treatments
Psychiatrist or Another Physician?
Q: Should everyone with Schizophrenia be cared for by a Psychiatrist?
A: This really depends upon the individual patient’s needs.
Introduction
This question is a difficult to answer with a simple statement, as there are several factors that must be considered before a recommendation can be made. Every patient with Schizophrenia is an individual and each case of this illness is different.
Furthermore, the number of particular symptoms that each person experiences and their severity may vary over time within the same patient. Many patients also have other comorbid medical or psychiatric illnesses (especially substance abuse disorders).
Not all patients take medications.
Medication
Most sufferers of Schizophrenia receive medications, but there are some who do not. Rarely, people with this illness have symptoms that don’t respond at all to medications. Some have been advised to take medications, but refuse. This refusal may simply be related to their convictions about medications in general; or it may be based upon past unpleasant experiences with medications.
Those few people with Schizophrenia who are not taking psychotropic medications may not require the regular attention of any type of physician for the management of their Schizophrenia. They may only be seeing a therapist or other non-physician provider.
They should however see their primary care doctor on a regular basis for management of any other medical conditions they may have and should pursue regular check-ups so that they can be screened for any of the comorbid illnesses they are more prone to acquire.
This should be forcefully encouraged, since people with Schizophrenia are less likely to receive the general medical care that they need than are people without this disease.
If a patient is taking medication and is seen exclusively or periodically by a Psychiatrist, this Psychiatrist should be one who possesses extensive knowledge in the area of Psychopharmacology (the effects of medications on the brain and their side effects, including all of the medications used outside of psychiatry). Fortunately, most Psychiatry Residency Training Programs now include this as a standard component of their training.
Illness Complexity
People with Schizophrenia who have complex forms of the illness, constellations of symptoms that are severe or have been relatively refractory to treatment in the past, or who have significant comorbidity (complicating medical or psychiatric illnesses); should be followed by both a Psychiatrist and one or more other medical doctors.
Other patients who have fairly simple medication regimens or symptoms that are relatively stable over time are often managed by their primary care physicians. There are many Family Practice doctors who take an interest in mental health issues and over time become quite accomplished at managing a variety of psychiatric symptoms, including the use of medications.
They are also much more likely to be skilled in dealing with any of the comorbid medical conditions that patients with Schizophrenia may have, including many of those caused or worsened by the use of antipsychotic medications.
In the case where primary management is provided by another type of physician, I believe that the best scenario involves regular follow-up with the primary care physician along with the option for patients to see a Psychiatrist whenever necessary.
Necessity for a referral to a Psychiatrist for a second opinion may exist simply if either the patient or their primary care doctor believes this would be wise for whatever reason. More typically referrals are considered when a patient has responded poorly or not at all to several medication changes, has developed serious or unexpected side effects, or appears to require changes in treatment that are beyond the scope of expertise or comfort level of their primary care doctor.
At times patients with Schizophrenia are regularly, but infrequently, seen by a Psychiatrist. This often reduces the number of emergent referrals.
Availability of Psychiatrists
As a specialty, Psychiatry is underrepresented in most areas of the country. It is likely that this problem will worsen in the future, rather than improve. Thus, in certain areas, routine treatment for all patients with mental illness simply cannot be provided by Psychiatrists.
In areas where this is true, one of the options reviewed above may represent the most logical and practical approach to serving the needs of the majority of patients with mental illness.
Accommodation and Cooperation
Whether patients with Schizophrenia are managed solely by a Psychiatrist or primarily by another physician with reliable access to a Psychiatrist, the Psychiatrist selected must be one who works well with other physicians.
He or she must be willing to communicate freely and in a timely fashion with all of the other doctors providing care to the patient. The becomes necessary when Psychiatrists must respond to telephone inquiries about patients from other medical doctors and when Psychiatrists are in need of other medical doctors' expertise (when Psychiatrists have concerns about their patients that appear to be related to medical problems).
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The ideal Psychiatrist would be one who received training in Psychiatry, but also had a background in Family or Internal Medicine. Since there are not sufficient Psychiatrists to meet the current needs, this would be too much to hope for. The best compromise involves a close and comfortable working relationship between Psychiatrists and primary care physicians.
Fortunately, there are some Psychiatrists who have some additional training related to general medical practice (those who may have changed specialties or those inclined to maintain an up to date working knowledge of other areas of medicine outside the field of Psychiatry).
Extensive medical knowledge beyond the scope of Psychiatry is becoming increasingly important as we become familiar with the other illnesses that people with Schizophrenia are likely to develop. It is particularly relevant to the illnesses related to the use of various medications employed in the treatment of this Schizophrenia, such as Metabolic Syndrome X.
Summary
A small number of people with Schizophrenia may not require the regular attention of either a Psychiatrist or another physician. Some will be cared for primarily by Psychiatrists. Many others can be effectively managed by other physicians, provided there is some access to the expertise of Psychiatrists if this becomes necessary.
In either case, the best care is provided when all of the patient’s physicians, including the Psychiatrist, work together as a team without barriers to timely and extensive communication.
(Sources: The author’s knowledge base, unless otherwise noted.)
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