The Missing Link in Mental Health Care: When and How Doctors Should Refer to a Psychiatrist

Another World Mental Health Day has come and gone. Once again, much of the conversation centred on stigma: people who won't seek help, families who stay silent, and the courage it takes to say “I need support”. But what if part of the problem begins earlier, inside the very system meant to catch people when they do reach out? Many people living with mental health concerns never walk into a psychiatrist's clinic first. They walk into a GP's clinic or a specialist's OPD with a stomach complaint, weight changes, pain that no scan explains, or trouble sleeping. Whether they ever reach the right care depends on what happens in that room, and on how well the system has prepared the doctor sitting across from them. Manoj's story is one such case. Manoj (name changed) was 60 when COVID-19 came and went. What stayed behind was harder to name. Over the following months he lost 30 kgs. He had persistent acid reflux and slowly became homebound. Like most of us would, he went to his doctor.'Be a Man & Shake it Off': The Stigma Men Face and the Struggle to Seek TherapyHis GP took the symptoms seriously. Unexplained weight loss in a man in his sixties calls for a careful search, and the workup was thorough: an MRI, an endoscopy, a colonoscopy, and advanced allergy and blood tests. The tests ruled out the most feared causes, but they did not explain why Manoj kept getting worse.He was diagnosed with irritable bowel syndrome (IBS) and treated for months, including with medicines commonly used for anxiety.When his weight continued to fall, he consulted a gastroenterologist. Faced with the same puzzle, this doctor investigated further, including with a PET scan. Over time, Manoj's prescriptions came to include anti-anxiety medicines, antidepressants and, at one point, an antipsychotic. For four years, Manoj moved from one doctor to the next, looking for answers. The answer finally came through a psychiatric emergency and an admission to a tertiary care hospital.It is easy to read a story like this and look for someone to blame. That would miss the point. Manoj's story is not about one doctor or one decision. It is about a gap that many patients, families, and clinicians run into. Mental health conditions can present through physical symptoms. A WHO study across 14 countries found that nearly 70 percent of primary care patients with depression reported only physical symptoms. Changes in mood and stress can affect sleep, appetite, digestion, and the experience of pain. These symptoms are real, and they may coexist with physical illness. The challenge is not to choose between physical and mental healthcare, but to recognise when both need attention and to ensure that the professionals involved can work together. Dr Lakshmi Kota, a psychiatrist at VIMHANS, says, “Helping patients understand the connection between mind and body takes time, trust and the right words, all three of which can be in short supply in a busy clinic.”She adds, “Primary care doctors are rarely trained in how to suggest a psychiatric referral. Given the stigma around mental illness in India, the conversation requires particular care and sensitivity. Handled badly, it can undermine a patient's trust and push them out of care altogether.” This is not to say that every patient needs a psychiatrist. Given India's shortage of mental health specialists, primary care doctors play an important role in identifying and treating common mental health conditions, including through medication where appropriate. For many patients, this care is sufficient. The challenge arises when a condition is difficult to diagnose, treatment is not working, or a patient's needs exceed what primary care can safely manage. Without timely reassessment or specialist input, the right diagnosis and treatment may be delayed, allowing the illness to progress.'A Mental Battlefield': What It’s Like to Live With Drug-Resistant TuberculosisSeveral Indian studies have reported very low rates of psychiatric referral in hospital settings. One study found that fewer than one in 200 patients from other departments were referred to a psychiatrist. Yet, when researchers have screened patients in these departments, they have found mental health conditions in at least one in five. These findings come from different studies and cannot be compared directly, but they raise an important question: are mental health needs being recognised early enough, and are patients who need specialist care reaching it in time? To understand why mental health conditions can go unrecognised in a general clinic, or why referral rates are so low, it helps to look at how India's doctors are trained. The undergraduate medical curriculum has historically given psychiatry limited teaching time, in both lectures and clinical postings. For many doctors who trained before the 2000s, including many of today's department heads and senior clinicians, exposure to psychiatry was largely limited to severe mental illness. It is worth asking whether that gap has quietly shaped hospital culture, and with it the training of the interns and residents these doctors now mentor.Dr Evita Taneja, an anaesthesiologist and critical care specialist at the Asian Institute of Medical Sciences, says, “When I graduated in 2012, our exposure to psychiatry was limited to a 15-day placement, and it was optional: we chose between dermatology, anaesthesiology, and psychiatry. It was only with time, and through my own lived experience, that I became more sensitive to it. I have seen senior doctors who trained earlier often dismiss mental health and push patients to simply be strong."Dr Taneja adds, "It is not a question of intent; they trained at a time when many medical colleges barely had a psychiatry department, and they rarely saw a peer opting for psychiatry. There is certainly a palpable shift in sensitivity now, but more needs to be done.” The curriculum has since evolved, and psychiatry now has more teaching and practical time. Whether those changes have translated into consistent clinical competence is a separate question. Training must prepare doctors not only to recognise common mental health conditions, but also to know when a presentation goes beyond their expertise and needs specialist assessment.Dr Kota often sees prescriptions from primary care doctors and other nonspecialists listing several psychiatric medicines at once, a practice known as polypharmacy. When that happens, it is difficult for a psychiatrist to tell which drug has helped and which has not. She is careful to explain why. Nothing technical stops a non-specialist from prescribing these medicines, but adjusting doses and switching between drugs is a skill learnt in psychiatric training, not something an MBBS degree is expected to cover. Dr Sonali Bali, senior consultant at VIMHANS, Delhi, and CK Birla Hospital, Gurugram, emphasises the importance of timely psychiatric referral. “GPs and other specialists treating patients for psychiatric disorders should refer them to a psychiatrist if there is diagnostic uncertainty, inadequate response to treatment, worsening symptoms, significant clinical complexity or concerns about patient safety,” says Dr Bali. Manoj's case met several of these signs: no clear diagnosis, treatment that wasn't working, and a weight that kept falling. She adds,“Choosing psychiatric treatment begins with an accurate diagnosis and a comprehensive assessment of factors such as severity of illness, age, physical health, co-existing conditions, ongoing medications and previous treatment response. Side-effect profile, affordability and availability further guide the choice, with medication and dosage personalised to response and tolerability. There is no one-size-fits-all in psychiatric care.”Cost, Access & Long Queues: Why NRIs Return Home to India For Medical TreatmentsSeveral changes could help close the gap. Bodies such as the Indian Medical Association could run regular, accessible training for practising doctors on recognising common mental health conditions and knowing when to refer, and periodic mental health refreshers could become a condition of licence renewal. Habit-forming benzodiazepines could carry a time-limit, with a specialist review needed to continue them. France, for example, legally caps anti-anxiety benzodiazepine prescriptions at 12 weeks, and in Australia, longer-term use of certain psychiatric drugs requires special authorisation.Finally, the Indian Psychiatric Society could partner with other specialist associations to help their members recognise and refer mental health conditions, so that the specialties work together rather than in silos. Dr Taneja believes this collaboration should reach every specialty. “It would help if every gynaecologist explained postpartum blues to patients and their families, and if oncologists did the same for their patients, referring them to therapy where needed, because some procedures can affect mental health. We need to be more preventive in our approach. Treating physical health in isolation may not be in the patient's best interest,” Dr Taneja notes.Dr Kota's guidance is clear: “If test after test comes back normal and you or your loved one is still getting worse, this itself warrants a psychiatric evaluation.”Dr Bali encourages patients and caregivers to understand their prescription. “Every patient is entitled to clear information about their diagnosis, treatment and possible side effects. If a psychiatric medicine is part of your prescription, it is helpful to discuss with your doctor: What is it for? How long will it be needed? What are the possible side effects? And what is the plan ahead?”You may be wondering what happened to Manoj. He is now under psychiatric care and on the road to recovery, but the road has been longer than it needed to be. He still moves between doctors, and years of overlapping prescriptions have made it harder for his psychiatrist to know which medicines will truly help. His story is not about one wrong turn. It is about a system that, for four years, did not have a clear route to the right door. In mental health, as in the rest of medicine, time matters. The earlier an illness is recognised and treated, the better the chances of recovery. If someone you love is on their fourth or fifth specialist, with a file full of normal reports and no relief, it may be time to ask a different question. Not what else should we test? but who else should we see? (Patient details have been changed to protect privacy. The author is an ex-banker, now consults organisations in the mental health space, and is also a practising coach. She is an alumna of IIM Kozhikode and TISS. This is an opinion piece and the views expressed are the author's own. The Quint does not endorse or is responsible for them.)

BECOME A MEMBER

Mental Health: When and How Doctors Should Suggest Psychiatric Care

Primary care doctors are rarely trained in how to suggest a psychiatric referral, say experts.

Read Latest News and Breaking News at The Quint, browse for more from fit and health-news

Topics: Mental Health Members Only