Integrating Mental Health Services into Primary Care

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Integrating Mental Health Services into Primary
Care
Theresa Huber, PA-C Physician Assistant Womens
Clinic Minneapolis VA Medical Center

• Linda Van Egeren, Ph.D.
• Clinical Psychologist
• Womens Clinic
• Minneapolis VA Medical Center

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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

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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

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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.

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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

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

• Primary Care Providers deal with patients
  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

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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

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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

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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 153-26.

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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

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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

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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

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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 153-26.

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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

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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 others 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

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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 others
  roles/cultures.
• Operates as a team - regular collaboration

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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

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Womens 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

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Womens ClinicMinneapolis VA Medical Center

• Basic understanding of each others
  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

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Womens 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

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Womens 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

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Womens 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