The Register Report, Spring 2009 Illustrating the Primary Care Psychology Approach by: Leonard J. Haas, Ph.D. and Frank V. deGruy, M.D. This article was adapted from Handbook of Primary Care Psychology, Oxford 2004. Reprinted with permission Return to Table of Contents

The psychological needs of primary care patients can be classified into three general categories, related to (a) psychopathology or true mental disorders, (b) stress-related symptoms and problems related to chronic medical conditions or behavioral health problems, and (c) membership in vulnerable populations, including abuse victims, those who are socially isolated, and those who are economically disadvantaged.

Sara James comes to her primary care physician complaining of deep fatigue. Sara is 36 years old, works part time as a paralegal, is married to a busy contractor, and is the mother of three small children. She wonders if she has mononucleosis or perhaps a thyroid problem like her sister. Her physician does a thorough physical examination and finds no evidence of poor thyroid functioning, infection, or other biomedical explanation for her fatigue.

Scenarios like this occur many times every day in the offices of pediatricians, internists, family physicians, and gynecologists across the United States. What happens next depends on the training and attitudes of the primary care physician and the health care professionals involved in the patient’s care. This scenario could follow at least three different pathways:

The Biomedical Pathway: Suspicious that he hasn’t exhausted all possibilities, the physician suggests additional tests to Ms. James. Eager to discover if she has something serious, Ms. James agrees to a full workup. When results are normal, her worries are not assuaged. She requests a referral to a specialist in fatigue-related medicine. Her doctor reluctantly refers her to a rheumatologist, who also cannot explain her condition with a conventional diagnosis. Ultimately, she finds an alternative medicine practitioner who practices herbology, where she receives a diagnosis of multiple chemical sensitivities and a prescription for aromatherapy and herbal remedies.

This scenario conforms to data on the pathways patients commonly take in primary care when their symptoms have no medical explanation (e.g., Kroenke & Mangelsdorff, 1989). The physician who is unwilling to consider psychosocial or emotional causes of distress and dysfunction often begins to pursue increasingly rare conditions. Convinced that there is something wrong, the patient may turn to complementary and alternative medicine, such as acupuncture, herbology, or aromatherapy. Or, the case could continue along a different path.

The Psychiatric Pathway: Recognizing that women are more likely to experience depression and knowing that her mother suffered from depression, the physician suspects that the fatigue may be related to underlying depression. He probes Ms. James about her mood and her life. She notes that things have been a bit frustrating at work, and she has found herself uncharacteristically out of sorts, even sad, since a coworker with whom she had a long and satisfying work relationship was transferred to another state. On further probing, she reveals that her sleep and appetite have been disturbed, she has lost interest in sexual intimacy, and she becomes tearful every day. Believing that he has successfully diagnosed a case of major depressive disorder, the physician prescribes an antidepressant and suggests that Ms. James follow up with him in one month.

This is probably the second most common scenario in primary care when the physician encounters a likely mental health problem. The majority of psychoactive medication prescriptions are written by primary care physicians and not by psychiatrists. However, it is also clear that prescribing antidepressants does not mean that the depression has been treated. In fact, the evidence suggests that half of antidepressant prescriptions either are not filled or are taken improperly, and a considerable proportion of responses to them are placebo responses (Moncrieff, Wessely, & Hardy, 2001).

Psychiatric Pathway Continued: One month later, Ms. James returns to her primary care physician, noting that she is still tired and admitting that she took the fluoxetine he prescribed for 1 week, but found that it gave her diarrhea, and discontinued taking it. She felt better briefly but now is tired and wonders what is going on. Telling her that she needs to have a thorough evaluation and empathizing with her difficulties, her physician suggests that Ms. James should restart the medication and also see a psychologist who specializes in depression. Although the psychologist’s office is located several miles away and he is on a different insurance panel, Ms. James agrees to make an appointment. Her physician suggests that she should return for a follow-up visit in six weeks.

This aspect of the case illustrates the traditional method of linkingmental health and primary care through referrals. However, this isan inefficient and often not helpful method because it puts additionalbarriers in the path of the patient who wants help. Assume forthe sake of this illustration that Ms. James is able to overcome thechief obstacles that account for the dismal rate of successful referralsfrom primary to specialty mental healthcare, namely: she isable to schedule an appointment within a reasonable time, she ismotivated enough to make her way across town to see the psychologist,and she is savvy enough about health care benefits toarrange to have the services reimbursed.

Psychiatric Pathway Continued: At the initial appointment, the psychologist does a thorough history of Ms. James’s symptoms and then begins to explore her self-esteem, her sense of loss, and her relationship with her husband. Ms. James rapidly becomes defensive and wonders why the psychologist needs to know this. Can’t the psychologist simply suggest a better medication or give her some techniques that will make her feel better? The psychologist reflects on whether she is resistant or has some deeper personality pathology that was misdiagnosed by the primary care physician. He returns to evaluating her symptoms and considers that perhaps she would be better diagnosed as having atypical somatoform disorder with depressive personality disorder features, rather than having major depressive disorder. He privately concludes she is not a good candidate for therapy. He suggests that she try to think more optimistically and concludes the session, indicating that he can suggest a psychiatric referral or Ms. James could return for further work with him. She does not make a follow-up appointment.

This scenario describes what we believe is a typical difficulty in traditional mental health practice as it relates to primary care. The primary care patient may not believe that she has a mental health problem, and may not be ready to agree to psychological treatment. In addition, the presentation of common psychological problems in the primary care arena is often different from the presentation in specialty care, and the psychologist must be attuned to the ways in which psychological distress may be expressed. Consider the following as an alternative:

The Primary Care Psychology Pathway: After exploring Ms. James’ reluctance to restart fluoxetine and the fact that her improvement was probably not attributable to the medication, her physician suggests that she see a psychologist. Although privately worried that perhaps her doctor believes she is just a hypochondriac and is trying to get rid of her, Ms. James agrees so that she can at least say that she tried what he recommended. The psychologist, who practices in the physician’s clinic 2 days each week, is able to see her that same afternoon for a brief initial visit. This session primarily involves the psychologist explaining psychological treatment to her and exploring her understanding of her condition. Ms. James expresses her puzzlement at the referral because she does not understand how just talking could help her and wonders if what she really needs is an energizing medication such as modafinil, which she has recently learned about on television.

Agreeing that he will discuss this idea with the primary care physician at a later point, the primary care psychologist explains that it sometimes helps to talk over things that are on one’s mind and briefly explores her symptomatology. She acknowledges that she experienced a significant loss when her colleague was transferred because she is quite isolated and lonely. She agrees to come back in 3 days for a psychotherapy session. After four additional sessions over the following 2 months and some homework exercises aimed at improving her social support, Ms. James indicates that she feels much better and feels no need for further counseling.

Although he recognizes that Ms. James is likely at risk for further depressive reactions, the psychologist agrees that she has made considerable progress and leaves the door open so that if she experiences similar symptoms in the future she will find it easier to come in for a short course of therapy. He then reviews with her the common symptoms of social isolation and depression and notes that, in her case, sadness and fatigue are warning signs that she is becoming isolated. He then dictates a brief note to her physician describing her progress and notes what the physician might see in the future that would suggest the need for further treatment.

Although this case is not meant to imply that all fatigue is maskedminor depression, it does illustrate the need for the primary care psychologistto make services accessible and understandable to patientswho may not initially understand the connection between the somaticsymptoms they present to their primary care physicians and theiremotional lives. Practicing psychology in primary care offers theopportunity to address mental health issues where they are most oftenpresented; the opportunity to address the psychosocial aspectsof medical complaints; and the prospect of helping the primary caresystem truly meet the needs of its patients without erecting more barriersto care. However, the practice of primary care psychology demandsskills, attitudes, and a knowledge base broader than thattypically obtained by the conventionally trained psychologist. continue

 

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