An Interprofessional Approach to Addressing Psychological Disorders

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.

Additional Resources

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

https://www.sbm.org/publications


Alcohol Overconsumption and Abstinence May Increase Risk of Dementia

by Bill Nguyen

With dementia prevalence predicted to triple by 2050, it is critical to bring attention to potential contributors. Among the list of speculated contributors to dementia is alcohol use. A study conducted by a team of researchers from Inserm (French National Institute of Health and Medical Research) suggests that overconsumption of alcohol during one’s midlife may lead to an increased risk of developing dementia during old age. Even more surprising, the same study suggests that those who abstain from alcohol consumption during midlife also risk higher chances of developing dementia later in life when compared to those who drank 1-14 “units” of alcohol each week.

A conclusion that can be drawn from this study is that alcohol consumption in moderation is the most effective method of mitigating the risk of developing dementia. However, it should be noted that drinking alcohol, even in moderation, may lead to other illnesses, such as liver disease and cancer. Moreover, the study did not reach any solid conclusions and remains mainly speculative. Additional rigorous research is needed to better understand the link between alcohol consumption and dementia in old age.

Further information regarding the study, the BMJ article can be accessed here.

For those who have dementia or know people who do, help and support can be obtained here.

For those struggling with alcohol abuse or know people who are, treatment can be found here.

To receive more case-specific advice, reach out to a licensed specialist or physician.

Tourette Syndrome Overview and Facts

by Bill Nguyen

Introduction

Tourette syndrome (TS) is a neurological disorder characterized by the presence of tics, which are rapid and repetitive movements made involuntarily by an individual with the syndrome. Tics can be categorized into two groups: motor (e.g., blinking, shrugging, arm jerking) and vocal (e.g., humming, shouting, grunting). Symptoms usually begin during early and late adolescence and may gradually disappear as an individual ages. However, the disorder has been known to persist throughout adulthood as well.

Causes

While the exact cause of TS is currently unknown, research has suggested that the disorder may be inherited genetically or may be a result of abnormalities in one’s genetics.

Treatment

As the cause of the disorder remains unknown, there is no cure for TS. Medication can be offered to temporarily repress symptoms, allowing individuals with TS to function normally throughout the day. However, these medications come with side effects and do not offer a lasting solution. Although not a cure, behavioral therapy can help individuals suffering from TS cope with their symptoms as well as help reduce the severity of tics. Ultimately, it is recommended that individuals with TS visit a certified physician or specialist to consider which treatment is best suited to them.

Notable Facts

  • It is estimated that 1 out of every 160 children in the United States ages 5 to 17 suffers from TS.

  • Individuals with TS have a higher risk of other mental disorders, such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, and depression.

  • Males are more likely to suffer from TS than females are.

Below is a video containing interviews with actual individuals diagnosed with TS.

How Your Smartphone Is Affecting Your Mental Health

by Bill Nguyen

Smartphones have become embedded in our society, defining our casual and even professional interactions. However, some people fear the mental health implications of smartphones, and thus, rumors are created and spread, regardless of their validity. To clear up any misunderstandings and acknowledge legitimate concerns, listed are various mental health effects of smartphones along with recommended solutions.

Sleep Disruption

Shorter wavelength blue light, released by computer monitors, televisions, and smartphones, confuses one’s circadian rhythm and disrupts sleep if exposed to after sundown.

Solution: Limit smartphone use after dark. An alternative option is downloading a smartphone application that greatly reduces blue light emission. This setting is known as “Night Mode” on Android devices and “Night Shift” on iOS devices.

Distraction

Smartphones often distract their users. This is especially detrimental when considering the implications for health care professionals. One study by Risk Management and Healthcare Policy demonstrated that, when health practitioners are interrupted by their smartphone even once during a patient visit, the chance of the practitioner mischecking or misdiagnosing the patient increases by at least 12%.

Solution: When performing critical tasks, it is best to refrain from using your smartphone. Muting or silencing your smartphone can greatly help with this. Furthermore, during a medical checkup with your provider, feel free to politely ask them to set aside their smartphone.

Impaired Social Interaction

The ease of sending a text message as opposed to talking in-person has led to many individuals (particularly teenagers) sacrificing real-life interactions with virtual ones. This can cause a lack of empathy or trust among those communicating and ultimately disrupts the intimacy many have during physical interactions. In fact, even the presence of a smartphone during interactions can inhibit the closeness of those interactions. Interestingly, teenagers who participate in more social activities tend to have lesser risks of depression and suicide.

Solution: Put your smartphone completely away or hidden when interacting with others. In addition, make the effort to arrange physical meetups with friends and families to preserve intimacy and bonding. Remember the importance of engaging in social activities, such as joining a club or sport.

Addiction

The satisfaction and dopamine acquired from receiving a notification or Facebook “react” is thrilling--and can be addicting. This may lead an individual to constantly crave this sense of fulfillment gained from their smartphone, leading to significant overuse. This can induce all the problems discussed previously, as well as the countless physical health issues not mentioned.

Solution: Set restrictions on smartphone use. These restrictions can take the form of completely turning off your smartphone when not in use or downloading apps that restrict access to the most enduring parts of the phone. Setting your smartphone in a separate room can also help with resisting its use.

 

Sources:

Smartphone Dangers: Could Your Cell Phone Be Bad for Your Health? (OnHealth)

Cellphones and unhealthy side effects (The Washington Times)

Phone Addiction is Real -- And So Are Its Mental Health Risks (Forbes)

Mental Health Of Transgender People Is Under Stress, Study Finds

Diana Feliz Oliva, a 45-year-old transgender woman who grew up outside Fresno, Calif., remembers being bullied when she was younger and feeling confused about her gender identity. She was depressed and fearful about being found out, and she prayed every night for God to take her while she slept.

“I was living in turmoil,” said Oliva, who now works as health program manager in a clinic for transgender people at St. John’s Well Child & Family Center in Los Angeles. “Every morning, I would wake up and I knew I would have to endure another day.”

Oliva’s experience is strikingly consistent with the findings of a new report from UCLA that shows transgender adults in California are more likely to have suicidal thoughts than other adults in the state, and more likely to have attempted suicide.

They are also more likely than their non-transgender peers to face severe psychological distress and to be disabled because of a physical or mental health condition, the report found.

The mental health gap is worrisome because it points to ongoing discrimination and bias, the study’s authors said.

The data — released Tuesday as part of the annual UCLA California Health Interview Survey — highlight health disparities among a marginalized population. The survey, a collaboration between the UCLA Center for Health Policy Research and the Williams Institute at UCLA School of Law, covers demographics, access to health care and health status.

California prohibits discrimination against transgender people in employment, insurance, housing and public accommodations. Williams Institute researcher Bianca Wilson said the UCLA report underscores the need to determine how well these anti-discrimination policies are being implemented throughout the state. Across the nation, 30 states lack similar anti-discrimination laws, according to the study.

“There are also national debates and national policies that impact individual trans folks regardless of where they live in the country,” said Wilson, a senior scholar at the institute. “And on the national front, we still have a lot of work to do.”

Around the country, controversy has raged about transgender bathroom access and military service. The White House order banned transgender troops from serving in the military, but a federal judge on Monday blocked that policy temporarily, finding that it was probably unconstitutional.

“We have made some really great strides, but with this new political administration, people are living with an increased amount of anxiety and depression. Our community is at risk,” said Oliva.

In her late 20s, Oliva moved to Los Angeles, earned money as a sex worker and ended up spending time in jail. That’s when she decided she had better figure out who she truly was and what she wanted. She started her gender transition in her 20s and went to school at Cal State Los Angeles to study social work, eventually earning her master’s at Columbia University in New York.

The UCLA report, she said, is spot on. “Everything that report says is everything I experienced. I have gone through all the barriers and struggles and challenges.”

The data used in the UCLA study were collected in 2015 and 2016. About 92,000 Californians between the ages of 18 and 70 are living with a different gender identity than the one they had at birth, according to the study. Nearly half identify as transgender, while 32 percent identify as female and 7 percent as male. About two-thirds identify as non-Hispanic white — a higher percentage than among other adults. Transgender adults are also less likely to be Latino.

Transgender people differ markedly in sexual orientation from other adults. Just 28 percent of them said they were heterosexual, compared with 93 percent of adults who aren’t transgender.

They have similar levels of education, citizenship and poverty as those who aren’t transgender. They also have similar rates of diabetes and asthma, but higher rates of HIV. The report found that transgender adults have similar health care access overall, but are more likely to delay filling prescriptions made by a doctor — or not get the prescriptions at all.

Stigma and bias likely contribute to the mental health problems among transgender people, said Cecilia Chung, senior director of strategic projects for the Oakland-based Transgender Law Center. Recent prohibitions — including on bathroom access and military service — have created a crisis in the transgender the community, she said.

“Their poor mental health will continue and worsen if our government continues to show hostility toward transgender people,” said Chung, a transgender woman. “The well-being of transgender citizens of our country is not being prioritized.”

More than 20 percent of transgender adults have attempted suicide, compared with about 4 percent of those who are not transgender. And they are over three times more likely to have had suicidal thoughts. One-third of transgender adults suffered serious psychological distress in the past year, compared with 9 percent of those who are not transgender.

Jody Herman, a scholar at the Williams Institute, said the study underscores the need for more training on transgender issues for mental health professionals. The study’s authors also urged more research on the health of the transgender population and of possible solutions to improve their mental and physical well-being.

Chung said she would like to see better answers to explain the differences in mental health — especially given the demographic similarities between transgender and non-transgender populations. “What actually sets them apart in terms of the health outcomes?” she asked. “What is the reason for the higher rates of suicide attempts?”

Oliva said that although she now has a job, insurance and an apartment, she still worries every day about getting physically assaulted for being a transgender woman. “My constant prayer on a daily basis is to make sure I stay alive,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.


Republished from California Healthline's Insight. Insight provides an in-depth look at health care issues in and affecting California.

Mental Effects of Sleep Deprivation (and How to Get Better Sleep)

by Bill Nguyen

The average American is notorious for being sleep-deprived. In fact, according to a report released by the Centers for Disease Control and Prevention, 1 in 3 Americans do not get sufficient sleep on a regular basis. Results were based on identifying a healthy sleep duration as seven or more hours per night. But what harm can missing a few hours of nightly winks cause? And what steps can one take to ensure a better night’s rest?

REM sleep is a phase of sleep in which one’s ability to learn and memorize is enhanced. When this period of rest is interrupted or not reached at all, one may experience faltered memory or impaired thinking. This may affect how one functions throughout the day and may stunt productivity, as the person is in a constant state of drowsiness. Effects of sleep-deprivation may also prove lethal. For example, a weary individual may drive comparably (and, in some cases, worse than) someone who is under the influence of alcohol. The National Highway Traffic Safety Administration marks driver fatigue as causing 100,000 motor vehicle accidents and 1,500 deaths every year.

But before solutions for achieving better sleep can be discussed, one must first address the factors contributing to bad sleep. Mental illness may play a paramount role in one’s inability to sleep. Individuals suffering from depression, anxiety, or ADHD may experience regular difficulty sleeping, inducing the aforementioned effects of sleep deprivation. However, a lack of sleep is commonly a result of an individual’s inability to maintain a regular and healthy sleep schedule, oftentimes due to a tight workload or poor time-management skills.

So what can one do to ensure a good night’s rest and avoid the detriments of sleep fatigue? For starters, an individual can greatly reduce their intake of caffeine, alcohol, and nicotine before going to bed as the three substances are infamous for causing restlessness. Eliminating their consumption entirely would be ideal, but a significant reduction in consumption would serve as a viable alternative. For those suffering from anxiety or any form of restlessness, meditation can help clear the mind from intrusive thoughts and allow one to fall asleep comfortably. Furthermore, those with busy schedules or poor time-management skills can reflect upon their situation and create a schedule that will best allow for regular sleep. Exercise can also lead to better sleep as it causes one to fall asleep faster and with fewer interruptions. Additionally, the National Sleep Foundation offers a resource for improving sleep hygiene. However, for those struggling with serious mental disorders or cases of restlessness, medication may be necessary for allowing proper sleep.

Sleep is vital to preserving one’s mental wellbeing. In order to remain healthy and alert, one must aim for at least seven hours of sleep per night (although the exact number varies depending on the individual). An individual struggling from sleep deprivation must take time to thoroughly address their situation, identify steps that can be taken to ensure a better night’s rest, and consider seeking support from a medical professional or psychologist specializing in sleep psychology.

Sources and Further Readings:

Centers for Disease Control and Prevention Report

Harvard University Article on Sleep Deprivation

Lesser-Known Facts on Sleep

National Sleep Foundation Resource