Many primary care physicians,
especially those located in rural communities, have asked me how to set
up and manage a treatment care that will work in a community with meager
psychiatric resources. Most of these questions have pertained to the
Questions such as, "How can I tell if the cut is a suicide attempt?"
If the cut is a first cut and causes serious bleeding, you cannot tell.
If on examination, you find other cuts or scars, usually scattered on
the non-dominant forearm, your patient has committed one more ritual
cut. She needs to begin to communicate to someone what this cutting
means to her. Ideally, this person should be a psychotherapist who is
familiar with this disorder. If the therapist is a non-medical
therapist, a psychiatrist must also be brought into the team for
consultation and medication - this is usually necessary. In the case of
patients who burn themselves, a plastic surgeon should also be part of
the treatment team.
As the primary care physician you may feel alone, lacking specialization
in the other two or three fields. When we feel alone and anxious
treating a patient, we need support on a regular basis. When we have
organized this outpatient team, the patient is calmer as well. Your
regional hospital will appreciate cases this outpatient team can handle
without involving its emergency room as well.
The same questions have come from psychiatrists, non-medical therapists,
ad plastic surgeons. You all need to network with each other.
In the case of anorexia nervosa, the outpatient team consists of many
professionals. On the mental health section we have often a non-medical
therapist, usually a person with a social work degree. A psychiatrist
may also be part of the team, when medication is required, though many
psychiatrists practice psychotherapy as well. A nutritionist can be
helpful, but only when a patient is in the last stages of weight gain.
Since nutritionists provide information, there is no point in dispensing
it to someone who has emotional blocks against using it, as do patients
suffering from anorexia nervosa.
On the medical front with anorexia, we add to this team an endocrine
specialist to monitor metabolism, and a gynecologist to monitor the
reproductive system for signs of permanent deterioration. In some cases
these may be the same physician, or may be the primary care physician,
who in addition to all other responsibilities (vital signs, blood
values, etc.), may have to monitor gastroenterological functioning,
especially if the patient is abusing laxatives, or vomiting. In cases of
chronic low weight anorexia, periodic bone density tests may be advised
to determine if estrogen augmentation and other hormones are necessary.
The most permanent and difficult impairment to treat includes
deterioration of the vascular system, which is easily identified by the
appearance of purplish hands and feet. This disorder requires a team who
all need to be in regular communication with each other.
Obsessive-compulsive disorders use a smaller team, which may include the
non-medical therapist and prescribing psychiatrist. It is often a
difficult trial and error period of prescribing medication until the
most helpful combination is found. This patient must truly be patient
with his or her psychiatrist.
In all three of these disorders, I have mentioned the minimum care and
investigative levels for each. All three disorders may include
additional diagnoses which will require psychological testing,
hospitalization, family therapy, and long-term therapeutic living
environments. The depth, complexity, intensity, persistence, and
chronicity of each case will dictate the need for further help.
Hopefully, it will be available and affordable.