When is it Time to Refer to Psychiatry?
James Peacey, MD
PAL Consultant
It is not news that there are workforce issues in the field of child and adolescent psychiatry. Primary care practices have stepped up, increasing the amount of mental health diagnosis and treatment provided there. From the vantagepoint of the Partnership Access Line, it is not unusual that callers are well versed in diagnosing ADHD and prescribing treatments consistent with published guidelines. They have become familiar with measurement-based care of anxiety and depression and have developed comfort using SSRIs and changing treatment when problems with side effects or lack of response occur. They have become familiar with monitoring treatments that have been started in psychiatric settings, and they know when to refer for evidence-based psychotherapies. But there are situations and conditions where psychiatric evaluation and management is still needed that typically include elements of complexity, seriousness, and lack of treatment response. A more specific list of problems leading to psychiatry referral would include complex comorbidity, psychosis or mania, persisting problems with treatment response, dangerousness, problems with support network, needed access to specialized treatments, and/or patient wanting to see a psychiatrist. Many of these problems can be seen in a single case. For example, it is not farfetched to see a 15-year-old with gestational substance exposure, early trauma and family history of unspecified chronic mental illness who presented in early elementary years with learning difficulty and ADHD and then had worsening depression and anxiety in middle school. Now on their third antidepressant combined with their stimulant treatment, they are complaining of mood swings, have started cutting, are using marijuana and have been to the ED twice in the past month for suicidal crises. They are failing classes. Divorced parents disagree on what treatment should be.
Even when it is clear that a psychiatry referral would be appropriate, barriers to access are often present. The most immediate access is usually through hospitalization. Even when that is possible, the crises may be managed, but results can be disappointing with regard to other goals of diagnostic clarification and finding a more effective medication treatment. Practices with integrated mental health services often enjoy the best psychiatric support with clear procedures for referral and short wait times. But for most practices, long wait times before a psychiatric appointment are typical. Community mental health settings that serve patients with Medicaid plans can have their own referral procedures depending on the patient’s engagement in therapy. Patients with insurance but otherwise limited means may not mention that high out of pocket expense was the reason they never followed up on the referral you provided. In some localities, there is a perception or reality that there are no psychiatrists available. And after a period of psychiatric treatment, patients may return to you with their condition improved but on medications less familiar to you and for reasons that aren't clear. And when symptoms return or side effects emerge, it may not be obvious what to do next.
So, consider the following when considering psychiatry referrals. Begin talking with families early about the possibility of psychiatric referral when red flags begin to appear and anticipate the wait that will likely be necessary once a referral is made. PAL Social Work can help with referrals. The shift to telemedicine during the pandemic has made access to psychiatric services possible now for some traditionally underserved areas. Use the Partnership Access Line for help with management during the wait for a psychiatric appointment. If possible, communicate directly with the psychiatrist or psychiatric nurse practitioner before, during and after specialty care. That will improve the chances that your questions and concerns are addressed, that you understand the rationale for any treatment changes, and that you may get ideas for what to do next based on future course of illness. Another consequence of the shift to telemedicine is that psychiatric practices may be more dependent on primary care for monitoring parameters such as growth, vital signs and labs. Good communication and effective sharing of treatment usually leads to greater willingness of psychiatrists to see your patients back when needed or to take new referrals from your practice. The roles of and relationship between primary care and psychiatric specialty care in addressing mental health treatment needs of patients have changed a lot in recent years and will likely continue to change. We all share in the goal of best outcomes for patients.
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