Q: Psychotherapist Asks for Prepared Info for Physicians and Patients re.
Dear Dr. Phelps,
I am a psychotherapist working in a medical practice in Arizona. Psychiatric
appointments can be hard to come by in our community and it has been estimated
that family practice and ob/gyns are prescribing approximately 65% of all
psychotropics. I am desperate for information I can share with physicians to
prevent the sometimes indiscriminate prescribing of SSRI's. I see patients all
the time with significant family histories and multiple soft bipolar signs who
are not being referred for a comprehensive psychological evaluation prior to
being prescribed meds.
My request is two-fold: Do you have any prepared information for physicians to
alert them to the dangers of potentially doing more harm than good by casually
prescribing SSRI's? (I have a Bachelor's degree in nursing, a Master's in
counseling, and I am a Licensed Professional Counselor. I have been a therapist
for 13 years but without "MD" behind my name, the information I share with
physicians seems sometimes undervalued.) Secondly, do you have any prepared
information that encourages patients to consider having a comprehensive psych
assessment before asking their prescriber for an antidepressant? In part because
of the competitive nature of medical practice, physicians often feel compelled
to give patients what they (reasonably) ask for when it comes to psychotropics.
Thank you very much for your time and attention. I look forward to attending one
of your conferences in California in November.
Dear Paula --
As you are probably aware, your questions are music to my ears. I've been
working on trying to address this problem of too-easy-prescribing of
antidepressant medications for years. As you describe from experience, in most
settings there is no screening for bipolarity before antidepressants are given.
None. I can tell, even though in the last five years there has been a
substantial consciousness-raising about bipolar disorder. That's because when
I tell the primary care docs that a requirement for bipolar screening can be
found in every antidepressant prescribing information (the rice paper tickertape
that the pharmacist hands out with the pill bottle), I still see a look of
surprise in their eyes.
Meanwhile, up here in Oregon -- just as you describe for Arizona --
and primary care prescribing of psychiatric medications is becoming more and
more common. The East Coast doctors don't seem to worry about this so much, but
out here in the West, it is the norm, not the exception, to be unable to refer
patients to a psychiatrist without a waiting time of many months.
So, this combination of inability to access psychiatric
consultation, plus a lack of training for how to screen for bipolar disorder and
the common conditions which accompany it (anxiety disorders, particularly PTSD;
and substance use, especially), creates a situation of risk for patients. What
is to be done?
As you may have gathered, I am trying to teach psychotherapists
about bipolar variations that are now well recognized by mood experts around the
world, so that they might intercept patients before an antidepressant is given
by an otherwise well-meaning a primary care physician who really does not have
the time (even if they once learned about bipolar II) for a systematic
evaluation of mood or anxiety symptoms. Thus the workshop you are planning to
attend in California (delighted to hear it; I will look forward to meeting you
At the same time, I am trying to teach primary care doc’s that an
untapped source of help for them is the group of therapists who have learned
just what you have already learned (you will enjoy the workshop, but you’ve
already integrated one of the main messages). Instead of trying to get the
patient to a psychiatrist, which is difficult or impossible in many places in
the West, send the patient to a therapist who has the skills to do that
comprehensive diagnostic assessment; who will send the doc’ a typewritten
assessment – not long, but thorough in differential diagnosis; and who is
skilled in a variety of psychotherapies likely to cover the needs of a spectrum
of patients, from unipolar depression to bipolar depression to bipolar
episode-prevention to anxiety disorders of all kinds (what else are the primary
care doc’s seeing? not much else, it appears; psychosis goes to county mental
health programs, perhaps after hospitalization. What a system). Such a report
and ongoing management of all issues except medication trials will go a long way
toward lowering that “no M.D. degree” barrier which is unfortunately common at
So, one attempt at the solution you are seeking is underway (and
surely there are others), though slow in coming; together we can move it along.
I’ll look forward to meeting you in November. Please to introduce yourself
Oh, what about your specific questions, now that I’ve waxed
grandiose for a while. Well, you’ll find an attempt at the “prepared materials”
on my website, PsychEducation.org. Take the Mood Swings but Not Manic link and
you’ll find a version for primary care doc’s and a version for patients,
respectively. Not exactly on target for your requests; not effective all by
themselves; but part of a partial solution, I hope.
Published November, 2008