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 self-mutilators.

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.