As a primary care physician, managing medications for mentally ill patients can seem a bit daunting.
But a family physician who manages patients’ behavioral health medications daily in his practice and a psychiatrist who regularly consults with primary care physicians about these medications say this type of behavioral health integration (BHI) doesn’t have to be intimidating.
“You can do this. Your patients want you to do this,” said Ryan Laschober, MD, director of the Waco Family Medicine residency program at the Waco Family Medicine Institute in Texas and editor of the Waco Guide to Psychopharmacology in Primary Care. , at a recent Overcoming BHI Obstacles Webinar hosted by the AMA, “Integrating psychopharmacology into primary care: when and how.”
in some ways, the primary care setting is the best place to do psychiatry, said webinar panelist John Kern, MD, clinical professor of psychiatry and behavioral sciences at the University of Washington’s AIMS Center.
“He has a responsiveness and ability to respond to medical issues, especially emergencies, that is simply not available in a psychiatric setting in the vast majority of instances,” Dr. Kern said.
During the webinar, Drs. Kern and Laschober discussed key steps and interventions that primary care physicians can take to address common and complex behavioral health issues.
First, primary care offices must assess patients. This can be done using rating scales – for example, the PHQ-2 – and a team-based approach.
Then start with basic care. They work, Dr. Kern said, even for complex patients. Primary care physicians should familiarize themselves with some of the most tested pharmaceutical options for treating mental health conditions and try them first. The concept is no different than a doctor having, say, a few ACE inhibitors that he sees first for patients with high blood pressure or heart failure.
Then start with a low dose and titrate through the dosages. The #1 mistake among primary care physicians is improper dose titrations, Drs. Kern and Laschober said.
Every one to two weeks, doctors should increase the dose unless there has been an adequate response to the drug, the side effects have become intolerable to the patient, or the maximum dose of the drug has been reached and there is no answer.
The worst thing is to try a small amount of one thing and move on to the next, Dr. Kern said. “It takes a while to titrate a bunch of doses. Especially if you go slow. So you’re looking at months.
Doctors and patients start thinking that the drugs won’t work, or maybe the diagnosis was wrong. But, Dr. Kern said, “you have to remember the evidence and move on. … It takes two, three or four tries to improve most of your people. You have to remember that because your instincts will tell you something else.
In an effort to provide high quality care in the primary care setting, Dr Laschober said it was crucial to make guidelines on mental health issues – usually written for psychiatrists – more accessible to doctors in primary care.
To fill the void, Waco Family Medicine Residency School and Massachusetts General Hospital School of Psychiatry created “The Waco Guide to Psychopharmacology in Primary Carewhich describes more than 60 decision aids to guide internists, family physicians, and other primary care physicians in the management of patients with mental disorders.
It is not industry funded and includes guidelines for adult, pediatric and perinatal psychopharmacology.
WADA established the BHI collaboration with seven other leading physician organizations to catalyze the effective and sustainable integration of behavioral and mental health care into medical practices. Find out more with the collaborators Overcoming Obstacles Webinar Series.
Also check out the BHI Collaborative Behavioral Health Integration Compendiumwhich provides healthcare organizations with a proven path to delivering integrated behavioral healthcare and ensuring they have the most up-to-date, actionable insights.