Primary Care Psychiatry

Primary care psychiatry involves the diagnosis and treatment of children and adults with psychiatric symptoms. It has been estimated that about one-half of patient presentations to primary care physicians involve psychiatric symptoms. 

Children in the primary care psychiatry

In children, the most common symptom presentation involves distractibility and agitation, which often lead to the ADHD diagnosis. In adults, the most common presentations are depressive and anxiety symptoms.  Not surprisingly, primary care physicians (PCPs) and pediatricians are the most common prescribers of amphetamines in children and of antidepressants and benzodiazepines in adults.  We have described elsewhere our approach to treating ADHD in children, and depressive and anxiety conditions in adults.  The common theme to our approach is to emphasize treating diagnoses and diseases, not symptoms.

Symptom-oriented primary care treatment: The wrong way

The most common approach to the practice of primary care psychiatry is to use medications for symptoms:  amphetamines for distractibility, antidepressants for depressive symptoms, and benzodiazepines for anxiety symptoms.  This approach leads to overuse of medications.  PCPs know that it is bad medical practice to treat someone with fever, chills, and night sweats with a pill for fever, a pill for chills, and a pill for night sweats; instead, the scientific practice of medicine involves identifying the single disease that causes those multiple symptoms, and treating that single disease with an antibiotic. 

Symptom-oriented treatment, although very popular, breaks the Hippocratic tradition in medicine, and causes more harm than good.  

The approach PL recommends is that PCPs take a similar approach to distractibility, depression, and anxiety as they take to fever, chills, and night sweats.  Look for single diseases, like unipolar depressive illness or bipolar illness, that may cause such symptoms.  Nonetheless, sometimes symptom-oriented treatment can be necessary, as long as it is provided, as with all medical symptom treatment, at the lowest dose and for the shortest duration possible.

A general approach to Hippocratic psychopharmacology, which is disease-oriented rather than symptom-oriented, is relevant to primary care setting as well as standard psychiatry (provided here). 

Neurotic depression in primary care

It should be noted that probably the most common psychiatric presentation in the primary care setting in adults does not have a DSM label:  neurotic depression, described further here.  Such patients are chronically anxious and depressed to a moderate degree, with many physical (somatic) complaints.  Antidepressants and anxiolytics provide modest symptom benefit at best.  No simple drug solution exists for such patients, but long-term antidepressant and anxiolytic treatment, at standard to high doses, is not likely effective and may not produce more benefits than harm. 

Summary

A summary maxim for primary care psychiatry would be:  Treat disease, not symptoms, as much as possible.  This contrasts with the current status quo of treating symptoms aggressively, and failing to diagnose diseases whose treatments are different from mere symptom management.

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