Integrating Mental Health Services into Primary Care

Linda Van Egeren, Ph.D.

Clinical Psychologist

Women’s Clinic

Minneapolis VA Medical Center

Theresa Huber, PA-C

Physician Assistant

Women’s Clinic

Minneapolis VA Medical Center

Association Between Physical & Mental Problems in Primary Care Patients

10-20% of general population will seek primary care for a MH problem

Studies show prevalence of mental health problems: PRIME-MD: average 26% have psychiatric

disorder while another 13% have significant functional impairment

WHO: average of 21% had psychiatric disorders

2/3 of primary care patients with psychiatric diagnosis have significant physical illness

Association Between Physical & Mental Problems in Primary Care Patients

Chronic medical illness increases probability of depression by two to threefold

Psychiatric disorders in primary care are less severe than those in MH settings

Health status, quality of life, functional status-better correlated with psychosocial factors than physical disease severity

Medical Outcome Study (MOS) indicates functional impairment due to depression compares to that of COPD, diabetes, CAD, hypertension, and arthritis

Recognition & Treatment of MH Problems in Primary Care

1/2-2/3 of patients meeting criteria for psychiatric diagnosis go unrecognized by primary care providers

Even when recognized & treated, dosage & duration of antidepressant meds are usually inadequate

In naturalistic studies, there was no difference in outcome between treated and untreated depressed patients in primary care setting.

Health Care Utilization

Studies indicate objective disability or morbidity alone can predict only 10-25% of health care use

One study found 60% of all medical visits were by “worried well” with no diagnosable disorder

Patients with MH problems, when compared to unaffected counterparts, use twice the medical resources.

Patients with somatization disorder use 9 times national norm of medical resources

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Primary Care Providers deal with patient’s untreated psychological problem- identified or not

Psychosocial/behavioral problems take up Primary Care Provider time regardless of degree to which problems are explicit focus of practice

1/3-1/2 of Primary Care patients will refuse referral to MH professional

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Patients who refuse referral tend to be high utilizers with unexplained physical symptoms

Dichotomizing patients problems into physical & mental leads to: Duplication of effort Undermines comprehensiveness of care Hamstrings clinicians with incomplete data Insures that the patient cannot be completely understood

Why Should Primary Care Providers Integrate Mental Health Services Into Primary Care?

Many prefer to receive MH services in Primary Care because not construed as “mental healthcare”

With expectation of seriously mentally ill, basic MH services can be managed in Primary Care setting

Growing evidence that integrated primary care is cost-effective

Conclusions

Mental healthcare cannot be divorced from primary medical care - all attempts to do so are doomed to failure

Primary care cannot be practiced without addressing mental health concerns, and all attempts to neglect them will result in inferior care

deGruy, F.V. (1997). Mental healthcare in the primary care setting:

A paradigm problem. Fam. Syst. & Health 15:3-26.

Barriers to Providing Mental Health Services to Primary Care Patients

Competing Demands and Tasks of Primary Care Providers

Average primary care visit last 13 minutes

Patients have average of 6 problems on problem list

Inadequate time to adequately assess for mental health

problems and manage once assessed

A zero-sum game. No room for provision of new services

without eliminating another or adding resources for additional

work

Barriers to Providing Mental Health Services to Primary Care Patients

Limitations of Specialty Mental Health Service for Primary Care Setting

Focus of Psychiatry is increasingly on diagnosis of seriously

disturbed patients and prescription/monitoring of psychotropic

medication

Psychiatric diagnostic systems that do not fit clinical

phenomenology

Mental Health Providers not trained to address

psychological/behavioral problems common in primary care

settings somatization chronic pain noncompliance with medical regimens

Barriers to Providing Mental Health Services to Primary Care Patients

Patient Barriers to Providing Mental Health Services

Concerns about stigma of psychiatric diagnosis

Significant negative consequences for pursing mental health

care Domestic abuse

Criticism from family

Patient Somatization: Problems not perceived as

psychological

Patient has no psychiatric diagnosis, but still in need of

psychological care

Conclusion

“The problem of underdiagnosis and undertreatment cannot be remedied by simple provision of guidelines and protocols, no matter how elegant; it will require a reordering of the actual structure and process of primary care.”

deGruy, F.V. (1997). Mental healthcare in the primary care setting:

A paradigm problem. Fam. Syst. & Health 15:3-26.

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level One: Minimal Collaboration - Providers in Separate Locations

Separate systems

Rarely communicate about patients

Most private practices and agencies

Handles adequately problems with little biopsychosocial

interplay & few management difficulties

Handles inadequately problems that are refractory to treatment

or have significant biopsychosocial interplay

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Two: Basic Collaboration on Site

Separate systems but share same facility

No systematic approach to collaboration - do not share common

language or in-depth understanding of each other’s worlds.

Misunderstandings are common

Common in HMO settings

Handles adequately problems with moderate biopsychosocial

interplay requiring occasional communication about shared

patients

Handles inadequately patients with ongoing and challenging

management problems

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Three: Close Collaboration in Fully Integrated

System

Same site, same vision, and same system in a seamless

web of biopsychosocial services

Staff committed to biopsychosocial systems paradigm.

In-depth understand of each other’s roles/cultures.

Operates as a team - regular collaboration

Models of Collaboration Between Primary Care and Mental Health Care Providers

Continued... Level Three: Close Collaboration in Fully Integrated System

Fairly rare. Occurs in some hospice centers and special

training and clinical settings.

Handles adequately most difficult and complex

biopsychosocial problems with challenging management

problems

Handles inadequately problems when resources of health

care team are insufficient or when there is breakdown with

larger service system

Women’s ClinicMinneapolis VA Medical Center

Mental health care staffing in clinic Health psychologist is located on site Psychiatrist in clinic 1 hour/month & available for consultation

Share same scheduling & charting systems

Regular face-to-face interactions about patients

Mutual consultation

Coordinated treatment plans only for difficult, complex patients

Women’s ClinicMinneapolis VA Medical Center

Basic understanding of each other’s role/professional culture - varies by healthcare provider

Team building elements incorporated into meetings

Works well with challenging, complex patients

Clinic is within a larger system - inadequate when potential for tension/conflicting agendas among providers & providers outside of clinic

Women’s ClinicMinneapolis VA Medical Center

What behavioral healthcare problems

are managed in primary care?

Garden variety mood disorders

Substance abuse problems with a focus on health consequences

such as alcohol abuse and smoking

Domestic abuse

Sexual trauma

Eating disorders

Somatizing patients

Women’s ClinicMinneapolis VA Medical Center

What behavioral healthcare problems

are managed in primary care?

Coping issues Living with chronic illness Dealing with family stressors

Noncompliance with medical regimens

Other health-related behaviors - weight loss

Infertility evaluations

Some Axis II patients - histrionic personality disorder

Patients who refuse mental health referral

Women’s ClinicMinneapolis VA Medical Center

What mental health problems do we NOT

manage in primary care?

Patients with serious mental illness-psychotic patients

Patients needing multiple MH providers or MH team approach

Patients not likely to respond to time-limited psychotherapy

Patients not responding to initial medication trial

Patients with more serious psychiatric problems than were initially

apparent - in need of specialty MH care