Integrating Mental Health Services into Primary Care

1. 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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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