential diagnosis, psychopharmacology, psychotropic medication classes, treatment algorithms, and drug-drug interactions.
BK: Knowledge gaps in these important areas for non-specialist NPs may impact patient care. For example, primary care providers might miss more subtle signs of depression or other mental illnesses and only diagnose the most severe patients. They also may not understand the nuances of prescribing psychotropic medications.
SL: Let’s look at an example of a patient treated by a primary care provider who is less familiar with differential diagnoses for depression. A patient who we’ll called Maria visited her primary care provider for an annual well visit. Her physical exam was normal, and she appeared healthy by all measures, not noting any concerns. Toward the end of the visit, Maria paused and admitted that she had been struggling with low mood for the past few months, which had been affecting her sleep patterns and keeping her from focusing while at work. Based on this discussion of symptoms, her provider diagnosed Maria with MDD.
Her provider recommended initiating a commonly used SSRI. Maria completed a standard course of treatment, but her symptoms worsened. Her provider decided to switch Maria to another SSRI in the hopes of getting a better outcome. Unfortunately, Maria’s mental health declined further, and she had to take a leave of absence from work. Unsure of what to do next, her provider referred Maria to a specialist.
A psychiatric nurse practitioner thoroughly evaluated Maria’s symptoms and discovered that her diagnosis was not unipolar depression but rather bipolar disorder. When probed further, Maria reported experiencing racing thoughts in addition to having trouble concentrating at work. She had also run up her credit card bill from late night online shopping, which was causing her financial stress. According to the DSM-5, Maria’s symptoms met the criteria for bipolar disorder. She discontinued the SSRI and was prescribed an appropriate treatment for her Bipolar I disorder. Maria responded to the medication and was able to return to work.
BK: Samantha, this really highlights how differential diagnosis is a key first step in the decision-making process that many primary care providers may miss. Providers see a wide range of patients with different conditions every day, not just those with mental health symptoms concerns. They are also more likely to encounter patients with symptoms of depression or anxiety. Knowledge gaps and time constraints could result in making an incorrect diagnosis, like in Maria’s case.
Motivational interviewing is an important tool that can be utilized during a primary care visit for a range of behaviors including identifying symptoms of mental health conditions.. This is an important step in building a therapeutic alliance between the patient and primary care provider. Due to their training model, NPs are uniquely positioned to provide this kind of patient-centric care.
Motivational interviewing can also help primary care providers advise their patients on lifestyle changes that may contribute to improved mental health, using counseling strategies to increase awareness of health conditions and encourage behavioral change. Studies have shown that this method can be associated with improvements in health measures, such as weight loss or reduction in blood pressure.
SL: A second type of education gap illustrated in our patient case example is that primary care NPs may not be that familiar with psychotropic medications; for example, knowing that an antidepressant can possibly trigger a manic episode in a patient with undiagnosed bipolar disorder.
Regardless of the type of medication being prescribed, it is essential that the healthcare provider communicate the information their patient needs to start therapy in a safe and appropriate manner once they walk out the door with a prescription. Patients, especially those who have never taken a psychotropic medication, must be told to take their medication exactly as prescribed and that medications do not work unless taken– stress that adherence is key.
SL: Primary care providers also need to set proper expectations about treatment outcomes. They should explain to patients when they might expect to experience a change in symptoms, and how these medications are slow to work so they may not see the effects for weeks. Patients also need to know the possibility of experiencing potential side effects. Again, it’s important to emphasize that they should report these side effects and not stop the medication, as many of these can be managed.
BK: Samantha, setting expectations for our patients is so important. Finally, while primary care providers may not routinely check in with their patients, they should communicate the importance of scheduled check-ups to track the course of symptoms and response to medications; these check-ins can help the provider monitor for risks, including suicide prevention. If their patient is having suicidal thoughts, they should be directed to emergency services and let you know as soon as possible.
These check-ins also provide an opportunity to keep the patient informed about their care and address any questions. There is a lot of information, as well as misinformation, lurking on the Internet. Patients may hear about incredible success stories or terrible cases that could affect perception of their condition or the medication they are taking. Patients need to know they can ask questions and raise any concerns that they might have, both at the initial visit and at subsequent check-ups.
SL: Primary care NPs should consider how they can work in collaboration with specialists to help optimize patient outcomes.
In turn, psychiatrists and psychiatric nurse practitioners can partner with primary care providers to guide them in proper diagnosis, management, and monitoring of patients, as well as to ensure a continuum of care.
BK: Samantha, I use these principles of collaborative care in my own practice. There are several different models of collaborative care, but the goal of each is to establish a multidisciplinary group of HCPs who can provide mental health care in a coordinated and effective manner to best meet patient needs. At the core of these models is the primary care provider, the first point of contact for patients.
Following initial assessment and potential treatment, care managers can facilitate patient referrals to specialists. Depending on the patient’s needs, they may be connected with additional clinical resources to receive care, such as behavioral health physicians or substance abuse counselors.
SL: Patients with mental health conditions benefit when their primary care NPs utilize their networks and keep lines of communication open with psychiatric specialists.
BK: That’s right, Samantha. Primary care NPs have a unique advantage of building long-term relationships with their patients, and specialists can provide them with important tools to help identify and manage mental health conditions within an integrative care team at every step along the way.
Thank you for joining Samantha and me for this important review of the role of primary care NPs in providing psychiatric care. We hope you find the material reviewed useful for your clinical practice. We look forward to seeing you next time!
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