Primary Care America's Health in a New Era (1996) / Chapter Skim
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D Mental Health Care in the Primary Care Setting
D Mental Health Care in the Primary Care Setting
Pages 285-311
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From page 285... ...
Among the most interesting and complex issues we face are those having to do with the complementarily and integration of services between these two systems, the proportion and makeup of the population that will avail themselves of these respective systems, the factors that affect the interface between primary care and {Frank deGruy is Associate Professor, Department of Family Practice and Community Medicine at the University of South Alabama College of Medicine, Mobile.
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From page 286... ...
First, let us consider the clinical relationship between physical and mental problems. Mental distress, symptoms, and disorders are usually embedded in a matrix of explained or unexplained physical symptoms, as well as acute and chronic medical illnesses.~-3 Generally, primary care clinicians deal with mental symptoms as part of something part of a larger, more general problem.
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From page 287... ...
One-third to one-half of primary care patients will refuse referral to a mental health professional;5 6 those who refuse tend to be high medical utilizers with unexplained physical symptoms, but refusers cut across all demographic and diagnostic groups.7 Securing the consent of primary care patients for clinical trials of treatment by mental health professionals for mental disorders is even more problematic, unless the primary care clinician participates in the protocol.8 In other words, a certain large proportion of primary care patients prefer to receive mental health care in medical settings, and this is in part because it is not construed as "mental health care." Thus, one can describe the range of mental disorders that occur in primary care, and this description is accurate inasmuch as it counts symptoms and diagnoses that are actually present. But when seen from the inside, these symptoms and diagnoses are embedded in a matrix of physical symptoms, disorders, and diseases; other mental symptoms and disorders; and social predicaments and stressors.
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From page 288... ...
Most of the patients with diagnosable mental disorders appear under a different diagnostic label and are receiving care for problems other than mental illness. In other words, the primary care clinician is laboring under the burden of competing demands during every encounter; this concept of competing demands will be developed more fully as we explore the adequacy of care rendered to patients with mental diagnoses.
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From page 289... ...
The Range of Mental Problems Seen in Primary Care A great deal of research has gone into describing the psychological problems of primary care patients; I will summarize the most salient features of this research. Some 10-20 percent of the general population will consult a primary care clinician for a mental health problem in the course of a year.~° ii About 40-50 percent of primary care patients who are high utilizers exhibit significant psychological distress.4 i2 The proportions of pediatric primary care patients with significant psychosocial or psychosomatic problems are about 15 and 8 percent respectivelyi3 i4 Some 10-40 percent of primary care patients have a diagnosable mental disorder.
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From page 291... ...
SOURCE: Rosenblatt RA. Identifying primary care disciplines by analyzing the diagnostic content of ambulatory care.
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From page 292... ...
Wells first demonstrated this with the Medical Outcomes Study (MOS) study, in which depressed patients were seen to have functional impairment comparable to patients with chronic medical conditions such as chronic obstructive pulmonary disease, diabetes, coronary artery disease, hypertension, and arthr~tis.2i The PRIME-MD data set offers a look at patterns of impairment by specific mental diagnosis and affords a comparison between the relative contributions to impairment of physical and mental disorders.
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From page 293... ...
Patients with mental diagnoses show consistently higher utilization of medical resources than their unaffected counterparts, generally on the order of twice the baseline utilization rates.22-24 In some cases, such as with somatization disorder, the increased utilization is quite extraordinary nine times the national norm.25 Confounding these differences between the phenomenology of mental disorders in the primary care and the mental health specialty settings are probable demographic differences between patients who seek care in these respective systems: the old, the less educated, the poor, and the non-white in other words, the vulnerable are more likely to appear for care in the primary care setting.2i Classification: The Web of Comorbidity, Threshold, and the Breakdown of Diagnostic Categories Up to now, primary care clinicians have lacked an adequate classification system for mental disorders, but quite a bit of work is under way in this area.
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From page 294... ...
The ICD-9-CM is an example of a classification system; since ICD-9-CM codes are required by all payers for reimbursement of services, it is safe to say that all primary care clinicians use this system. But this system is of little value in advancing our understanding of the nature of mental disorders in primary care, because it contains neither diagnostic criteria nor a systematic framework for clinical decision rules to guide clinicians and researchers in making diagnostic judgments.
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From page 295... ...
Appropriate management takes into consideration such factors as patterns of functional impairment and patient treatment preferences.30 In summary, the current diagnostic systems for mental disorders, developed for use in mental health care systems, are difficult for primary care clinicians to use and are inadequate to characterize the phenomenology of mental illness as it occurs in primary care settings. Although such efforts as DSM-IV-PC and the
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From page 296... ...
Some primary care practices deal with children only, some deal with adults only, whereas others deal with both; some practices are in urban areas with a wealth of ancillary resources available nearby, whereas others are rural and self-contained; some practices are made up of large groups with inhouse resources such as consultant and laboratory support, social workers, and patient educators, whereas others consist of solo practitioners and an assistant or two; some primary care clinicians have practices that emphasize obstetrics, adolescent medicine, geriatrics, or sports medicine; some practices are family-oriented and some are community-oriented; some practices emphasize procedures whereas others refer all patients needing procedures; some are organized around unique cultural needs; some are organized around occupational concerns; some are organized around teaching programs. This bewildering variety does not even take into account the practice variation caused by variations in reimbursement systems, which are discussed below; nor does it take into consideration the differences that follow from physician preferences and a perceived ability to manage mental health problems.
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From page 297... ...
Thus, even when suspected, mental diagnoses are sometimes not recorded because of pressure from insurers and patients not to do so. Management Purely on the basis of the rate of underdiagnosis, one could infer that the mental health needs of primary care patients are not being adequately addressed.
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From page 298... ...
Clinical guidelines for treatment in primary care exist only for depression.4i We can, therefore, conclude that for depression, treatments that have been shown to be effective for some patients in primary care are underutilized; for other mental diagnoses, treatments shown to be effective in other settings are underutilized, but their effectiveness in the primary care setting has not been demonstrated and may in fact not exist. Competing Demands and the Tasks of the Primary Care Clinician One of the major impediments to the successful integration of mental health care into the primary care setting has been the assumption that diagnostic skills (or aids)
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From page 299... ...
The pace of primary care practice. It has been customary for primary care clinicians to see four or five patients per hour.
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From page 300... ...
Capitation has become the de facto standard reimbursement system under managed care and will most likely remain so for the forseeable future. In its most basic form, without any supplemental incentives, clinicians would be motivated not to identify mental health problems in their patients and if identified, would refer them elsewhere for care; if treatment is rendered by the primary care clinician, this system favors low-intensity, short-duration treatments.
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From page 301... ...
(There are exceptions to this general rule, such as the finding of Smith and colleagues that a specific management of primary care patients with somatization disorders lowers the use of the primary care clinician's services.5~) Thus, with some exceptions, identification of mental disorders in primary care is locally expensive, and under a system of straight capitation, the primary care physician will be motivated to avoid this effort.
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From page 302... ...
If primary care clinicians must pay other providers for mental health services to their patients, they have a strong incentive to not recognize mental symptoms, and their role has become that of gatekeeper in the worst sense of the word. Mental health carve-out systems have major drawbacks and in fact can subvert certain core principles and values of primary care comprehensiveness and continuity.
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From page 303... ...
In this instance, the primary care was more expensive, specialty care and social services cost the same, whereas emergency care and inpatient care were much less expensive. With respect to mental health outcomes, the most compelling evidence is again related to the management of depression: both Schulberg and colleagues56 and Katon and colleagues36 have demonstrated that integrating mental health professionals into the primary care setting to accomplish selected aspects of mental health care results in impressive improvements in patient outcomes, sometimes at minimal net cost.
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From page 304... ...
These similarities allow us to apply the lessons we learn in our relationships with mental health professionals to our relationships with other specialists. For example, we might expect to see differences in the presentation, natural history, recognition rate, and optimum management for a given diagnostic entity across specialties; we might expect the problem of subthreshold conditions and extensive comorbidity to be an issue; we might expect management recommendations developed in specialty settings to be difficult to implement or downright inappropriate in the primary care setting; we might expect multidisciplinary primary care teams to be useful in augmenting and extending the capacities of the primary care system; and so on.
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From page 305... ...
Several years ago Strain, Pincus, and colleagues undertook an ambitious survey of the psychiatric training of general medical practitioners.58 This survey described a rich variety of relationships between the two disciplines, but what was missing was a sense that they were converging on agreement about what was being observed, what needed to be learned, who should teach it, and how the relationship between them should be configured. Finally, it makes sense to administer some treatments in the primary care setting, but not by primary care clinicians.
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From page 306... ...
At this time, the single most effective strategy for improving the mental health of the people of this country and one of the most effective strategies for improving the overall health of these same people would be to make a significant investment in primary care mental health research. The systems are already in place, awaiting our informed modifications and aug.
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From page 307... ...
This should involve observational studies during the innumerable natural experiments now under way, as well as effectiveness trials. We need tests of the effectiveness and cost-effectiveness of different collaborative and consultative modes between mental health professionals and primary care clinicians.
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From page 308... ...
Management guidelines and diagnostic instruments are being developed for the most common mental diagnoses in primary care; now we must learn how to implement these tools into our routine clinical activities. This process will need to transpire under the eye of services researchers, economists, mental health professionals, and primary care clinicians but mostly patients themselves should decide who will do what to whom.
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From page 309... ...
Diagnosis and management of children in an organized primary health care setting. Bethesda, Md.: National Institute of Mental Health; 1987.
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From page 310... ...
The role of primary care clinician attitudes, beliefs, and training in the diagnosis and treatment of depression.
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From page 311... ...
A specialized mental health plan for persons with severe mental illness under managed competition. Hosp Community Psychiatry.
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