When to refer a nonadherent patient to a mental health specialist

September 4, 2009

Consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts.

There are positive steps you can take to help your nonadherent patients adhere to treatment and make lifestyle changes.

"Nonadherence for one patient is not the same as nonadherence for another," says Scot G. McAfee, MD, a psychiatrist specializing in the psychological aspects of chronic medical disorders.

One patient with cardiometabolic disorders may not take his oral medications, and that's typically what people think of when they say "nonadherence," says McAfee. It may be a refusal to take medication because the patient may actually not believe that he needs the medication, or he may fear adverse side effects.

McAfee recommends primary care physicians consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts. He cautions, however, that such a referral could result in considerable resistance.

"The patient may feel 'Now I have two things wrong with me-I've got diabetes and they think I'm crazy,'" says McAfee.

It's very difficult to come up with referral guidelines that apply to all patients, says McAfee. He adds that if the primary care physician believes the patient is depressed and that the pessimism that is generated by the depressive illness is affecting the patient's ability to feel optimistic about his care or his ability to manage the disorder, a referral is indicated. Then the psychiatrist or mental health provider can treat the patient's depression and, ideally, help the patient become more optimistic and motivated to take his medications for hypertension, blood lipids, and diabetes, and adopt the appropriate lifestyle changes.

"Patients who are having complicated medical issues do not need to be burdened by a psychiatric illness at the same time," says McAfee.