Wake-up call for British psychiatry: responses

Craddock et al ¹ make some interesting points about the role of the psychiatrist. It is unashamedly made from a psychiatrist's perspective.

We would like to comment from a primary care perspective, since many of the issues raised have a significant bearing on the way primary care works currently and how it may work in the future.

The authors make the point that ‘psychiatry is a medical specialty’ and that general practitioners should have the opportunity to refer patients for an opinion when they are unclear about the diagnosis or treatment. Sadly, in our experience, this rarely happens, as patients who have a mood disorder such as depression or anxiety are often told that they do not fulfil the criteria for referral (understood by the patient to mean that they are not ‘ill enough’) to see a psychiatrist. It is a rare occurrence where a psychiatrist will intervene in the administrative chore of ‘bouncing the patient’ back to the GP, so that the patient does benefit from their opinion. Such referrals are often pejoratively labelled as inappropriate, implying a lack of competence by the referrer.

This behaviour, of screening out people with certain conditions, is justified on the grounds that psychiatrists should concentrate on the most ill, that is the psychoses, and they quote the National Service Framework for Mental Health as supporting this stance. No other medical specialty diverts patients away from a medical opinion in the same way. It is a sad testament to both primary and secondary care clinicians that the person who was able to negotiate an improved level of care for people with a significant mental illness such as depression or anxiety was an economist, making an economic argument at the highest level of government.

The authors also make the case that they should be responsible for managing the physical healthcare needs of the people for whom they care. They are, according to the authors, first and foremost highly trained doctors. What has stopped psychiatrists providing this care in the past? Are the authors really making the case that they should manage not only the psychiatric needs of a person with schizophrenia, but also that person's diabetes, hypertension, obesity and osteoarthritis? Surely not. Readers were offered a thought experiment; we offer another thought experiment to the authors: if you had diabetes, hypertension, obesity and osteoarthritis, would you want these conditions managed by a psychiatrist, or a GP?

If there is a real concern that psychiatrists no longer have the opportunity to practise the specialty in which they trained, then they should do something about it. The National Service Framework for Mental Health is coming to an end – so the restrictions on who psychiatrists will see should also come to an end. If psychiatrists wish to behave as other medical consultants, then they should see the referrals made to their teams – as team leaders it is in their gift to do so. It may well be that some form of screening may be necessary, but do so based on patient need, not on the basis of a diagnosis.