Posted by Kim White, MD  

According to the CDC, approximately 13% of Americans are taking antidepressants. Yet across the United States, there is a growing shortage of Psychiatrists. This shortfall is more evident in rural regions of the country, but even here in the Boston suburbs, it can be tough to find a psychiatrist who is accepting new patients into their practice.

How can so many people be receiving treatment with so few available psychiatrists? One answer is that the largest amount of care for basic mental health now is provided by Internists and Primary Care physicians . The majority of prescriptions for antidepressants are written by them. They do much of the front line assessment for depression and anxiety. Many of you will have filled out a 2 or 9 point screening test for depression at your last annual check up. And when Internists identify a mood or anxiety problem they will often initiate medication therapy. Despite the time constraints on their daily schedule and appointments, internists know the burden and suffering that depression and anxiety cause in all spheres of health and life, and they are including its treatment under their purview.

In addition, there has been a strong rise in clinical nurse specialists who have advanced education and training in Psychiatry and Mental Health. They work independently, and are trained to evaluate and treat mental health disorders, and can prescribe psychiatric medications (in Massachusetts they prescribe under the clinical supervision of a Psychiatrist).

So, when to call a Psychiatrist?

In general, since psychiatrists are specialists, we are usually the second line of treatment. Similar to a cardiologist or gastroenterologist, we commonly meet with a patient after their internist has identified a health problem, made a first treatment intervention, and the problem hasn’t gotten better with usual care. Many internists and PCPs have psychiatric colleagues with whom they have referring and collaborative relationships.

There are a number of scenarios when a psychiatrist’s expertise is valuable. For a new referral, a psychiatrist will perform a detailed diagnostic mental health evaluation in order to confirm and differentiate the diagnoses, possible medical contributions, and psychosocial issues. A psychiatrist can offer new approaches (including therapy), reconsider the diagnosis, adjust medication or make new medication recommendations. In addition, some people have more serious mental health disorders, such as bipolar disorder, treatment resistant depression, or paranoia and psychotic disorders, that need the specialist training of a psychiatrist. Or there may be multiple co-existing mental health issues that create a more complex picture. And if someone needs to take a combination of psychiatric medications, psychiatrists are comfortable at balancing those medications and managing the underlying disorders.

Can you call a psychiatrist directly? Yes, absolutely. Some people have a history of a mental health issue that has returned and they recognize that a psychiatrist’s expertise is needed. Others just prefer to start with medical specialists when managing any health issue, or wish to have the integrated care of therapy and medication treatment that some psychiatrists provide. Sometimes a therapist might suggest to their client that they could benefit from psychiatric medication and there is a psychopharmacologist with whom they like to collaborate.

Some psychiatrists, like me, are trained both in psychotherapy and psychopharmacology, and enjoy working with patients integrating both modalities. But increasingly psychological therapy is the domain of psychologists and psychiatric social workers. Psychopharmacologists (the term for psychiatrists who focus on psychiatric medication treatment) can work hand in hand with non-MD therapists, in order to bring the dual approach to treating mental health disorders that ultimately is the most powerful.

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