Transcript Integrating Mental Health Services into Primary Care

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
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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
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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
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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
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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?
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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?
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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?
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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
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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
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Competing Demands and Tasks of Primary Care Providers
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Average primary care visit last 13 minutes
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Patients have average of 6 problems on problem list
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Inadequate time to adequately assess for mental health
problems and manage once assessed
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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
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Limitations of Specialty Mental Health Service for Primary
Care Setting
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Focus of Psychiatry is increasingly on diagnosis of seriously
disturbed patients and prescription/monitoring of psychotropic
medication
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Psychiatric diagnostic systems that do not fit clinical
phenomenology
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Mental Health Providers not trained to address
psychological/behavioral problems common in primary care
settings
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somatization
chronic pain
noncompliance with medical regimens
Barriers to Providing Mental Health
Services to Primary Care Patients
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Patient Barriers to Providing Mental Health Services
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Concerns about stigma of psychiatric diagnosis
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Significant negative consequences for pursing mental health
care
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Domestic abuse
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Criticism from family
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Patient Somatization: Problems not perceived as
psychological
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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
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Level One: Minimal Collaboration - Providers in
Separate Locations
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Separate systems
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Rarely communicate about patients
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Most private practices and agencies
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Handles adequately problems with little biopsychosocial
interplay & few management difficulties
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Handles inadequately problems that are refractory to treatment
or have significant biopsychosocial interplay
Models of Collaboration Between Primary
Care and Mental Health Care Providers
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Level Two: Basic Collaboration on Site
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Separate systems but share same facility
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No systematic approach to collaboration - do not share common
language or in-depth understanding of each other’s worlds.
Misunderstandings are common
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Common in HMO settings
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Handles adequately problems with moderate biopsychosocial
interplay requiring occasional communication about shared
patients
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Handles inadequately patients with ongoing and challenging
management problems
Models of Collaboration Between Primary
Care and Mental Health Care Providers
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Level Three: Close Collaboration in Fully Integrated
System
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Same site, same vision, and same system in a seamless
web of biopsychosocial services
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Staff committed to biopsychosocial systems paradigm.
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In-depth understand of each other’s roles/cultures.
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Operates as a team - regular collaboration
Models of Collaboration Between Primary
Care and Mental Health Care Providers
Continued...
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Level Three: Close Collaboration in Fully Integrated System
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Fairly rare. Occurs in some hospice centers and special
training and clinical settings.
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Handles adequately most difficult and complex
biopsychosocial problems with challenging management
problems
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Handles inadequately problems when resources of health
care team are insufficient or when there is breakdown with
larger service system
Women’s Clinic
Minneapolis VA Medical Center
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Mental health care staffing in clinic
 Health psychologist is located on site
 Psychiatrist in clinic 1 hour/month & available for consultation
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Share same scheduling & charting systems
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Regular face-to-face interactions about patients
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Mutual consultation
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Coordinated treatment plans only for difficult, complex patients
Women’s Clinic
Minneapolis VA Medical Center
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Basic understanding of each other’s role/professional culture varies by healthcare provider
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Team building elements incorporated into meetings
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Works well with challenging, complex patients
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Clinic is within a larger system - inadequate when potential for
tension/conflicting agendas among providers & providers outside of
clinic
Women’s Clinic
Minneapolis VA Medical Center
What behavioral healthcare problems
are managed in primary care?
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Garden variety mood disorders
Substance abuse problems with a focus on health consequences
such as alcohol abuse and smoking
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Domestic abuse
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Sexual trauma
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Eating disorders
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Somatizing patients
Women’s Clinic
Minneapolis VA Medical Center
What behavioral healthcare problems
are managed in primary care?
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Coping issues
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Living with chronic illness
Dealing with family stressors
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Noncompliance with medical regimens
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Other health-related behaviors - weight loss
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Infertility evaluations
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Some Axis II patients - histrionic personality disorder
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Patients who refuse mental health referral
Women’s Clinic
Minneapolis VA Medical Center
What mental health problems do we NOT
manage in primary care?
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Patients with serious mental illness-psychotic patients
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Patients needing multiple MH providers or MH team approach
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Patients not likely to respond to time-limited psychotherapy
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Patients not responding to initial medication trial
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Patients with more serious psychiatric problems than were initially
apparent - in need of specialty MH care