As a primary care physician, managing medication for patients with mental health conditions may seem a bit daunting.
But a family physician who manages patients’ behavioral health medications in his practice every day and a psychiatrist who consults with primary care doctors on these medications on a regular basis say this type of behavioral health integration (BHI) doesn’t have to be intimidating.
“You can do this. Your patients want you to do this,” Ryan Laschober, MD, program director for Waco Family Medicine Residency at Waco Family Medicine Institute in Texas and the editor-in-chief of The Waco Guide to Psychopharmacology in Primary Care, said during a recent Overcoming Obstacles BHI webinar hosted by the AMA, “Integrating psychopharmacology into primary care: When and how.”
in some ways, the primary care setting is the best place to do psychiatry, said webinar panelist John Kern, MD, clinical professor of psychiatry and behavioral science at the University of Washington AIMS Center.
“It has a responsiveness and an ability to respond to medical issues, in particular to emergencies, that is just not available in the psychiatric setting in the vast majority of examples,” Dr. Kern said.
During the webinar, Drs. Kern and Laschober discussed key steps and interventions primary care physicians can take to address routine and complex behavioral health conditions.
First, primary care offices need to assess patients. This can be done by using rating scales—for example, the PHQ-2—and a team-based approach.
Then start with basic treatments. They work, Dr. Kern said, even for complex patients. Primary care physicians should get comfortable with a few of the most tested pharmaceutical options for treating mental health conditions and try those first. The concept is no different than a physician having, for example, a couple of ACE inhibitors they go to first for patients with high blood pressure or heart failure.
Next, start at a low dose and titrate through the dosages. The No. 1 error among primary care physicians is inadequate dose titrations, Drs. Kern and Laschober said.
Every one to two weeks, physicians should increase the dose unless there has been an adequate response to the medication, the side effects have become intolerable to the patient or the maximum dose of the medication has been reached and there is no response.
The worst thing is to try a small amount of one thing and move on to the next thing, Dr. Kern said. “It takes a while to titrate though a bunch of doses. Especially if you go slow. So, you are looking at months.”
Physicians and patients start to think medications aren’t going to work, or maybe the diagnosis was wrong. But, Dr. Kern said, “you have to remind yourself of the evidence and move forward. … It takes two, to three or four trials to get most of your folks better. You have to remember that because your gut is going to tell you different.”
In an effort to provide high-quality care in the primary care setting, Dr. Laschober said it was crucial to make guidelines on mental health conditions—typically written for psychiatrists—more accessible to primary care physicians.
To fill the void, the Waco Family Medicine Residency faculty along with Massachusetts General Hospital Psychiatry Academy faculty created “The Waco Guide to Psychopharmocology in Primary Care,” which outlines more than 60 decision-support tools to guide internists, family physicians and other primary care physicians in caring for patients with mental health conditions.
It is not industry funded and it includes guidelines for adult, pediatric and perinatal psychopharmacology.
The AMA established the BHI Collaborative with seven other leading physician organizations to catalyze effective and sustainable integration of behavioral and mental health care into physician practices. Learn more with the collaborative’s “Overcoming Obstacles” webinar series.
Also, check out the BHI Collaborative’s Behavioral Health Integration Compendium, which provides health care organizations with a proven pathway for delivering integrated behavioral health care and ensuring they have the most recent, actionable information at their disposal.