Primary Care or a Psychiatric Provider for Your Medication?

Who prescribes antidepressants today

Much of this care happens outside mental health clinics. A CDC data brief on antidepressant use in 2005–2008 found that less than one-third of Americans taking one antidepressant, and less than half of those taking more than one, had seen a mental health professional in the past year. The same brief found that more than 60% of people taking an antidepressant had taken it for 2 years or longer.

That is not a problem in itself. The U.S. Preventive Services Task Force recommends screening all adults for depression and says the follow-up care can come from “primary care clinicians, mental health specialists, or both working collaboratively.” NIMH also lists a primary care doctor, alongside a psychologist or psychiatrist, as someone to talk to if you think you may have depression.

And the setting does not decide the result on its own. In the first step of NIMH’s STAR*D study, which followed 4,041 outpatients at 41 clinical sites, remission rates were similar for people treated in primary care and in outpatient mental health clinics, where both kinds of practitioners followed the same treatment guidelines.

When staying with primary care makes sense

Your primary care clinician is a reasonable person to keep managing your medication when most of these are true:

• Your medication is helping, and any side effects are mild or fading.
• You have one main diagnosis, such as depression or an anxiety disorder, and no history of periods of unusually high energy or little need for sleep.
• You take one psychiatric medication, or a simple combination your clinician is comfortable with.
• You have regular follow-up, and someone asks how your mood is doing, not just whether you need a refill.
• You are still within a fair first trial. NIMH notes that antidepressants usually take 4 to 8 weeks to work.

Primary care also has advantages a psychiatric practice cannot match: one clinician who knows your whole medical history, your other medications and your lab results. For people whose depression is treated in primary care, the VA/DoD depression guideline strongly recommends collaborative or integrated care models, in which a care manager and a psychiatric consultant support the primary care team. A Cochrane review of 79 trials with 24,308 participants found collaborative care improved depression and anxiety outcomes compared with usual care, though the benefit was not shown in the very long term.

When a psychiatric provider adds value

These are the situations where a clinician who works only in mental health can usually add the most:

What counts as a “fair trial”

“I’ve tried two medications” can mean very different things. A trial only tells you something if the medication was given a real chance:

• Long enough. NIMH says antidepressants usually take 4 to 8 weeks to work. The VA/DoD guideline describes non-response as a partial or no response to a first medication, at an optimized dose, after at least four to six weeks.
• At a dose that was adjusted as needed, not left at a starting dose because nobody followed up.
• Taken consistently, without frequent missed doses.
• Not stopped early because of side effects that might have been managed. That is useful information, but it is not the same as the medication not working.

NIMH’s medication guide notes it may take several tries to find the medication that works with the fewest side effects. In STAR*D, about half of participants became symptom-free after two treatment steps, and almost 70% of those who stayed in the study did over four steps. Persistence pays, and so does a careful look at the plan when the first two steps fall short. For how to judge progress, see how long psychiatric medication takes to work and measuring whether a medication is working.

You don’t have to choose one

The options are not all-or-nothing. Common arrangements:

• A one-time consultation. A psychiatric provider evaluates you and recommends a plan, and your primary care clinician keeps prescribing.
• Shared care. The psychiatric provider manages your psychiatric medications while your primary care clinician handles everything else, and they share information with your written permission.
• A full transfer of your psychiatric medications for a period, often until things are stable, after which some people move back to primary care.

In every case, tell each clinician about every medication and supplement you take, and name one clinician as the prescriber for each medication so nothing is doubled up or dropped.

Questions to ask your primary care clinician

• How will we know whether this medication is working, and when will we decide?
• If this one does not help, what would we try next?
• Is there anything in my history, such as periods of very high energy, that we should look at before going further?
• Would you be comfortable managing more than one psychiatric medication for me?
• At what point would you want a psychiatric opinion?

A good primary care clinician will welcome these questions. Some practices also have a behavioral health team or a consulting psychiatric clinician you can be referred to.

How to bring in a psychiatric provider without a gap

1. Keep taking your medication as prescribed while you arrange the visit. NIMH advises against stopping a prescribed medication, even if you feel better, without a provider’s help.
2. Write down every medication you have tried, roughly how long, the highest dose you reached, and why it stopped.
3. Gather recent lab results and the names of your primary care clinician, therapist and pharmacy.
4. Book the evaluation before your supply runs low, and ask your current prescriber to keep covering you until the new plan is in place.

The next guide walks through the handoff in detail, including records and controlled-substance timing.

Where Willow & Stone fits, and when it doesn’t

Dr. Stacey Forbes, DNP, APRN, PMHNP-BC, is a board-certified psychiatric-mental health nurse practitioner (not a physician). She sees people ages 10 and older by secure video in the seven states where she practices, starting with a 90-minute integrative psychiatric evaluation that reviews your history and every medication you have tried. If medication management continues with her, follow-up visits run 25 to 50 minutes. With your written permission, the practice can share the plan with your primary care clinician. First appointments are typically available within 1 to 2 days; see fees and insurance by state.

Willow & Stone is the wrong first call if you are in crisis or in danger now (call or text 988, or call 911), if you need more support than outpatient visits can give (see which level of care you need), or if you specifically want to see a physician; see psychiatrist vs. psychiatric nurse practitioner. If your primary care clinician is managing your medication well, you may not need us at all.

Common Questions

Sources

• CDC NCHS Data Brief No. 76: Antidepressant use in persons aged 12 and over, 2005–2008
• USPSTF: Depression and suicide risk in adults: screening (2023)
• NIMH: Depression
• NIMH: Mental health medications
• NIMH: STAR*D level 1 results Q&A
• NIMH: STAR*D all medication levels Q&A
• VA/DoD Clinical Practice Guideline for MDD (2022)
• Archer J, et al. Collaborative care for depression and anxiety problems. Cochrane 2012
• DailyMed: Zoloft (sertraline) prescribing information
• NIMH: Bipolar disorder

This article is general education, not a diagnosis or advice for your situation. Only a clinician who has evaluated you can diagnose a condition or recommend treatment. Do not start, stop, or change a medication without talking to the clinician who prescribes it.