Psychiatrists Face Barriers to Managing Common Medical Conditions

Psychiatrists may become more involved in managing general medical care for their patients in the coming years, suggests a study published online December 1, 2017, in Psychiatric Services in Advance.

The report found that only 37 percent of the sampled visits to psychiatrists involved general medical management activities such as measuring weight and blood pressure and ordering blood work. In comparison, 74 percent of visits to other specialist physicians involved these activities. The researchers focused on four medical diagnoses commonly encountered in both general medical and psychiatric settings: hypertension, hyperlipidemia, diabetes, and obesity.

“Psychiatrists are significantly less likely than most other physicians, except for ophthalmologists, to conduct physical examinations and significantly less likely than most other physicians, except for dermatologists and ophthalmologists, to measure blood pressure or weight,” wrote Ramin Mojtabai, M.D., Ph.D., of Johns Hopkins University School of Medicine and Mark Olfson, M.D., of Columbia University and New York State Psychiatric Institute.

For the study, Mojtabai and Olfson relied on eight years of data (2006-2013) from the National Ambulatory Medical Care Survey (NAMCS)—an annual survey of visits to office-based physicians. A sample of visits to each physician was drawn during a randomly selected one-week period. To be included, an adult had to have seen a physician during the visit.

A total of 236,246 visits to 11,724 physicians met the criteria and were included in the sample; these visits included 11,046 to 735 psychiatrists, 66,267 visits to 3,024 general medical physicians (general and family physicians and internists), and 158,933 visits to 7,965 physicians in other specialties.

For each visit, information was extracted from medical charts regarding the patient and characteristics of the visit, including diagnoses made, laboratory tests ordered, whether a physical exam was conducted, and/or health education and counseling were offered.

The authors specifically focused on general medical management activities including recordings of hypertension, hyperlipidemia, diabetes, or obesity; prescriptions of medications for hypertension, hyperlipidemia, or diabetes; blood pressure or weight measurements; ordering glucose, glycohemoglobin (HbA1c), lipids, or cholesterol laboratory tests; and education or counseling for weight, exercise, diet and nutrition, or tobacco use.

Overall, psychiatrists were found to be less likely to engage in management of common general medical conditions. However, differences between psychiatrists and all other physician groups were smaller for health education and counseling.

One of the key barriers, explained Olfson in an interview with Psychiatric News, is that psychiatrists with office-based practices often have large caseloads and are stretched to the limit. “Adding more functions for these psychiatrists may be unreasonable, especially considering the shortage of psychiatrists,” he said. Additionally, psychiatrists in solo or small group practices often have few or no support staff, limiting their ability to conduct basic health assessments.

Additionally, the authors wrote, “Psychiatric assessment and treatment, which are priorities in psychiatric visits, are time consuming and often involve extensive mental status examination, assessment of safety, and psychotherapy.”

Still, Olfson said that he believes it is important for psychiatrists to expand their roles as much as possible to include general medical care, especially for patients with major psychiatric disorders, such as schizophrenia and bipolar disorder. “This [issue] is less about what psychiatrists want and more about what patients need,” he said.

The authors noted that a major driver of the low prevalence of general medical management activities during psychiatric visits was the substantial percentage of psychiatrists who did not did not engage in general medical activities for any of their sampled visits. For example, the study found that 67.6 percent did not prescribe any medications for the treatment of hypertension, hyperlipidemia, or diabetes, and 89 percent did not order any laboratory tests for glucose-HgA1c or lipids-cholesterol—proportions that were higher than with other physician groups.

Psychiatrists were as likely as general medical physicians to provide tobacco counseling, a finding Mojtabai and Olfson noted was possibly due to the high prevalence of tobacco use among psychiatric patients. Psychiatrists were also more likely than many other specialists to provide counseling and health education for patients with specific health conditions, such as hypertension and diabetes.

Among psychiatric diagnoses, researchers found that schizophrenia was consistently associated with higher odds of general medical management activities by psychiatrists, followed by bipolar disorder. However, diagnoses of mood disorders were associated with lower odds of general medical care activities.

“With ongoing trends toward integration of general medical and mental health care, demands on psychiatrists to expand their scope of practice will likely increase. Identifying appropriate opportunities for such expansion and providing necessary medical support services and continuing medical education may encourage psychiatrists to increase their involvement in the general medical care of their patients in the coming years,” the authors wrote.

Still, the authors cautioned, “efforts to expand psychiatrists’ scope of practice to include general medical activities should be moderated by judicious considerations of competing demands on their attention and time.” ■

“Management of Common Medical Conditions by Office-Based Psychiatrists” can be accessed here.