Mental Health Providers in Primary Care Settings
Are primary care providers and health care professionals engaging in more mental health screening of their patients? I recently sat on a panel with other individuals from different health professions. Optometry, pharmacy, podiatry, physical therapy, veterinarian medicine, and dental medicine were some of the professions represented at the panel. As I listened, I heard panelists name a variety of mental health assessment measures while using language commonly used by psychologists. It is not entirely surprising. Neuropsychiatric disorders account for six out of ten leading causes of disability. They represent approximately 12.3% of disability-adjusted life years lost. Often, primary care providers serve as the entry point for patients seeking psychiatric or mental health care. Patients often receive antidepressants or anti-anxiety agents from their primary care providers.
Still, many primary care providers have “limited” training in mental health treatment and approaches to psychiatric disorders and severe mental illness. Because behaviors are often at the root of several medical disorders (diabetes, hypertension, sexually transmitted infections, traumatic brain injury, other conditions due to accidents or injuries, etc.), behavioral health specialists should be present on the team with primary care doctors and healthcare professionals. Often, they are not.
As I participated and listened to my co-panelists, several thoughts came to mind. Mental health professionals rely on healthcare providers to rule out medical disorders or endocrine disorders as the cause of a mood disorder. Why don’t medical professionals rely on mental health professionals more than they do? Also, the tendency to refer patients directly to psychiatry as a first line referral persists in the healthcare profession. While not necessarily the wrong choice, it sometimes presents limited treatment options for the patient unless the psychiatrist is trained to provide other forms of mental health treatment, such as cognitive behavioral therapy.
Further, some patients fail to follow-up with a referral to a psychiatrist due to fear of stigma or shame, concerns about psychiatric medications, or misperceptions about what it means to see a mental health provider. Often there is a narrow understanding of what mental health services can be provided to the patient outside of medication. Using a warm hand-off, members of the care team can introduce the patient to the psychologist after they have shared information about what mental health services are. This offers an opportunity to correct inaccurate beliefs that contribute to stigma about mental illness.
Conversations with Patients
Conversations and words used are important. This is especially true for patients who are in emotional distress and sensitive to how they are being perceived and treated by others. Providers may unintentionally use language that further perpetuates stigma and shame, preventing patients from wanting to have conversations with their doctors about sensitive issues. For example, health professionals often refer to condomless sex as “unsafe sex.” One patient may present with significant distress about a potential unplanned pregnancy. Another may be struggling to have a conversation with a provider about pre-exposure prophylactics (PrEP) for the prevention of HIV infection. A common communication practice in mental health and social sciences is the deliberate separation of the psychiatric diagnosis from the patient (e.g., a patient with bipolar disorder instead of a bipolar patient). Any terms that can be perceived as judgmental when describing behaviors are removed. Instead of “unsafe sex,” which tends to convey danger or fear about sexual behavior and sexually transmitted infections, most mental health professionals use the term “unprotected sex.” Such a minor detail in language makes a significant difference to the patient, albeit at the annoyance of many health care providers.
Similarly, some health care providers are uncomfortable having conversations with patients about their sexual identity or sexual behaviors. Continuing education and the education of new providers is helping practitioners to improve their efficacy in competently addressing issues of sexual health with transgender and intersex patient populations. Studies have found that many LGBTQI individuals separate their primary care needs and their sexual health care by obtaining services from LBGTQI-serving centers and clinics. LGBTQI people report having more trust and comfort at LGBTQI-serving centers and clinics, making them the preferred choice for sexual health and other health care services. Unfortunately, this results in fragmented care unless health information is shared freely between primary care providers and these centers.
Finally, another topic that can be especially difficult for some people to discuss is suicide. However, effective suicide risk assessment is a critical skill for all health care providers, not just mental health clinicians. Mental health first aid is a resource that is available to health and social services practitioners. Training includes assessing not only for suicide risk but homicidal ideation and risk of harm to others.
Conveying a sense of understanding of a patient’s culture and a nonjudgmental attitude toward their behaviors may be a means to “meet patients where they are,” and lay a foundation for a trusting relationship that can lead to improved health outcomes. For this, psychologists may be a great resource for some health care providers. I have also noticed that with the rising suicide rate as reported by the Centers for Disease Control and Prevention, more health care providers are hypervigilant when assessing for suicide risk. I think that is wonderful! An entire health professional community should be on the lookout for the emotional well-being of their patients. Just as important as being aware of suicide risk is being mindful that not all patients who report feelings of sadness or other difficult emotions are clinically depressed. A psychologist will be able to determine if the patient is simply struggling with adjustment to significant life events rather than experiencing a mood disorder or depressive episode.
History and Psychosocial Factors Are Important
Another way psychologists, social workers, and other mental health clinicians can help in the integrated care setting is in their ability to spend time that medical providers are unable to spend with the patient. People function within systems and relationships that play a role in health and well-being. Primary care teams that include both psychologists and physicians are better equipped to address known barriers to better primary health care. Mental health professionals who work with patients and serve on a treatment team can understand how complex biopsychosocial history and current factors contribute to disease and maladaptive health-related behavior. The American Psychological Association offers a number of resources and publications that show how lack of attention to behavioral factors and limited patient access to needed care compromises health care quality.
Psychologists trained in behavioral medicine or integrated settings learn how to convey only the most relevant information about the patient to medical providers. For suicide, personality disorders, and many psychological disorders, the patient’s history is key. Not only the patient’s medical history but their psychosocial history. Using lifespan development theories, psychologists can piece together the patient’s trajectory that has led them to seek the care they currently need. A number of studies have shown how cumulative adverse childhood events are strongly related to negative long-term physical and mental health in adulthood. We cannot escape the history of the individual despite the financial and systemic pressures to focus on the immediate symptom presentation and quick resolution with medication or an outside referral. Interprofessional practice not only improves quality of care but also decreases the risk of medical error and missed diagnoses.
Proximity of Providers: Co-locating Behavioral Health and Primary Care and the Prospects for an Integrated Workforce (PDF, 314KB) https://www.apa.org/pubs/journals/releases/amp-a0036093.pdf
Applying the Inter-professional Patient Aligned Care Team in the Department of Veterans Affairs: Transforming Primary Care and Tipping Points in the Department of Defense’s Experience with Psychologists in Primary Care (PDF, 214KB) https://www.apa.org/pubs/journals/releases/amp-a0035909.pdf
Integrating Primary Care and Behavioral Health With Four Special Populations: Children With Special Needs, People With Serious Mental Illness, Refugees, and Deaf People (PDF, 102KB), by Robert Q. Pollard Jr., PhD, Jennifer K. Carroll, MD, and Steven Barnett, MD, of the University of Rochester; Jeanette A. Waxmonsky, PhD, William R. Betts, PhD, Frank V. deGruy, MD, Laura L. Pickler, MD, and Yvonne Kellar-Guenther, PhD, of the University of Colorado Denver School of Medicine. https://www.apa.org/pubs/journals/releases/amp-a0036220.pdf
Journals of the Society of Behavioral Medicine
Annals of Behavioral Medicine
Translational Behavioral Medicine: Practice, Policy, Research