Psychiatry’s Mismatch With Primary Care

Mental illnesses in primary care often present with physical symptoms.


1. Effective mental health care in medical settings requires awareness of physical symptoms as well as psychological symptoms.

2. Chronic illness patients with lifestyle limitations often have unrecognized depression, anxiety, or substance abuse.

3. Disabled, chronic disease patients typically do not offer psychological symptoms and focus instead on physical symptoms.

4. In those disabled with a chronic physical disorder, ask specifically about depression, anxiety, and substance abuse.

A similar version of this post occurred earlier today in Psychology Today

As you know from a recent post and an earlier post, medical clinicians experience difficulties identifying mental disorders. This should not surprise. Medicine has not trained them to diagnose or treat mental illnesses. Nevertheless, many have tried valiantly to learn about mental health problems on their own. Turning for help to psychiatry, its textbooks frustrate the clinicians because they still cannot identify mental disorders in their practices. Let’s examine why because the vast majority of mental health problems are in primary care.

The psychiatry approach centers about psychological symptoms suggesting a mental illness, for example, feeling depressed and hopeless in depression or feeling unduly worried and afraid in generalized anxiety disorder. Great benefit has resulted in the mental health community as a result. But medical settings differ.1

Ian Furst: Person massaging their hand due to pain; CC-BY-SA-4.0

Many primary care patients with a mental illness do not offer psychological symptoms. Instead, they present long-term physical symptoms. Trained in diagnosing chronic diseases, the clinician pursues these clues in hopes of making a diagnosis. Sometimes they find a disease, but just as often they do not, the latter patients designated as having medically unexplained symptoms with such diagnoses as chronic pain, irritable bowel syndrome, chronic fatigue syndrome, or fibromyalgia.

Frigole: Suffering Little Dog; CC-BY-SA-4.0

How important are physical symptoms in mental health care? The greater the number, severity, and duration of the symptoms, the more likely patients have an associated mental illness—approaching 100% when physical problems significantly disable the patient; it makes no difference whether the doctor can identify a disease or not.2-4 The disability itself leads to depression and anxiety.1,5 These patients incur tremendous losses in their everyday lives, for example, no longer able to work, play golf, have sex, or attend church. And those with chronic pain often resort to using legal or illegal substances—which drugs produce depression and anxiety to exacerbate the problem.

How do different expectations play out in identifying a mental health problem? Psychiatry seems to expect that the depressed patient might say something like, “I’m feeling down, out of hope, and that life’s not worth it.” While that occasionally occurs in medical settings, more often than not primary care physicians can expect patients to say, “The pain’s so bad, I can’t even play with my kids, much less work, when do I get better—can you refill my Vicodin.”

Why don’t primary care patients just come out and mention the psychological symptoms in addition to the disabling physical symptoms? There are many possibilities.1 First is stigma, the fear of acknowledging a mental problem. Second, patients often believe their clinician lacks interest. Indeed, this gains credence when the doctor focuses on many tests and consultations for the physical problem—and fails to ask about possible mental symptoms. Third, patients’ simply aren’t accustomed to discussing such personal complaints. Finally, they may not themselves be completely aware of feeling depressed or anxious, and they may deny substance use problems. Then, aggravating an already difficult circumstance, even when patients acknowledge a psychological symptom, many diminish or dismiss it with something like, “Well, wouldn’t you feel depressed with this much pain.” This implies anyone should expect depression in their situation. That indeed is true, but the implication that it’s of no significance is not.

Unhappily, most psychiatry textbooks ignore the physical mode of presentation in their discussions of common mental disorders. If they do address physical symptoms, they typically cordon the discussion off in a section at the end of the book on somatization. This only worsens the hopeful clinician’s plight when s/he reads about the confusing, unvalidated, and ever-changing criteria for various somatization syndromes.

So, in summary, how does the medical doctor identify patients with mental illnesses? First, understand that chronic physical symptoms accompanied by disability foretell an associated mental illness. Consider impairment in function from any chronic physical symptoms to represent “red flag” warnings that these patients also may have a mental illness—a previously hidden diagnosis.5 Then, specifically ask about the psychological symptoms of the common primary care mental disorders.1,2 Once the clinician identifies psychological symptoms, standard textbooks, including our recent one for primary care,1 present the details for making a diagnosis of the underlying mental illness. And they describe how to treat it. Importantly, the clinicians will find treatment of the mental illness highly effective.1

Copyright Robert C. Smith July 2021


1. Smith R, D’Mello D, Osborn G, Freilich L, Dwamena F, Laird-Fick H. Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting. New York: McGraw Hill, Inc; 2019

2. Kroenke K. The interface between physical and psychological symptoms. Primary Care Companion J Clin Psychiatry 2003;5 (suppl 7):11-8.

3. Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Int Med 2001;134:917-25.

4. Smith RC, Dwamena FC. Classification and diagnosis of patients with medically unexplained symptoms. J Gen Intern Med 2007;22:685-91. PMCID: 1852906.

5. Smith RC. It’s Time to View Severe Medically Unexplained Symptoms as Red-Flag Symptoms of Depression and Anxiety. JAMA Netw Open 2020;3:e2011520.