Psychiatric disorders and referral obligations

Recognising one’s clinical limitations and the need for them to be augmented by others’ specialised knowledge and experience is a key component of professional reflectiveness and humility. Referring a patient to a specialist should never be experienced as a reflection of inadequacy or as a slight upon the quality of one’s care. It is an opportunity to provide enhanced treatment and to draw collaboratively upon the specialisation and wisdom of a respected colleague.1 It is also an important ethical obligation.2

By contrast, a failure to be conscious of one’s limitations can lead to insensitivity to the repercussions of patients’ symptoms, erroneous diagnoses and treatment, and a failure to attend adequately to risk factors. There are many possible reasons for this, which have been described in some instances as potentially including narcissism, grandiosity or a sense of omniscience,3 or therapeutic nihilism.4 Depending on the clinical outcome, non-referral can result in actions for negligence and disciplinary consequences.

Mental illness is, by nature, episodic, with symptoms waxing and waning at different periods of a patient’s life and in response to different triggers and vulnerabilities. This highlights the need for a longitudinal perspective on the course of a mental disorder to identify improvement, deterioration or the existence of cycles of symptoms, all of which can give rise to therapeutic opportunities. Continuing evaluation of the need for pharmacotherapy, psychotherapy or any other modality is important. Matters can be complicated by patients resorting to unorthodox forms of intervention, such as “vitamin therapies”, past-life therapy and counselling from unqualified practitioners, all of which have the potential to exacerbate or briefly camouflage symptoms and warning signs.5

Practitioners’ perspectives of their patients’ mental states are inevitably snapshots taken at times that might not be representative of the course or trajectory of the illness. This is especially so in relation to bipolar disorder. Bipolar II disorder poses particular clinical challenges because of the risk that a practitioner seeing a patient irregularly will fail to identify hypomanic episodes and misdiagnose by reference only to observed or reported depression or anxiety. This risk is graphically illustrated in this issue of the Journal by Parker, in the context of the coronial inquest into the death of Charmaine Dragun.6

It is incumbent upon practitioners to be alert to dangerously labile moods suggestive of bipolar I or II disorder. Where signs of bipolar disorder are identified, there is frequently a need to refer the patient to a psychiatrist to manage and to titrate medication. Such referrals must be informed and suitably selective. Indiscriminate referrals run the risk of using the services of a psychologist or a counsellor in cases where such practitioners may not be the most suitable providers of treatment. This can be a particular issue in the era of mental health care plans, in which there can be pressures on general practitioners, driven by financial considerations, to refer to non-medically qualified practitioners who may not be the best equipped to deal with psychiatric illness.

A survey of psychiatrists in the United Kingdom and the United States identified early referral to appropriate specialist care as being one of the “highest priority needs” in the effective management of patients diagnosed with bipolar disorder.7 Such patients are at real and foreseeable danger of lifestyle harm (such as severe embarrassment and financial loss), of taking risks that might endanger their own or others’ safety, and of suicide. These dangers can be avoided by timely referral to specialists with experience in the diagnosis and treatment of patients with bipolar disorders. However, the advantages of suitable and timely referral go beyond the practice of prudent and defensive medicine. Such referral enables focused and intensive provision of treatment for patients who might have limited insight into their illness and the need for treatment, as well as ambivalence about seeking assistance for their symptoms.

In the legal context, the scenarios in which failures to refer have most commonly been litigated have been in relation to cancer investigations, when malignant tumours have been misdiagnosed as benign or have not been identified at all,8 and when there has been the potential for, or reality of, a boundary blurring or transgression. An example of the latter is when moves have commenced toward the creation of an unethical romantic or sexual relationship between practitioner and patient, and the doctor has not referred the patient to another practitioner. The principle underlying the obligation to refer in both scenarios is the same — that another practitioner is better positioned to advance the patient’s interests and that non-referral will disadvantage the wellbeing of the patient, breaching the obligation to exercise reasonable care and skill in the provision of professional advice and treatment.9,10 However, the referral must be clinically appropriate. In a New South Wales case, this was illustrated by a GP being found civilly liable to his patient for referring him to a chiropractor from whom he received treatment that was foreseeably clinically contraindicated because the patient had degenerative cervical changes and neurological symptoms from a disc injury.11

The same issue arises in respect of patients who might have bipolar disorder. This is not to say that a suitably experienced GP might not be able to treat such patients adequately; rather, that it can be negligent not to take active steps to enable patients to avail themselves of the specialist care that might be able to manage their illness most intensively at the time. Such a referral is also a significant protection for the practitioner, should allegations of insufficient or inadequately informed care be made later by the patient or the patient’s dependants.