Managing Mental Health in Primary Care

With more than 25 years as a clinical psychologist, Margaret Backman, Ph.D., formerly of New York City, remembers getting a referral from a primary care physician (PCP) who told her that “this patient seems to have a problem and I’d like your help.”

The patient was diagnosed with paranoid schizophrenia and told Backman that he wanted to burn down his house with his wife in it. “He wasn’t sharing those details with his doctor,” she says, but he did with her.

Perhaps your patient needs some mental health help. As a PCP, you’re not a psychologist or psychiatrist, and yet you find yourself dealing with issues that really do require a mental health professional. Maybe the patient exhibits hypochondria, unreasonable demands on your time or unwillingness to follow the treatment plan. The patient may share thoughts of major depression and anxiety, or even suicide — because at present, your PCP office is where they bring their mental health concerns.

In fact, the latest report from The Centers for Disease Control and Prevention (CDC) confirms that a fifth of primary care appointments end up being about mental health issues. Analysis from 2010 found these visits included at least one of these mental health indicators: depression screening, counseling, a mental health diagnosis or reason for visit, psychotherapy, or provision of a psychotropic drug. Statistics show that one in five Americans will have a mental health issue in a given year. As to which one, the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists 297 of them.

Access to treatment remains a major issue in some locations, as documented in the American Journal of Preventive Medicine, which found that most non-metropolitan counties are devoid of a psychiatrist, and nearly half don’t have a psychologist. In major metropolitan areas, patients find that many psychiatrists and psychologists don’t take insurance — because they don’t have to — so demand far exceeds supply and per-hour rates can be steep. A 2014 study in JAMA Psychiatry found that only about 55 percent of psychiatrists accepted insurance.

Feeling ‘a little better’

Most frequently, PCPs will write a prescription for medication. However, research has shown that combined treatment, meaning medication and psychotherapy, is more effective than medication alone for disorders such as major depression, panic or obsessive-compulsive disorder. With the average office visit clocking in at 15-17 minutes, talk therapy is a lofty goal, in addition to the fact that PCPs don’t train for that.

For Mary Johnson, manager of editorial for the National Council for Behavioral Health, a “cutting-edge” physician changed her life almost 35 years ago. “He recognized my depression and helped treat it — every time you went to his office, he had you fill out a short questionnaire and that’s how he recognized my depression.”

The doctor was ahead of his time, she says. “He realized that a significant percentage of the population experiences depression and that number was probably higher among sick people —the majority of his patients.”

This doctor also recognized the value of a good, brief chat. “Once he got me on medication, we talked every three days, just for a few minutes so he could gauge how I was doing. One day I said, ‘Phil, I think that maybe I might feel a little better.’ That was what he had been waiting for.”

Symptoms go ‘both ways’

The patient may not just complain of mental problems but may present with symptoms including fatigue, palpitations and shortness of breath, says Russell S. Phillips, M.D., director of the Center for Primary Care and an endowed professor at Harvard Medical School. He is also a primary care general internist at Beth Israel Deaconess Medical Center.

“These patients usually require medical evaluation, and often the need to explore whether a mental health disorder is contributing,” says Phillips. “Most PCPs now are increasingly prepared to help care for patients with mental disorders. It does take time to address the physical complaint to ensure there’s no risk associated with it, and to provide reassurance to the patient.”

The responsibility doesn’t have to fall solely on the PCP, and it’s also possible to help patients and “keep things simple” by just sharing information. The idea of the PCP and mental health provider “teaming up” was the subject of a small French study published in October 2018 in the journal Family Practice. It found, simply, that improved communication between GPs (PCPs) and mental health providers could reduce difficulties for GPs caring for people with mental health disorders and accelerate a whole patient–centered approach.

One increasingly prevalent practice model, especially at academic medical centers, includes a behaviorist — a psychologist or social worker (LCSW) integrated or “embedded” within the primary care practice. “It can be very difficult for smaller practices to afford this, since payment is usually not sufficient to support it,” Phillips says.

When treatment with a mental health professional is suggested and a patient resists, it helps to have the clinician right in the office, which helps to reduce stigma, he adds.

“It’s more ‘normalized’ when a patient sees someone in the clinic,” says Backman, who worked “embedded” in a VA hospital. She also authored the book The Psychology of the Physically Ill Patient for clinicians.

In the same location, “physicians got to know me, and I got to know them,” she says. “Patients don’t like to be dismissed, but they do respond to ‘Here’s another level of care you should avail yourself of.'”

Collaboration of care

A second model, the collaborative care model, has the most evidence-based research to support it, Phillips says, and has been shown to improve both mental and physical health.

“Currently, reimbursement is sufficient to support this model, but healthcare professionals who work this way may not be paid at as high a level as an embedded behaviorist,” he says. “This model involves managing a population of patients with depression, and tracking them over time to ensure things aren’t worsening. It’s akin to thinking about patients who have diabetes, to make sure they have good control.”

A population manager follows patients, usually starting with a screening using the PHQ-2 questionnaire, often graduating to the PHQ-9, to determine the level of depression. This person works under supervision of a PCP and can prescribe medication. The healthcare professional can refer the patient to a mental health specialist, depending on the individual’s need, as their progress is tracked, sometimes even by phone.

Finally, says Phillips, it’s important, albeit challenging, to note that traditional reimbursement models don’t do a great job of supporting models that integrate primary care with mental health. However, new Medicare billing codes, especially the Collaborative Care Model (CoCM), hold promise for elevating levels of mental health care in primary care settings.

In her blog for Physicians Practice, Nelae DeChurch, P.A.-C., also suggests that better utilization of physician assistants can help PCPs reduce their mental health workloads. She says PAs can identify patients needing mental health help, handle their medication management and patient education, and identify referrals to outside mental health professionals.

Backman says things are definitely much better for patients who need mental health care and share that need with their main care provider. “I feel mental health issues have been marginalized by medical professionals over the years,” she says. “It just wasn’t always treated with the same respect and ease as it is when someone is referred to a cardiologist for blood pressure that isn’t responding to medications.”