A Framework for Extending Psychiatrists’ Roles in Treating General Health Conditions
Publication: American Journal of Psychiatry
“Mr. I” is a 55-year-old married Caucasian man with major depressive disorder in remission and alcohol use disorder, active. He consumes 5–6 alcoholic beverages daily and has been engaged in treatment at a community mental health center near where he lives. His mood symptoms are well controlled on fluoxetine at 20 mg/day.
Mr. I presents for routine follow-up with his psychiatric provider. The patient’s blood pressure on intake is 143/85 mmHg, and on chart review the psychiatrist makes a diagnosis of hypertension from three prior readings dating back 6 months. Mr. I is amenable to making an appointment with “Dr. J” at a nearby primary care clinic that accepts his insurance. The psychiatrist then proceeds to engage Mr. I around his excessive alcohol use. Mr. I elects to taper his use over the next month. The rest of Mr. I’s treatment plan continues unchanged.
Mr. I returns to the psychiatrist 1 month later having markedly reduced his alcohol intake, to 3–4 beverages per week. His blood pressure remains elevated at 145/88 mmHg, and he missed his appointment with Dr. J because of transportation problems. He has another appointment scheduled with Dr. J in 3 weeks. At this point, Mr. I’s psychiatrist makes a referral to the community mental health center’s case management services for assistance in overcoming his transportation barrier. Mr. I’s medical problem remains routine and nonurgent. A case manager follows up with Mr. I and provides him with a bus pass.
Mr. I returns 3 months later after having seen Dr. J once. Dr. J started the patient on 10 mg/day of lisinopril, a common first-line therapy for essential hypertension. In clinic with the psychiatrist, Mr. I’s blood pressure is 148/92, and he reports that he is not taking the medication routinely because he was not aware that he would need to take it chronically. He also reports that he did not return for an appointment with Dr. J because he felt that he was not being adequately listened to, and so he would rather have his blood pressure managed in the community mental health center. The psychiatrist empathizes with Mr. I’s concerns, provides education on blood pressure management and the importance of adherence to treatment, and notes that the patient’s depression is worse. The psychiatrist increases Mr. I’s fluoxetine dosage to 40 mg/day, flags the case manager to follow up with primary care physician appointments and medication adherence, and discusses behavioral activation techniques, including regular walking. The case manager assists Mr. I with another appointment with a new physician at the primary care clinic. They are able to arrange a follow-up appointment at the community mental health center in 8 weeks.
At his follow-up psychiatric appointment, Mr. I’s mood is improved and he has been walking consistently, but his blood pressure remains elevated at 153/92. He is asymptomatic. He failed to make his new appointment with another primary care physician and reports that he would prefer to address his health issues in one place.
In the interval since his last appointment with Mr. I, the psychiatrist has reviewed common guidelines for management of hypertension as part of an online module for continuing medical education. In spite of multiple attempts to access to quality care, there have been consistent barriers, including patient-intrinsic factors, such as health literacy, and systematic barriers, such as transportation, that limit Mr. I’s receipt of care. At this point, 6 months have elapsed since the psychiatrist made the initial diagnosis of essential hypertension, and Mr. I’s blood pressure remains elevated in spite of cessation of alcohol, changes in his physical activity routines, and multiple attempts to connect him with primary care. The community mental health center clinic has been consistently monitoring Mr. I’s blood pressure and has on-site laboratory capabilities. The clinic recently invested in nursing support and electronic medical records to facilitate tracking of chronic conditions and outcomes. As noted, Mr. I wishes to consolidate some of his care within the community mental health center, and he would be comfortable with the psychiatrist prescribing his antihypertensive medications.
In light of this, the psychiatrist reinitiates treatment with lisinopril at 10 mg/day and arranges blood tests for electrolyte and creatinine levels, as well as a nonfasting lipid profile and a hemoglobin A1c level. The psychiatrist also calls Dr. J, the primary care physician, to discuss the treatments. Dr. J suggests that if Mr. I’s blood pressure remains elevated, the psychiatrist could increase the dosage of lisinopril in 10 mg increments every couple of weeks up to 40 mg/day and, if necessary, add a thiazide diuretic, such as hydrochlorothiazide or chlorthalidone. Dr. J agrees to see Mr. I again in follow-up if Mr. I desires, and he acknowledges that there were communication difficulties in their initial encounter several months back.
Mr. I returns for a follow-up with the psychiatrist in 4 weeks. He was able to get his blood testing done, and the results were all within normal limits. The psychiatrist calculated Mr. I’s 10-year risk of heart attack or stroke, which was 7.0%, and he did not find that the patient met criteria for daily lipid-lowering therapy (for persons at average risk, the cut-off is 7.5% [1]). Mr. I’s current blood pressure is 137/86, and he is consistently taking lisinopril at 10 mg/day without concerns. His mood is well controlled on fluoxetine at 40 mg/day, and his alcohol use remains in full remission. Mr. I is somewhat reluctant to return to the primary care clinic, and the psychiatrist is agreeable to continuing the lisinopril and following his hypertension in consultation with the primary care physician while continuing to engage Mr. I to overcome barriers to accessing primary care.
Evidence exists of widening health disparities between the general population and populations with chronic mental illness, attributable primarily to cardiovascular disease (2, 3). There are numerous explanations for this, including sedentary lifestyles, high rates of smoking, poor diets, poverty, underresourced environments, and medications utilized in the treatment of mental illness that contribute to cardiovascular disease risk (4–7). Adequate access to primary and preventive health care for persons with chronic mental illness is fraught with barriers and stigma (8, 9). Often psychiatrists are the only physicians a patient has access to or sees with regularity. Pressures are mounting in the field of psychiatry to better integrate within the house of medicine as health care services adapt to meet the changing needs of the U.S. population. APA recently approved a position statement (10) justifying the extension of the psychiatrist’s scope of practice to general health conditions in certain clinical situations and calling for improved access to education on general health topics, coordination with primary care, and more proactive monitoring and advocacy for the general health of psychiatric patients.
Emerging educational opportunities are available that equip psychiatrists with the skills necessary to identify and manage general health conditions commonly found in populations with mental illness (11, 12). The extension of the traditional scope of practice—the procedures, actions, and processes that health care practitioners are permitted to undertake in keeping with the terms of their professional license—may be warranted in many settings. However, practitioners lack guidance and rationale for when to do this, and many psychiatrists are concerned with medico-legal liability that may accompany such a change. Furthermore, overburdened public mental health systems and growing mental health workforce shortages demand that the limited supply of psychiatric providers be applied judiciously. As yet, there is no uniform framework that psychiatrists can use for a systematic approach to considering the extension of their scope of practice to treat common medical conditions. Such a framework could provide justification for the assumption of additional medico-legal risk resulting from action to manage certain physical health conditions and rationally reallocate precious mental health resources. We provide a theoretical framework by which a psychiatrist considering physical health management could do so in a reasoned, practical, efficacious, and person-centered manner, and we highlight how this framework may be applied in clinical practice. We propose that the decision to extend the scope of practice be made after considering five distinct domains: the nature and severity of the problem, the patient’s access to existing primary care services, the general medical training and comfort of the psychiatrist, the capacity of the provider’s environment for management and follow-up, and patient preference.
Nature and Severity of the Medical Condition
Routine screening for modifiable cardiovascular risk factors has been the standard of care for psychiatrists for over a decade for patients treated with second-generation antipsychotics, and recent advances in nonfasting screening for cholesterol and diabetes have removed several barriers to implementation of these practice guidelines (13, 14). Psychiatrists are often confronted with comorbid medical conditions that are highly prevalent in populations with severe mental illness (4), and classifying existing conditions as routine, urgent, or emergent can help the clinician determine the most appropriate course of action in referral, consultation, or management.
In routine conditions, the risk-benefit difference between treatment and nontreatment is relatively low, as many common conditions, such as essential hypertension, have relatively few risks of treatment and controlling them over time could yield significant benefits. Routine conditions may be identified through standard screening protocols, and the patient may not be aware of their existence. In these circumstances, the direct threat of morbidity or mortality is usually more distal. Examples of these include a hemoglobin A1c value of 6.8% detected during annual screening—diagnostic of diabetes, which may still be asymptomatic—or the calculation of a 10-year atherosclerotic cardiovascular disease risk of 10% from the results of an annual lipid panel, resulting in the need for a statin medication to lower cholesterol levels. Both situations, while complex, need proper identification and management and are “low-hanging fruit” for basic interventions, with low relative risk and high long-term benefit. In one analysis, up to 88% of patients with mental illnesses with identified dyslipidemias failed to receive any treatment for them (15). Extension of practice scope to treatment of these prevalent, high-benefit, and low-risk-of-treatment conditions is warranted under the right circumstances.
Urgent problems, and certainly emergent problems, represent a more proximal threat of morbidity and mortality and may be symptomatic. Since these circumstances would be encountered less frequently than routine conditions, extension of scope within these clinical contexts is anticipated to be less likely, and referral to appropriate medical care would be pursued more aggressively in the interest of the patient.
Access to Care
In ideal health care settings, all patients have a primary care provider who coordinates care across medical specialties (16, 17), with an emerging emphasis on team-based chronic disease management. In these settings, primary care physicians handle chronic medical conditions and preventive care, and, given adequate primary care access, psychiatrists may continue to practice as specialists. Under these conditions, patients are comfortable with their primary care physician, who has a thorough understanding of the patterns of disease common in persons with chronic mental illness. The patient has ready access to the primary care physician to facilitate easy referral to other specialty care as needed. Notably, access, continuity, and systematic management of populations of patients are central pillars of the “patient-centered medical home” and should become increasingly available (18). Furthermore, specialists and primary care physicians need to have good working relationships that facilitate many of the processes mentioned above. Unfortunately, in practice such systems are rarely realized for patients, especially those in the public mental health sector (19–21).
Consequently, there are instances when a psychiatrist could consider management of medical conditions, such as when the patient lacks access to quality general health care or when the psychiatrist develops the most consistent and/or frequent treatment relationship with the patient because of the dominance of particular disabling chronic conditions (e.g., schizophrenia in the context of high-intensity services such as assertive community treatment, ongoing long-term disabling substance use disorders, treatment-resistant depression, and so on). Other specialties, including neurology and nephrology, have set precedents for this specialist relationship under certain conditions, which exist at one end of the primary care–specialist consultative spectrum; the specialist assuming this role is referred to as a principal care physician (22, 23).
Lack of access to quality care can be further divided into systemic factors, clinician factors, and patient-specific factors. Appropriate care is not simply overcome by attendance at primary care appointments (21, 24). Identifying and rectifying barriers in each of these domains may obviate the psychiatrist’s need for extension of scope.
System-Level Barriers to Access to Care
Mental health practitioners should first consider whether a lack of access to care is resulting in poor physical health. Many persons with chronic mental illness are impoverished and cannot afford transportation to appointments or copayments for office visits or medication (6, 25). Patients may have difficulty planning for and managing appointments, resulting in discontinuity of care or the potential for refusal of services. Any of these factors could result in suboptimal care and, when present, may necessitate intervention from a mental health advocate, such as a care manager, to navigate these barriers. Indeed, such interventions have proved to be effective in improving access and the receipt of preventive health services, in lowering cardiovascular disease risk, and in bringing systemwide cost savings in public mental health settings (26, 27). If attempts to rectify these barriers cannot be overcome (e.g., the patient is consistently missing primary care appointments because of lack of transportation but does not have the same limitations for visits to the psychiatrist, and attempts to provide better transportation have failed), the psychiatrist may choose to manage medical conditions while continuing to pursue alternative solutions for engaging the patient and others within the team in their physical health care.
Clinician-Level Barriers to Access to Care
Provider factors may also contribute to poor-quality general health care. Studies have found marked disparities between persons with and without mental illnesses in quality of care across a variety of settings, such as lower rates of reperfusion treatments for patients with mental illnesses presenting with myocardial infarction (8, 9, 28). Persons with mental illness present additional challenges for primary care physicians to manage within harried safety-net settings, including the need for lengthier visits because of cognitive limitations associated with mental health conditions (29). Similarly, persons with mental illness seen in mental health settings in need of recommended health screenings for iatrogenic effects of medications prescribed by psychiatrists rarely receive this care in spite of established screening guidelines (30–32). Specialists and primary care physicians alike face similar challenges in time and appointment scheduling, evidence-based decision making, and knowledge of screening practices, although many primary care physicians may be less aware of monitoring guidelines for psychopharmacological therapies.
By virtue of their medical background and training, psychiatrists are better equipped than any other practitioners in the mental health field to recognize poor-quality general health care at the clinician level and to advocate among medical colleagues on behalf of their patients. For patients deemed to be receiving inadequate primary or preventive medical management because of any of the clinician-specific barriers, the psychiatrist may be better positioned to provide some of that management because of his or her familiarity and comfort with working with persons with mental illness. The psychiatrist may redirect the patient to an alternate primary care physician who is more adept at working with this population (assuming that alternative access is available) while balancing trade-offs in continuity and rapport associated with transfer of care.
Patient-Specific Barriers to Access to Care
Psychiatrists should evaluate whether patient-specific factors are resulting in inadequate medical care outcomes. Low health literacy, cognitive symptoms (e.g., apathy, anosognosia, paranoia, anxiety, reclusiveness), and low prioritization of physical health and wellness have all been associated with poor adherence to medications and follow-up appointments, low levels of physical activity, and poor medical outcomes (25). When such factors are present, facilitating referral to a well-qualified and attentive primary care physician may not necessarily result in receipt of care and improvement in health outcomes. If the patient continues to have poor outcomes and is consistently engaged in treatment with a mental health team with additional skills in motivational enhancement, extension of practice scope may be justified because of a higher probability of overcoming these patient-level barriers.
Lack of access to and receipt of quality primary care is a problem that should be routinely addressed. By systematically assessing the three common barriers to access to care and working to overcome them, psychiatrists can advocate for improved access through multiple platforms without the extension of their scope of practice. If these barriers remain after attempts to overcome them, extension of scope may be warranted given the nature of the condition being managed and the training background of the clinician.
Medical Training and Knowledge
Where there is a lack of access to care, the degree to which a psychiatrist provides general medical care for routine conditions also depends on his or her general knowledge and comfort in management and the degree to which local primary care physician consultation is available for assistance. The presence of primary care consultation could allow for further or earlier practice extension when the risk-benefit ratio reflects higher risk and less perceived benefit, but it is not a requirement for extension of scope. For example, a psychiatrist may initiate an antihypertensive medication in consultation with a primary care physician while arranging follow-up with the latter for ongoing management, thus reducing uncertainty about insufficient medical training or harmfulness of the intervention. Algorithms that are updated regularly could also serve to offset concerns with providing up-to-date standards of care.
Previous consensus panels have concluded that psychiatrists could be involved in managing more than half of 344 common medical conditions (33), and educational offerings are available to address gaps in medical knowledge necessary to overcome this barrier to scope extension (11, 12). A plethora of evidence-based guidelines that are patient-level recommendations are accessible for practitioners seeking further information (34). Additionally, certification could be developed to indicate that an appropriate level of education and skill has been attained. Psychiatrists who opt to engage in management of general medical conditions should maintain awareness of any limitations in their medical knowledge and seek ongoing educational opportunities as available.
System Capacity for General Medical Management
Once appropriate skills have been acquired, access to care has been deemed insufficient, and the nature of the problem has been considered, treatments should be evidence-based, systematically followed, and consistently pursued until well-defined clinical outcome targets are met. To accomplish this, developing a care team with defined responsibilities is often helpful or necessary. This may include ensuring that vital signs are routinely assessed at outpatient appointments, patient registries are developed to identify and track outcomes for patients being managed across certain chronic conditions, and clinical workflows and protocols are established to remove barriers to processes such as routine laboratory monitoring.
The larger clinical system may also be considered, including educational efforts highlighting the variety of services offered, informed consent procedures, and general awareness and support of wellness-related activities. Advancing this systematic capacity to monitor and address general health conditions within a mental health organization is part of a national agenda to integrate primary care within community mental health, and resources are becoming increasingly available to bring this system-level transformation to these settings (35, 36). Professional associations and practitioners should continue to advocate for appropriate reimbursement strategies that would allow physicians the flexibility to perform at the height of their medical training in the service of the population.
Patient Preference
Finally, and perhaps most importantly, persons afflicted with chronic illnesses should be granted the ability to determine where their care is delivered according to their preferences and within the constraints described above. Patient engagement and motivation to manage chronic conditions are essential, and they may be disrupted when personal preferences are ignored. Some patients will prefer to continue to seek access to primary care outside the mental health setting, and in such cases, extension of scope is not warranted and the psychiatrist’s role reverts to advocacy for the patient.
Discussion
Figure 1 presents an algorithm for determining when a psychiatrist should consider management of physical health conditions based on the five domains described above. Unfortunately, barriers to access and receipt of high-quality primary and preventive care are often insurmountable. Given the clinical characteristics of the populations served by psychiatrists today, there is a high likelihood that in certain settings, such as community mental health centers and assertive community treatment teams, psychiatrists may be called upon to extend their scope of practice more than in other settings. This guideline offers a balanced, patient-centered, and reasoned approach that avoids an unnecessary reallocation of precious specialty resources. Familiarity with appropriate screening for, diagnosis of, and evidence-based treatment of common medical conditions is a requisite for appropriate triage, oversight, and potential intervention. Consistent use of this approach could guide the psychiatrist’s or mental health team’s role in evolving models of integrated care.
The possible approach to the case of Mr. I in the vignette illustrates an application of this framework through navigation of these domains.
Conclusions
Psychiatrists are uniquely positioned to advocate for their patients or to extend their practice to management of physical health conditions, under the right set of clinical circumstances, such as those outlined above. Consistent application of this guideline will help ensure that the profession will continue to serve our patients in a patient-centered, holistic manner according to their preferences and within the bounds of practitioner expertise and systemwide resources in partnership with primary care. Through a rationed approach, practitioners can be engaged to lighten the mortality burden of those with mental illnesses across the system of care.
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Information & Authors
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Received: 22 July 2015
Revision received: 8 September 2015
Accepted: 21 September 2015
Published online: 1 July 2016
Published in print: July 01, 2016
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The authors report no financial relationships with commercial interests.
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