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January 8, 2014

How Can We Better Coordinate Medical and Mental Health Care?

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Larry Culpepper, MD, MPH

Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts

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In my last blog entry, I noted the recent Canadian Task Force recommendation against screening for depression in those not at increased risk. I did not argue that Canadians should follow the American status quo, in which routine screening is recommended as long as diagnostic and treatment services are available. On this side of the border, we are in very different circumstances. We are in the midst of establishing the parity of mental and medical care, and we are revamping the financing of care not only to broaden access by increasing insurance coverage but also to change the value equation for primary care physicians. Getting patients better and decreasing care utilization and costs through improved health status are now becoming the priorities. Quality control measures are reinforcing screening for depression and its subsequent diagnosis and treatment.

The past decade of routine screening for depression in primary care has brought about several advances. Depression is now better understood as a brain disease by the population, and stigma is decreasing. Physicians now recognize the need for using a screening tool that not only is in line with the DSM criteria but also can be used over time as a measurement tool for severity and treatment response. We are learning that integrating the care of depression with the care of chronic medical disease leads to much better outcomes than single disease care management. We are recognizing that the reduced morbidity, hospitalization, and disability from chronic medical conditions that are frequently comorbid with major depression (and the accompanying reductions in utilization and costs) dwarf the benefits related to the benefits of treating depression alone.

Our approach integrates depression care—both screening for it and then actively managing it—into current primary care practice and the evolving patient-centered medical home (PCMH). But other mental health conditions are as disabling as depression. For example, PTSD, OCD, bipolar disease, ADHD, and substance abuse all can derail lives, break up marriages, and lead to chronic unemployment. These conditions also often lead to circumstances in which the individual is uninsured. And, they lead to high medical and societal costs.

One corollary of the downward cascade that often follows the onset of these conditions is the emergence of huge barriers to the affected person in obtaining regular primary care services. Screening for mental illness in many primary care settings often yields only those with mild disease or disease that has been previously diagnosed and controlled because those with more severe disease simply don’t make it in the door. When screening does yield a patient in need of care, adequate expertise is often difficult to engage.

These patients, and their families, are one of the targets of the Affordable Care Act. As those with mental illness obtain medical insurance (or Medicaid coverage in states participating in its expansion), they will present to primary care practices. Systems that cannot provide effective primary care and coordinated specialty care will likely be bankrupted by their responsibility to instead provide high-cost inpatient and rescue care. The ban on exclusion of insurance coverage due to preexisting conditions, the required coverage of core services that include mental health care, and the abolishment of lifetime insurance payment limits are all powerful incentives to proactively assure that the needs of this (not small) population are met.

Within this framework, using the PHQ-2 for depression screening followed by the PHQ-9 for diagnosis is inadequate. Instead of having a single focus on depression, primary care physicians need new tools to identify patients with a variety of mental health conditions when they enter our practices or as they newly develop them. At a minimum, anxiety (particularly PTSD), bipolar disease, alcohol and substance abuse, and ADHD are diagnoses that members of PCMHs need to proactively diagnose and manage in the future.

New tools for screening and diagnosing more mental illnesses need to lead to care involving the newly reconstituted primary care team, which now includes those with psychiatric and counseling expertise. But what are the desired attributes of these new tools? Check back for my next blog describing the dream mental health tool for the PCMH.

Financial disclosure:Dr Culpepper is a consultant for Forest, Lundbeck, Merck, Sunovion, and Takeda.

Category: Depression , Medical Conditions , Mental Illness
Link to this post: https://www.psychiatrist.com/blog/how-can-we-better-coordinate-medical-and-mental-health-care/
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6 thoughts on “How Can We Better Coordinate Medical and Mental Health Care?”

  1. A physician has indicated the following (responses-mine):
    Item: Depression is now better understood as a brain disease by the population, and stigma is decreasing.
    Response: Depression is a brain disease, but in a similar fashion so is not knowing your multiplication tables (which can be debilitating and why we assign you to a third grade teacher to “modify your brain and neurons” for a year). With the limited scientific evidence for efficacy of antidepressants (less than 1/3 respond, and even responders are experiencing very small differences than placebo), mounting risk of long-term neuronal mutation, systemic problems, and interaction effects, and poor capacity of Primary Care Staffing to identify and treat these patients-we are in a crisis if we expect Primary Care Centers (unmodified) to effectively diagnose and treat depression.
    Item: Physicians now recognize the need for using a screening tool that not only is in line with the DSM criteria but also can be used over time as a measurement tool for severity and treatment response.
    Response: This statement belies a very limited, system crippling, and naiveté’ understanding of depression. First, screening instruments are notoriously poor in reliability and validity and only give a cue that depression is possibly present (hence the term “screening”…for the purpose of ordering further diagnostics! They are not adequate to differentiate between the large number of types of depressive disease, paring the disease with the literature and using that to select an appropriate (scientific) treatment technique or bundle of techniques called a “treatment plan”! Just identifying the possibility of one of the many depressive disorders and then choosing one technique (antidepressants with a limited effect with a minority of syndromes and patients) not only fly’s in the face of recommendations by the WHO, the FDA (which has written that modern physicians recognize that a “medication only” technique is not an adequate treatment plan for depression), and represents a lack of scientific, diagnostic, and treatment acumen! For Primary Care Centers to effectively deal with the approximately 25% of admissions with mental disorder they will need to be adequately staffed with psychologists or psychiatrists (and the psychiatrist workforce cannot cover the volume and geographical distribution even if they were trained and willing to do extensive psychotherapy and change oriented approaches). It would require serious interest in lab work (psychological) and diagnostic interventions and establishing available staff for adequate “comprehensive treatment plans”! A new law can’t do this without retooling Primary Care Clinics and Community hospitals and revising accreditation and licensure requirements for staffing and operations of these facilities!
    Item: Our approach integrates depression care—both screening for it and then actively managing it—into current primary care practice and the evolving patient-centered medical home (PCMH).
    Response: The concept of “management” rather than “growth and maturation of the brain” has plagued psychiatry, but not education, psychology, and industry! Great psychiatrists and psychologists have established a body of evidence that as learning, maturation, and socialization or re-socialization occurs “the brain changes” (and as the obverse of these occurs it changes for the worse). Every third grade math teacher “grows neurons”, “auto receptors” to put the brakes on impulses and inattention and wandering thoughts and behaviors! We give them the time and intensive involvement required to do so, but they can do it! Every college faculty takes naiveté’ and intellectually (and I might add developmentally) immature brains and in 4-5 years changes them dramatically and almost unrecognizable they are so different (intellectually, in terms of knowledge and memory, regarding maturity and socialization, etc.). Rat labs, cat experiments, and human labs have created depressions and alleviated them! Spontaneous remission (growth and maturity with positive relationships and positive institutional and activities experience) occurs regularly with depression and is almost never mentioned or factored into the base rate when techniques like SSRIs are evaluated!
    Item: But other mental health conditions are as disabling as depression. For example, PTSD, OCD, bipolar disease, ADHD, and substance abuse all can derail lives, break up marriages, and lead to chronic unemployment. These conditions also often lead to circumstances in which the individual is uninsured. And, they lead to high medical and societal costs.
    Response: Listen to the psychiatrist’s statements above and then try to justify “medication only approaches” so prevalent in primary care centers or the average psychiatrist’s practice. Try to justify seeing one of these patients for a 20 minute diagnostic interview, prescribing an SSRI, and then seeing them every 3 months! Try to imagine doing this as a general physician in a primary care center because the only psychiatrist (with the general physician illusion that they will treat the disease instead of apply a medication only) is 100 miles away and can’t get the patient in for a month and doesn’t understand the rural culture. With mental disorders, if we are scientific, tailor the treatment to the facets of the disease needing intervention (some mentioned above in the psychiatrist’s statement), it is tantamount to “witch craft” to prescribe an antidepressant and that be one’s only intervention or sensitivity to the myriad of symptoms of the disease that will not be “managed” by the medication and the harmful consequences that will occur if appropriate comprehensive treatment plans are not ordered! We are selling a primitive and unscientific understanding and treatment plan for depressive disorders and are encouraging with the statements above a very naiveté’ and overly concrete dialogue about the diseases, the Primary Care Clinics and Community Hospitals in America, and the healthcare systems complicity in “poor quality of care” and the “squandering of scarce healthcare resources” on partial, marginally effective, incomplete and partial treatments! The idea you can do this with a law such as the Affordable Care Act or applying the concept of Integrated Care without a more depth understanding of these diseases and a more systemic modernization of the Primary Care and Community Hospital System is to “pretend progress”, “invest in illusion”, and “believe our own BS”!
  3. This field represents a new branch of medicine. It is vast, like a million piece jigsaw of which we know about 5 pieces. Its time for constructive research to be expanded into this field. It will make a welcome difference to those who’s physical disease has significant behavioral components.
  4. I am glad you are highlighting this problem in this forum. This is clearly a broken link in the chain, isn’t it? I am a psychiatrist working in a large MCO, and we are working towards integrated med-psych care for all our patients.
    Obviously, there is no one solution to this problem. Continued discussions, and innovative proposals will eventually make our health care system more effective.
  5. It certainly is a barrier to adequate coordination of care when a patient with a severe mental illness is denied access by primary care docs. A startling example is the patient with bipolar disease whose PCP in solo practice retired. The patient called 17 different physicians in an attempt to become a patient in his/her practice. The receptionists all asked for the patient’s list of medications and said they’d call back; not ONE actually did. Said patient eventually found an excellent PCP whose receptionist did NOT ask for a list of meds first.
    One more reason for single-payer national health service NOW.
  6. We never ask the question, are biolgical markers primary or secondary to the disease. Autonomic function can vector physical disease. Autonomic function tends to dissociate and run wild under conditions of stress and trauma, especially if dissociative responses were learned as a child. Measurable change in cerebral function can result. Whether or not these measurable changes are consequences of dissociation or the prime cause of disease remains confusing to us.

    Its time for some thinking about this.

    David F.

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