The role of psychiatrists in primary care of patients with severe mental illness

Objective: This study sought to identify health conditions for which a prim ary care psychiatrist would be an appropriate treatment provider in an inte grated model of health care delivery for persons with serious mental illnes s. A primary care psychiatrist is a psychiatrist with primary care training who is supervised by an on-site internist. Methods: Rating methods for hea lth conditions were adapted from those jointly developed by Rand and the Un iversity of California, Los Angeles. A consensus panel of 14 hospital admin istrators, internists, psychiatrists, and nursing service representatives f rom three southern California Veterans Affairs health care systems was conv ened. Eleven physician-panelists, including five psychiatrist, five interni sts, and a medical specialist, rated whether a general psychiatrist, a prim ary care psychiatrist, an internist, or a medical specialist could reasonab ly provide evaluation, treatment, or preventive care for uncomplicated inst ances of each of 344 physical health conditions or procedures. Results: A p rimary care psychiatrist, with supervision by an internist, was rated as an appropriate treatment provider for most of the 344 conditions. The conditi ons included many of those cited by patients as the most common reasons for ambulatory care visits. Panelists identified some intrusive elements of pr imary care, such as a pelvic examination, as potentially injurious to the p sychiatrist-patient relationship and inappropriate for performance by psych iatrists. Conclusions: This study took the first essential step in evaluati ng the integration of primary care into the psychiatric setting. Further re search is needed to determine whether use of primary care psychiatrists wil l increase access to primary care by persons with serious mental illness an d improve outcomes.