It's okay to cry here.
On Oprah's 2020 Vision tour, Lady Gaga recently spoke candidly about her history of rape and subsequent PTSD. It is so difficult to be vulnerable on a public platform, and I respect her incredible courage in sharing her story so that others may recognize the importance of seeking help.
During the discussion, however, she stated:
"...if your primary care doctor is prescribing you an antidepressant, this should not be happening. Your primary care doctor should be introducing you to a psychiatrist who is an expert in brain medication."
Certainly there are some patients with mental health conditions for whom management by a primary care physician (PCP) is insufficient. For Lady Gaga, this may very well have been true, and I'm sorry that she struggled for years before being connected to the right person to help her. For many, however, it is absolutely appropriate for a PCP to initiate and continue management, and this is ultimately the best scenario for PCPs, patients, and psychiatrists (as is true for the broad range of other medical conditions that could very well be referred out to specialists but are safely managed by PCPs).
There are many areas throughout the country where psychiatrists are in short supply. Minnesota happens to be one of them. Telemedicine services are expanding in order to try to mitigate this deficit. https://www.minnpost.com/mental-health-addiction/2019/05/could-technology-help-address-minnesotas-serious-psychiatrist-shortage/ Even practicing in the metro area, while we have abundant, reliable resources to which to refer patients for counseling and therapy services, the other clinicians in my practice and I struggle to consistently connect patients with mental health practitioners who can prescribe medications. There simply aren't enough people out there doing it at a specialty level to meet the high level of need that is present. Given this, it is extremely important that those with the most clinically severe circumstances are prioritized for care by psychiatrists. For people in the direst of situations, it is dangerous to have to wait several weeks or months (for some, even just days would be too much) to be seen and started on the path to healing. Referring every patient with a mental health condition to a psychiatrist obstructs care to those who need it most.
Primary care physicians are specifically trained to handle a broad range of medical issues. They are meant to be longterm caregivers who are the first points of contact for patients in their times of need. They provide continuity of care as trusted allies and confidants. People absolutely love it - and do better - when they have a good primary care physician who can manage many of their issues. Primary care physicians certainly can and should provide mental health care.
I'm not ever going to pretend that I have the same role or knowledge base as, say, a family medicine physician, but we do a lot of primary care in OB/Gyn. I am the first to admit my shortcomings when it comes to managing certain medical problems, and I will quickly point patients in the correct specialty (or non-gyn PCP) direction when such issues arise. Mental health, though, is huge in my specialty. As OB/Gyns, we have unique relationships with our patients as we are privy to the most intimate details of their lives, both the positive and the negative. This poises us to often be the healthcare providers that patients confide in most. We hear about familial tensions, school stress, new relationships, old relationships, loneliness, affirming sexuality, affirming gender, facing discrimination, figuring out identity, uncertainty about the future, problems with sex, sexual assault, domestic violence, fertility frustrations, pregnancy loss, pregnancy complications, recovery from delivery, worrying about children, worrying about parents, infidelity, criticism from others, terrible things happening in the world, job stress, financial crises, burnout, deaths of loved ones, fear of death, and every other potential part of the struggle that existing on this earth can be.
On a daily basis, even the most reserved patients who report "no complaints" when brought to the exam room by my medical assistant may end up pouring their hearts out to me just based on the very nature of the topics we discuss and the setting of a sensitive exam. A box of tissues is always at the ready, and every day I tell at least one person, "It's okay to cry here." For some, their emotions are part of the typical course of humanity. For others, there is clear clinical anxiety, depression, or other mental health disorders. Just like for Lady Gaga, their honesty is courageous - and difficult. I listen. I hug (if okay with the patient). I offer all the support I can. Rarely, a patient needs emergent psychiatric services due to a high level of immediate concern for their life or wellbeing. In less urgent cases, I still sometimes know that a patient's condition is out of my safe scope of practice, and we find a psychiatrist by which the patient will be better served. For many, I know that I can do my best to start lifting them out of their dark places. We talk through how they might be helped by therapy and/or medication, if it seems appropriate for the circumstances. We discuss the risks and benefits of particular medications, what side effects may be experienced, and how long it might take them to cause a positive effect. Together we make a decision to start a medication or not and when to follow-up. As long as they do well, I continue to prescribe the medication for them. If circumstances change, we again make a plan together regarding the next step to take.
They've trusted me with the pieces of their minds and hearts that they like the least, that they wish were different, that are obscuring the light. I have to honor that trust. I have to do what I can with the training I have for the important person in front of me who deserves happiness and peace.