Reluctant psychiatry: Pragmatic responses to a real-world dilemma in Colorado community health centers

Providing integrated care is exceptionally challenging in community health centers (CHCs), where patients are from diverse cultural backgrounds, live in poverty, and have poorer physical and mental health than the general population. The extent and nature of these challenges is poorly understood but vital to identifying potential improvements for settings in which disadvantaged individuals are most likely to seek mental as well as physical health care. We sought to describe primary care providers' (PCPs) approaches to mental health care in CHCs and to identify factors that influence those approaches.

We used semi-structured interviews with 48 PCPs in 7 CHCs in the Denver, Colorado metropolitan area to explore PCPs' experiences with adults whose chronic disease care is complicated by psychosocial issues.

PCPs' descriptions of specific care situations revealed the practice of “reluctant psychiatry” – a PCP's approach to mental health care when the patient's needs are complex and the PCP is unable to refer the patient for specialty care. Two salient PCP behaviors evident within this domain include: (1) consciously ignoring cues signaling mental health issues, mindful of the inability to offer an appropriate solution, and (2) providing mental health care that is outside the scope of expertise, knowing the patient has no other care option.

Potential exists for reducing the cost and burden of chronic disease and disparate outcomes in disadvantaged populations by improving access to specialty mental health care, especially for the uninsured. Funding and delivery models need to acknowledge the systemic impact of the ever-growing mental health specialty gap.