Mental disorders are common in medical practice and may present either as a primary disorder or as a comorbid condition. The prevalence of mental or substance use disorders in the United States is 18.5%, resulting in an annual cost of $148 billion dollars, only slightly less than the costs of cardiovascular diseases. Only 15% of these individuals are currently receiving treatment.
The revised 4th edition for use by primary care physicians of the Diagnostic and Statistical Manual (DSM-IV-PC) provides a useful synopsis of mental disorders most likely to be seen in primary care practice. The current system of classification is multiaxial and includes the presence or absence of a major mental disorder (axis I), any underlying personality disorder (axis II), general medical condition (axis III), psychosocial and environmental problems (axis IV), and overall rating of general psychosocial functioning (axis V).
Changes in health care delivery underscore the need for primary care physicians to assume responsibility for the initial diagnosis and treatment of the most common mental disorders. Prompt diagnosis is essential to ensure that patients have access to appropriate medical services and to maximize the clinical outcome.
Validated patient-based questionnaires have been developed that systematically probe for signs and symptoms associated with the most prevalent psychiatric diagnoses and guide the clinician into targeted assessment. Prime MD (and a self-report form, the PHQ) and the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) are inventories that require only 10 min to complete and link patient responses to the formal diagnostic criteria of anxiety, mood, somatoform, and eating disorders and to alcohol abuse or dependence.
A physician who refers patients to a psychiatrist should know not only when doing so is appropriate but also how to refer, since societal misconceptions and the stigma of mental illness impede the process. Primary care physicians should base referrals to a psychiatrist on the presence of signs and symptoms of a mental disorder and not simply on the absence of a physical explanation for a patient’s complaint. The physician should discuss with the patient the reasons for requesting the referral or consultation and provide reassurance that he or she will continue to provide medical care and work collaboratively with the mental health professional. Consultation with a psychiatrist or transfer of care is appropriate when physicians encounter evidence of psychotic symptoms, mania, severe depression, or anxiety; symptoms of posttraumatic stress disorder (PTSD); suicidal or homicidal preoccupation; or a failure to respond to first-order treatment.
Revision date: July 4, 2011
Last revised: by Andrew G. Epstein, M.D.