Practical Provider Group
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When to Refer Out
A clinical decision framework for primary care providers managing psychiatric presentations.
As a PCP, you're managing more psychiatric presentations than ever before. This guide helps you quickly assess which patients you can manage in your setting and which need psychiatric specialty care — and how urgently.
Refer immediately or call 988 / 911
- Active suicidal ideation with plan, means, or intent
- Active homicidal ideation
- Active psychosis with disorganized behavior or inability to care for self
- Acute mania with impaired judgment and risky behavior
- Catatonia
- Severe self-harm requiring medical intervention
- Serotonin syndrome or neuroleptic malignant syndrome (medical emergency)
Decision Framework — Work Through These in Order
1. Is the patient in immediate danger to themselves or others?
Call 911 or send to ED immediately. Do not manage in office.
Continue to question 2.
2. Does the presentation involve psychosis, mania, or significant dissociation?
Refer to psychiatry urgently (within days, not weeks). Do not initiate antipsychotics without psychiatric backup unless in acute emergency.
Continue to question 3.
3. Have you tried at least one adequate medication trial for this condition (right dose, right duration) without response?
Refer to psychiatry or PMHNP for medication management. "Treatment-resistant" presentations need specialty eyes.
An adequate trial is typically 4–8 weeks at therapeutic dose. Initiate or optimize before referring for non-response alone.
4. Does the patient have a complex psychiatric history (multiple diagnoses, prior hospitalizations, history of medication trials)?
Refer or co-manage with psychiatry. Complexity compounds over time and is harder to manage without full psychiatric history.
Continue to question 5.
5. Does the patient need psychotherapy that you cannot provide or coordinate?
Refer to therapist (LCSW, LPC, LMFT). Medication alone is rarely sufficient for mood, anxiety, or trauma disorders.
Continue to question 6.
6. Do you feel confident in your diagnosis and management plan?
You may be well-positioned to manage. Document your reasoning and set a clear follow-up interval.
Trust this signal. Consult with or refer to psychiatry. Clinical uncertainty is a legitimate referral indication.
Conditions PCPs commonly manage well
- Mild to moderate depression (first episode, no psychotic features)
- Generalized anxiety disorder
- ADHD in adults with clear history and no comorbidities
- Insomnia (behavioral and pharmacologic)
- PTSD — coordinating with therapist
- Panic disorder — in stable, engaged patients
- Medication management continuation for stable, established psychiatric patients
This framework is a guide, not a protocol. Your clinical judgment, your relationship with the patient, and your practice context always take precedence. When uncertain, consult.