Behavioral specialists spend considerable time gaining patients' trust before those patients will talk openly with them, but family physicians are a big step ahead, having already obtained their patients' trust through years of collaborative interaction.
That relationship makes it easier for family physicians to get an honest answer when they ask patients, "How are things at home?" or "Do you feel safe?"
"Patients who would never go to a counselor or a psychiatrist may trust their family physician with their mental health problems," wrote J. LeBron McBride, Ph.D. M.P.H., director of behavioral medicine at the Floyd Medical Center Family Medicine Residency in Rome, Ga., in an article(www.annfammed.org) published in the September/October issue of the Annals of Family Medicine.
McBride discussed with AAFP News how family physicians can incorporate mental health care into their practices. As demanding as such cases can be, the large majority of behavioral and psychosocial issues can be addressed by family physicians.
"The key is knowing when to refer if the problem goes beyond the family physician's expertise or ability to address, just like with severe cardiac problems," McBride said.
- The trust that family physicians build with patients through years of collaborative interaction makes them particularly well-suited to treating mental illness, noted a recent article.
- Article author LeBron McBride, Ph.D. M.P.H., director of behavioral medicine at a family medicine residency in Rome, Ga., said that the majority of behavioral and psychosocial issues can be addressed by family physicians.
- Incorporating mental health care highlights the "family" aspect of family medicine.
McBride recognizes that the pressure physicians face to see patients in short time slots and the increasing demands of electronic health records may leave less time to address mental health, but he notes that issues such as a shortage of behavioral health services make the role of family physicians especially important.
"In some places, psychiatrists and mental health providers are not present, and the family physicians are trying to do what they can in difficult situations," McBride said. "I think most family physicians have an orientation toward incorporating the mental health care of their patients and have had to become the mental health providers in our health care system."
Incorporating mental health care into practice highlights the "family" aspect of family medicine. As with physical illness, family members of patients with mental illness may be "hidden patients" who also require care, McBride noted in the Annals article. The family might become isolated in an attempt to protect the ill person or the family's reputation, or relatives might not want to report a relative with a history of abuse or violence to avoid involving the justice system. In these cases, a family physician can step in, perhaps simply to listen or to explore the option of a psychiatrist or an attorney.
"Having a physician with whom families can discuss issues and at least vent their difficulties can relieve their stress," McBride wrote in the article. "The family physician can listen to the family members' stories, ask appropriate questions and offer hope."
At the Floyd Medical Center Family Medicine Residency, interns are encouraged to take an interest in patients' personal lives. The technique helped one patient, for instance, when she went in for treatment of back pain but a physical exam did not reveal conditions consistent with her complaint. The medical resident consulted with a supervisor and then asked the patient what else was happening in her life. The patient began crying and explained that she had just lost a parent.
"Taking a moment to ask about family relationships, personal fulfillments or disappointments, or a job does not have to take long, but it demonstrates interest and care," McBride told AAFP News.
Practices may use mental health screenings such as the PHQ-9 Patient Depression Questionnaire and have a plan for referrals. In areas with limited mental health facilities, religious leaders may help support patients. Regardless of practice location, physicians should be aware of local inpatient psychiatric and substance abuse centers.
"The physician has to become comfortable with not being able to solve all the problems in one visit," McBride cautioned. "Psychosocial issues can be messy and take months or even longer to address."
Mental health demands are rising in large part because financial support at the state level has diminished. McBride noted that a state psychiatric hospital that operated for decades near his facility is closed now, as are several others in Georgia.
"Many mentally ill patients who would have previously been sent to a psychiatric hospital now end up in our jails with little or no treatment," McBride said. "Others with severe mental illness seek treatment by family physicians when they need more intensive treatment."
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