10 September 2013
A Dangerous Game: GPs Prescribing Psychotropics
by Victoria L. Dunckley, M.D. in Mental Wealth, 11 March 2013
Is it dangerous to have a general practitioner prescribe psychiatric medication?
What are the dangers of obtaining psychotropic medications from a primary care provider?
Most of the time, patients approach their general practitionerfirst to seek help for mental health related complaints. If it’s a fairly straightforward case, the GP is usually able to address the situation appropriately. The problem arises when a more serious mental health condition is brewing, or there is a safety concern. The patient has a ten or fifteen minute appointment to describe their complaints--compared to a one or two hour session or multiple sessions with a psychiatrist or psychologist. The patient typically wants some action to be taken immediately, and the doctor only knows what the patient tells them. The physician feels pressure to do something to provide some relief, and voila—the patient walks out with a prescription (or two).
Generally speaking, primary care providers do not have the time or the expertise to obtain a really good psychiatric history and complete a thorough assessment. They’re not able to sit down with the patient and the patient’s family to discuss potential short and long-term risks of medication in detail, and may not even be aware of them. They also can’t fully assess or address psychosocial issues that may be relevant to the person’s well-being and safety.
Despite the fact that one in three visits to primary care are for psychiatric related complaints, these providers typically have very little specific training in psychiatry. After medical school and residency, much of their psychiatric education is delivered by pharmaceutical representatives.
Using psychotropics before a formal psychiatric evaluation has been performed
Obtaining a prescription for psychotropic drugs before a formal mental health evaluation has been performed can be quite risky. In psychiatry, there is a lot of symptom overlap, so the same symptom can represent more than one disorder, making diagnosis tricky—and increasing the likelihood of the wrong kind of medication being prescribed. Additionally, if there are multiple diagnoses occurring together—a fairly common scenario—sometimes a medication helps one condition but makes another one worse. And lastly, medications that are commonly used in primary care or urgent care settings, such as sedatives, sleep agents and anti-depressants, may sometimes unmask a mental disorder in a vulnerable individual. These medications can occasionally have aparadoxical reaction, meaning that instead of having a calming effect they cause disinhibition, agitation, or even psychosis. This reaction is more common in the elderly, in children, and in those with cognitive impairment.
People react to psych drugs very differently, and there is typically a lot of trial and error even with a very skilled psychiatrist. Combining drugs requires an even higher level of understanding and monitoring.
Our society likes a quick fix. Who isn’t super busy these days? But it is wise to obtain an evaluation from a mental health professional first, including a psychiatrist if medication is being considered. Many times complaints can be addressed with therapy, relaxation techniques, exercise and diet, and addressing psychosocial stressors. Medication isn’t necessary most of the time. When it is, the decision shouldn’t be taken lightly, and careful monitoring should take place.