Is developing a DSM-5 for primary care a good idea?

When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?

However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.

Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.

Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.

A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.

The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.

The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.

Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.

Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.

Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?

The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).

I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?

I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.

All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?

Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.

Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.

I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.

Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.

So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.

Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.

When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?

However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.

Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.

Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.

A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.

The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.

The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.

Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.

Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.

Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?

The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).

I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?

I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.

All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?

Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.

Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.

I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.

Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.

So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.

Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.

When I first learned that a DSM-5 for primary care physicians was underway, I thought this sounded like a reasonable and sensible idea. After all, most mental health diagnoses are made by family medicine doctors, internists, and pediatricians. And there is a primary care version of the DSM-IV. So why not continue to make it easier for these physicians to make the correct diagnosis and referrals to appropriate mental health specialists?

However, I continue to be disturbed by the idea that primary care physicians are equipped to treat patients with mental illness. First, primary care doctors generally know very little about serious mental illness. In fact, they probably know as much about our treatments as I know about treating cardiac disease. Our disorders require significant study and clinical experience, which the average primary care physician does not have.

Second, continuing the assumption that they understand illnesses we are trained to treat will continue to make our specialty less relevant. Over the last 50 years, we already ceded much of our profession, not only to medical doctors in other specialties but also to a host of mental health professionals with credentials ranging from bachelor’s degrees to doctorates. When psychoanalysis dominated psychiatry in America, our tendency was to invite everyone in to partake in the care of our patients. In the early 1960s and 1970s, big upheavals were occurring in the therapeutic and biological sides of psychiatry. The result is that we turned family and group therapy, as well as many other treatment modalities, over to the psychologists.

Furthermore, psychiatry failed to embrace electroconvulsive therapy as encouraged (Can. J. Psychiatry 2011;56:3-4) to do so by another great Fink (no relation, by the way). Also, cognitive-behavioral therapy and all of its ramifications were spurned by most practicing psychiatrists.

A patient whom I’ve treated for 7 or 8 years gradually overcame his post-traumatic stress disorder after discovering that his early life traumas had led to his condition. Toward the end of my work with him, he asked whether I would mind if he would go to see a therapist he heard of who used eye movement desensitization and reprocessing, or EMDR (Nurs. Times 2012;108:24-6). Of course I didn’t mind, I told him.

The patient came to his next appointment with me and announced that it would be his last. The psychologist had cured him. I congratulated the patient and sent him on his way, and did not try to convince him that the miracle was tied to our long, tedious work together. But I felt badly, and decided to go and find out about EMDR myself.

The psychologist was a delightful Ph.D. I tried out all of her gadgets, and I did get to relax. But I could not understand theoretically what was going on, nor did I tell her that was why I was there. Imagine how patients will feel being cared for by someone who does not do therapy, and uses lots of drugs, gadgetry, and pounds of reassurance. This is comparable to what could happen with primary care physicians who rely on their own version of the DSM. Over a period of years, those reading primary care versions might consider themselves proficient as therapists – with little or no basic grounding in the therapeutic process.

Being able to make a diagnosis is sometimes the smallest important part of the patient encounter. Perhaps requiring the primary care physician to take a course, or several courses for that matter, aimed at making the manual and subsequent activities clear, would allow for a deeper understanding about psychiatric treatments.

Early in my academic career, I was asked to prepare and give courses to nonpsychiatrists. Very few people signed up. The same people signed up year after year, and they never quite felt competent to do the work. The rest of the primary care physicians wanted courses in cardiology and other "more scientific" courses, which in many ways fit easier into their medical school education curricula.

Why do we want to give away our distinction as the diagnostician of mental disorders? Is this going to help psychiatry?

The fourth reason I’m opposed to this is economic. Why create a large cadre of competitors even greater than we have now? This will surely be converted by health insurance companies into a new reason to cut our fees even more and to work out more plans to include the GP on the team (after all, he knows the patient better than we do. There is so much he can contribute to a better understanding of the patient, his or her family, the context or circumstances of some of his or her behaviors, and so on).

I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?

I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.

All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?

Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.

Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.

I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.

Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.

So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.

Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at [email protected]. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.