Evaluation and Treatment of Mental Illness in Primary Care

[MJC2118]

For those of you who work in primary care, how do you approach patients who come to you with s/s of mental illness?? I lost my sister to suicide in January, and as an FNP myself, it has really had be reflecting on this topic. My sister has struggled with depression for a few years that I know of, and had been to her PCP off an on for this. She had been treated with different medications, but never went to counseling that I know of. To be honest, she wasn't real open about her mental health issues. I'm pretty sure she had undiagnosed bipolar disorder as well. I was just wanting to get others opinions and perspectives regarding this topic. How do you handle mental health/illness in your practice? How do you evaluate them? How often do you refer elsewhere? How comfortable are you with treating mental illness? Barriers to treatment? Do you feel like your FNP program prepared you to handle these patients? Any other thoughts??? Thank you!

[BCgradnurse, MSN, RN, NP]

I 100% agree that FNPs and other PCPs are not trained to manage complex psychiatric conditions. Harm can often be done despite the best intentions. However, many PCPs are in situations where psychiatric resources are not easily accessed. I worked for several years at an urban FQHC that had zero psych resources. We had social workers, but they were not trained therapists and there were no psych prescribers on staff. The wait for services in the community could be upwards of 4 months. There was no such thing as an early referral. Those who were clearly in severe acute crisis could be sent to the ER for evaluation, but the majority of patients who were at a lower level of distress were left hanging. It's a dilemma, and I think most PCPs are doing the best they can. It's too bad our education doesn't give us more education in psych. I would never want to manage 100% of a patient's psych care, but it would be helpful to know enough to actually help someone until we can bridge them to psych services.

[Jules A, MSN]

I 100% agree that FNPs and other PCPs are not trained to manage complex psychiatric conditions. Harm can often be done despite the best intentions. However, many PCPs are in situations where psychiatric resources are not easily accessed. I worked for several years at an urban FQHC that had zero psych resources. We had social workers, but they were not trained therapists and there were no psych prescribers on staff. The wait for services in the community could be upwards of 4 months. There was no such thing as an early referral. Those who were clearly in severe acute crisis could be sent to the ER for evaluation, but the majority of patients who were at a lower level of distress were left hanging. It's a dilemma, and I think most PCPs are doing the best they can. It's too bad our education doesn't give us more education in psych. I would never want to manage 100% of a patient's psych care, but it would be helpful to know enough to actually help someone until we can bridge them to psych services.

I hear that and appreciate your sentiments. There is a such thing as an early referral. It is simply making a psych referral/appointment to get your patient on the 4 month or whatever waiting list today, not 2 months from now, when it is clear things aren't improving. Delaying that referral by 2 months would set them back by 6 months for an actual psych evaluation. Appointments can always be cancelled with no shortage of wait list patients to fill the spot if your patient responds to the SSRI. Not making the appointment the minute a PCP starts prescribing psych meds doesn't make sense and usually ends poorly.

[BCgradnurse, MSN, RN, NP]

I hear that and appreciate your sentiments. There is a such thing as an early referral. It is simply making a psych referral/appointment to get your patient on the 4 month or whatever waiting list today, not 2 months from now, when it is clear things aren't improving. Delaying that referral by 2 months would set them back by 6 months for an actual psych evaluation. Appointments can always be cancelled with no shortage of wait list patients to fill the spot if your patient responds to the SSRI. Not making the appointment the minute a PCP starts prescribing psych meds doesn't make sense and usually ends poorly.

I misunderstood what you meant by early referral. Our patients were referred immediately. There was just no way to expedite the process of having them seen by psych.

[AnnieNP, MSN, NP]

My biggest roadblock is finding Psychiatrists / Therapists who will take medicare or private insurance. I do start SSRIs and short term Benzos and then pray we can find a Psych provider.

[Jules A, MSN]

My biggest roadblock is finding Psychiatrists / Therapists who will take medicare or private insurance. I do start SSRIs and short term Benzos and then pray we can find a Psych provider.

But why start with a benzo + SSRI combo? I do this at times but probably not more than 30% and only when someone is in significant distress or in the rare case on initial interview when I'm not exactly sure what I'm seeing and am cautiously monitoring for activation.

Automatically starting a benzo + stimulant is akin to offering a percocet for a headache prior to trialing an appropriate dose of ACTM.

While we are on it, should we discuss the reasons not to prescribe Ambien long term especially at 10mg for females? :)

[Oldmahubbard]

I don't start anyone on 2 drugs. No. I can't think of a situation when it is a good idea.

[AnnieNP, MSN, NP]

Let me clarify, those are two classes that I will prescribe, I didn't mean that I start people on both. I have, but not very often. I do have one Psych NP that may not be able to see the patient, but she is usually available for me to chat with.