Mental Illness: The New Dimension in Primary Care
Posted: April 1, 2023 | Category: News
By Mark Wendling, MD, Family Medicine Physician, Executive Director of Valley Preferred
The primary care physician has long been the starting point for many patients with mental health concerns. It’s estimated that 20 percent of all visits to primary care physicians include at least one of the following mental health indicators: depression screening, counseling, a mental health diagnosis or reason for visit, psychotherapy, or provision of a psychotropic drug.*
The role of the PCP continues to expand, in part because value-based payment models support a more holistic approach to health care, with some requiring behavioral health screenings to receive shared savings. This article looks at why mental health and primary care continue to become intertwined, and the logical steps in a comprehensive approach to caring for patients with mental illness in the primary care setting.
Mental illness is a chronic disease
Patients with mental illness appropriately visit their PCP for a number of reasons. Among them: reduced stigma for patients and their families, improved access to care, treatment for comorbidities, improved prevention and detection, and improved follow-up. Some see their family doctor because they simply feel more comfortable talking about mental health with a provider they know, and who is trained to assist. The co-joining of mental health with primary care also correlates to an important outcome of clinical research: An acceptance of mental health disorders as chronic diseases much like diabetes or heart disease.
In my practice, I approach diagnosis without separation between physical and mental health, as the two can be so closely linked. For instance, patients who have had a heart attack and who have depression are twice as likely to have another cardiac event within two years. Author Frank deGruy III, MD, MSFM, (“Primary Care: America’s Health in a New Era,” National Academies Press), puts it this way: “Systems of care that force the separation of ‘mental’ from ‘physical’ problems consign the clinicians in each arm of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, undermines comprehensiveness of care, hamstrings clinicians with incomplete data, and ensures that the patient cannot be completely understood.”
How does the PCP assess mental illness?
PCPs have ready access to evidence-based tools that make diagnosis of mental illness uncomplicated. Recommendations for behavioral health screenings in the PCP office have been generated by numerous entities, from national family medicine, internal medicine, pediatric, and obstetric organizations, to the U.S. Preventive Services Task Force (USPSTF). (See sidebar.)
According to the USPSTF, PCPs should screen all adults for depression, alcohol abuse, and drug abuse. Along with assessment, PCPs need to discuss mental health disorders with their patients, and if diagnosed, provide as much education on the condition as possible.
Individualized treatment and sustained follow-up
The ultimate goal of treatment under a PCP is to render the patient symptom-free and sustain that status for a period of time. The type of treatment recommended will be highly individualized, based on the patient’s particular situation. Mild illness can be treated by the PCP alone, while moderate and severe illnesses usually require a multidisciplinary approach, such as with behavioral health counseling. It’s up to the PCP to make certain there is appropriate diagnostic follow-up with a behavioral health clinician.
Among avenues for treatment are pharmaceutical and non-pharmaceutical; the latter including things patients can do to help themselves. If pharmaceuticals are determined to be helpful and appropriate, there are groups of medications available that are safe and effective without lots of side effects. I make certain patients understand their role in their own treatment plan, and the risks of not complying – for example, what will happen if they abruptly stop taking their medication. Data supports that not taking medication for the recommended period leads to a high relapse rate. Unfortunately, with every relapse, the disease gets harder to treat.
Severe illness and crisis management
If one of my patients shows signs of a psychotic illness such as schizophrenia, I will refer that patient to a psychiatrist. A lot of follow-up, possibly including an outpatient treatment program, will be required. Patients who are suicidal (anyone who says they are thinking of harming themselves) should be evaluated in a setting capable of managing this level of illness: Most of the time that means the hospital emergency department.
If a patient comes to my office and is suicidal, I will ask questions about intent: Have you thought about the method you will use? Have you thought about when and where? The more information offered about intent, the closer the patient usually is to realistically taking action. In this case, an immediate, emergency response is needed. Even if patients say they are thinking about suicide, they are emergent. Establishing a safety plan** is recommended. These patients need to be reassured, and the PCP must assist in getting them to a place where they can openly talk to someone who is trained on what to do.
PCPs and fighting the stigma
As the primary care office continues to be a first stop for patients with mental health concerns, PCPs can be highly influential in outcomes. Screenings in primary care settings can improve quality of life, help contain health care costs, and reduce complications from co-occurring behavioral health and medical comorbidities.*** As PCPs emphasize the significant risk of stopping treatment prematurely, and reinforce the idea that with the appropriate treatment, the chance of recurrence is lower and the chances of comorbidities are lower.
Since a lot of mental illness can be treated by a PCP, it’s important for patients to seek this relationship as well as with mental health providers. As PCPs assume the role of “first responder,” we have an opportunity for even greater impact by helping to demystify mental illness in our culture. As we reinforce that mental illness is no different than any other chronic disease and provide follow-through on this premise, we can begin to erode the reluctance people have to seek treatment.
Mental Health Screening Tools
Standard tools used by PCPs to assess whether patients may require treatment for mental illness follow Institute of Medicine (IOM) guidelines and are derived from the Patient Health Questionnaire (PHQ) and Patient Stress Questionnaire (PSQ). The tools below are appropriate for screening for multiple mental and substance use disorders:
- PHQ-2: Depression
- PHQ-9: Major Depression Disorder
- PHQ-4: Depression and Anxiety
- GAD-2: Panic Disorder, Social Anxiety Disorder, PSTD
- GAD-7: General Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, PSTD
- AUDIT-C: Alcohol Use Disorder
- AUDIT-10: Alcohol Use Disorder
*https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a6.htm (2010 data)
** A safety plan is a prioritized written list of coping strategies and sources of support that people who have been deemed to be at high risk for suicide can use before or during a crisis. The plan is brief, easy to read, and in the person’s own words.