Integrating Primary and Mental Health Care

The increased integration of mental health care into primary care is one of my pet issues. Currently, primary care providers (PCPs), also called general practitioners, provide over half of mental health treatment in the United States – which results in up to 50% of mental health problems going unindentified, undiagnosed, and untreated through the primary care system. This is a wasted opportunity, as PCPs have significant opportunities to identify behavioral health problems early and provide interventions and treatments to prevent further deterioration.

This indicates a significant split between the physical health care and mental health care systems, where people are expected to go to their PCP for physical health issues and to self-refer to a mental health care clinic or specialist for mental health treatment. This is problematic for a whole host of reasons – primary among them the simple fact that this system simply isn’t working – even though the prevalence of mental disorders in primary care is somewhat higher than the overall population, PCPs are ineffective at identifying those people and providing them with treatment. Expecting people to identify themselves as experiencing a mental disorder, overcoming societal stigma to seek diagnosis and treatment, and assuming they have the ability to access mental health services through a fragmented and poorly financed system erects barriers to treatment that are likely insurmountable to someone experiencing an untreated mental health problem. Unsurprisingly, these barriers are likely more pronounced for already vulnerable populations such as the elderly and low-income minorities.

There are a lot of benefits to better integration of mental health care into the PCP’s role. The PCP is usually the patient’s first contact with the health care system and an individual is much more likely to know how to access care from a PCP than from an unintegrated mental health system. Patients are often more willing to attend appointments with and follow up with their PCPs because of the removal of stigma from receiving treatment. Other patients may not have meaningful access to a separate or nonintegrated mental health system, either due to financial barriers, long waiting lists, or other barriers.

The most significant problem, in my view, is the expectation that an individual should be able to determine they are experiencing a mental health problem. Given that the majority of PCPs, who have medical degrees and extensive training, fail to identify and diagnose mental health issues, expecting untrained laypeople to do so – while they are experiencing the mental health problem – is beyond absurd. It is even more absurd given that many mental health issues have a physical component. Depression results in fatigue and appetite changes, as does mania. The physical experience of a panic attack is often interpreted as a heart attack. Auditory or visual hallucinations could easily be interpreted as problems with the sensory organs themselves. This is sometimes heightened by an individual’s cultural context, as many Asian cultures describe the experience of depression almost exclusively in physical terms. Expecting an affected individual to untangle the complicated interplay of physical and mental effects and diagnose themselves with a mental health problem prior to seeking treatment is bound to fail.

Another argument in favor of integration is the huge overlap between physical and mental health problems. Estimates of this comorbidity vary wildly, but range somewhere from 20% to 80% of primary care patients (useful data, no?). Having a patient access two separate mental health care systems for their treatment ensures fragmented treatments that may contradict each other and are certainly not coordinated for maximum effect. Better integration would ensure treatments for physical and mental health issues complemented each other and treated the patient as a whole person.

This seems like an uncontroversial and common sense suggestion. It was embraced by the United States Surgeon General in 2001 and by the World Health Organization in 2008, but has seen little progress or momentum since then. Some local treatment systems are taking steps towards integration, such as these trainings done by the British Columbia health system, but there have been few steps towards addressing this issue in the larger health system.

16 Comments

  1. In my experience, PCPs are really not the person to talk to about mental health problems. Most are unsympathetic. Many, even with training, would still be unsympathetic. And most of them are unqualified (at best) to prescribe treatment for a mental illness. While it would be lovely if they could be helpful to folks with mental illness, I don’t see it happening. I would rather PCPs recognize their limitations and send the patient on to a therapist or psychiatrist.

    My therapist was the head of my treatment ‘team.’ She coordinated between my PCP (medical monitoring), my psychiatrist (medication monitoring), nutritionist (weight and diet monitoring) and anyone else who might need to be involved. Since she was the person I saw the most often, it only made sense. PCPs can be helpful, but I don’t think they should be primary in the treatment of a mental illness. They aren’t trained for it and, even if they were, I’m not sure many have the temperament suited for the job. Therapists, psychiatrists and psychologists have that training. Let them lead in the treatment of mental illness.

  2. “Auditory or visual hallucinations could easily be interpreted as problems with the sensory organs themselves.”

    Contrarywise, when at a behaviorial science unit, the first thing physicians think of is ‘mental health issue’ when doing a check on any thing about yourself they might find unusual. Here’s a common one – visual issues do not always equal hallucinations. Instead of being a problem with sensory organs (eyes, ears), it’s your brain interpreting the information oddly (tho not due to a particular mental illness). They really do need to combine the practices, it’s ridiculous.

    Before they combine them, however, I’d like the lot of ’em on both sides to wake the fuck up on what disability is and is not (re:stereotypes).

    Further, how are we supposed to know if we’re physically disabled or neurodiverse? The same ignorant assumptions of “You should know if you have mental health issues” apply there as well. Mental health and physical disability tie into each other, and ….yeah. As far as general practitioners go, most of the people, including myself, don’t have one. I don’t particularly trust the mental health personal I’ve seen – with myself, the great bulk of them have been wildly inaccurate, nay, deliberately obtuse and incompetent. While I like the idea of being able to get mental health issues seen at a general practitioners’, I don’t like the idea of having some schmo diagnose me with something I don’t have, ignore what I – do – have, and have it permanently on my medical record regarding mental health. Again.

  3. That should be “…most of the people I know…”, sorry for the typo.

  4. Am I mistaken in thinking that integration would require all PCPs to undergo training to be able to appropriately diagnose and prescribe treatment for mental health care?

  5. This is a *very* different kind of post from what I’m used to seeing in the US. I’m sure you’ve seen it too – posts & editorials & articles about how, with direct-to-consumer drug advertising, people self-diagnose themselves with ~everything they see on TV, and rush rush to the doctor to get pills. Which the doctor happily dispenses. And so mental illness is overdiagnosed & overtreated etc. etc.
    These consumer patients apparently have no qualms about identifying as mentally ill or sick. Some of the critiques of consumer marketing make it sound like these people are in the wrong, not for being mentally ill, but for seeking treatment for it.

    The perspective offered here is refreshing. I have no doubt that it’s often true too.
    .-= K´s last blog ..Guest Post – 10+ years with vaginismus =-.

  6. “…many Asian cultures describe the experience of depression almost exclusively in physical terms.”

    I’d be very interested to read more about that–could you point me to a source? (I tried a search but apparently I’m not picking good search terms, because I didn’t find anything relevant.)

  7. @millefolia – I’m working from a number of sources, including “Diagnosis in a Multicultural Context,” by Freddy A Paniagua. Here’s some relevant info:

    “In the case of Asian clients, their efforts to prevent others outside the family from knowing about their emotional problems is one of the most significant variables to consider during assessment and treatment. . . Feelings of shame and humiliation and guilt resulting from making mental disorders public may lead to another cultural variable in the assessment and treatment of many Asian clients, namely, their efforts to express symptoms of mental disorder in somatic terms. Therefore, during the initial evaluation, an Asian client would likely spend a great deal of time talking about physical medical complications, such as chest pain, palpitation, nausea, abdominal pain, fatigue, and significant weight loss, but would avoid labeling these symptoms as examples of a given mental disorder. The reason for refusing to attach these symptoms to a mental disorder is that many Asian clients would consider reports about physical symptoms more acceptable in their community than reports about emotional difficulties.” (internal cites omitted.)

    obviously any generalization based on race or ethnicity is inherently an overbroad generalization, but in my work, this has been how Asian clients present their mental health issues more often than not.

    everyone else – training PCPs is one method of ensuring better integration, but not the only one. several organizations have proposed more co-location of mental health professionals in primary care facilities, so doctors can better share information, refer between each other, and provide holistic care. this also reduces the stigma of going to a “mental health care” facility rather than a broader health care facility. which is to say there’s a lot of potential mechanisms for achieving this integration which would hopefully account for some of the issues y’all have raised in comments.

  8. This is interesting to me. My desire has always been to integrate psychiatry and psychology, not psychiatry and primary care. The disconnect between psychiatry and psychology frustrates me; my psychiatrist just goes down a checklist of symptoms every time I see him, the same stuff every time, instead of having an actual conversation. And in general I’ve found psychiatrists are not so great at therapy, and going to them makes me feel like a specimen under a microscope instead of an actual person. So I’ve often wished that there could be some kind of intermediary step, like maybe psychologists could get some kind of certification to prescribe psychiatric meds without having to get an entire medical degree. I understand that there are reasons for not doing so but it’s annoying to have to see two different doctors (one of whom is condescending and impersonal) for what’s essentially the same problem. Not to mention expensive.

    The one time my primary care provider tried to prescribe me psychiatric meds, he got the dosage wrong, and I only knew that because I was familiar with the medication and could tell he wasn’t doing it right. And most doctors nowadays seem (in my experience) to be super busy and don’t take much time to actually listen to a patient because they have to be getting to their next appointment. This doesn’t instill in me a lot of confidence in primary care doctors’ ability to deal with mental health problems.

    I’m sure there are people who have had good experiences with doctors prescribing them psychiatric meds. But until I can get my doctors to actually spend time listening to what I have to say and encouraging me to take an informed role in my physical health, I’m not too eager to let them deal with my mental health as well.

  9. I don’t have a psychiatrist, so my primary care doc prescribes my medication for my mental health issues. She herself isn’t super comfortable with this and always asks me if I’d like to find a psychiatrist, but continues to be willing to prescribe, much to my relief. I do see a psychologist, and while she can’t prescribe meds, she knows what’s going on with my mental health and I myself, after many many years of navigating my mental health issues, am very aware of what’s going on with my meds and how they are working. I haven’t needed a change in mental health meds in about a decade, because I’m one of those lucky few who has actually found the right combo and dosage of meds.

    To me personally, the idea of adding yet one more health care appointment to my schedule seems daunting. I already see two doctors and a therapist on a regular basis, and each appointment is a whole negotiation of setting up transportation and making sure I am rested up enough to make it out of the house that day and then possibly having to cancel and reschedule and I barely make it half the time anyway. If I had to go see a psychiatrist every three months or whatever just for a five minute session for her or him to ask “how is everything working?” and for me to say “still just fine” and that be it (which is what my experience of psych appointments have been unless I am seeking a new diagnosis or the meds aren’t working or are very new), it would be very frustrating.

    I mean, I don’t think I’d trust my primary care doc to switch my meds or dosage around. But I’m comfortable with her continuing to renew the scripts for what I already have. If a change was needed, I’d first talk with my therapist (who is a psychologist) for recommendations and then seek out a psychiatrist if necessary. But I feel very grateful that my primary doc is willing to keep prescribing to me what I already know works without requiring a whole other appointment for me!

  10. @notemily: I’ve found a happy medium. Worked w/ psychiatrist to get decent meds, then my PCP is comfortable refilling them. When something goes wrong, it’s back to the psych.

  11. abby_jean, thank you! That’s exactly the kind of thing I was wondering.

  12. My PCP would *not* write any SSRI prescriptions, and said my insurance wouldn’t let him. Later that day, I went into the psych ward. If he’d been allowed to (he’s not a doctor, he’s a NP or something – my official PCP is a doctor, but he’s just the name of the clinic, I’ve never seen him), I could have avoided the worst experience in my life.

    So imagine my surprise when Dr Ego (a gyn) prescribed an anti-depressant just like that a few months later.

    I know communication among doctors is hard, but I swear, I will sign it, just talk, please! I’d really like a database so my 3 main doctors knew when I changed dosages or started a new medication. But I know HIPAA is more important.

  13. I agree that physical and mental health care should be more integrated, but I also agree to the people who have said PCPs can be icnompetenet at mental health treatment. I myself happen to have had a relatively (1) good experience with a GP trying to help me with my mental disorder, but still I wish I could’ve accessed the mental health center. Also, PCPs are not supposed to handle specialist physical care, either,s o certain mental conditions should remain treated by psychiatirsts/psychologists.

    Also, in the Netherlands, the push for integration between general (medical) hospital psychiatry and segregated mental health services has diminished the quality of the integrative care provided by general hospital psychiatrists.

  14. “Currently, primary care providers (PCPs), also called general practitioners, provide over half of mental health treatment in the United States”

    Just curious – I’m an MFT and core faculty in a graduate program training practitioners – what’s your source for that one? (Glad to see you referencing the Panaigua book – such a great source for multicultural perspectives on diagnosis!)

  15. @SA – i found that in an issue brief from the Bazelon Center for Mental Health Law, which is a great resource – here’s their page on mental health care. in their issue brief on Primary Care Providers’ Role in Mental Health (pdf), they say that “primary care providers now furnish over half of mental health treatment in [the US]” and cite … well, a 1993 paper by D. Reiger, W. Narrow, and D. Rae in the Archives of General Psychiatry, called “The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services.” so … there may very well be some updated data on that!

  16. abby jean – thanks for the reference. Looking at the original source, which is “Archives of General Psychiatry,” I’m going to go out on a limb and say that I bet they’re conceptualizing “mental health treatment” as “medication.” And I wouldn’t be surprised to learn that over half of people on psych meds were getting them from a GP in 1993, though I *would* be surprised if the study distinguished between people who originally worked with a psychiatrist to establish a treatment regimen and then got refills from a (cheaper, more accessible) GP, versus people whose GP was their only prescriber. (And how would one classify a person who says to their GP “Doc, a psychiatrist put me on Wellbutrin and I took it for three years, and have been off it for a few now, but I’m feeling depression symptoms again – can you write me another scrip for it so I don’t have to jump through the managed care hoops?”

    What I am betting is *not* meant by the study is that half of all mental health treatment *including individual, couple, family, and group therapy* is provided by GPs. Because a depressed person might see their GP for 3-5 20-minute visits even if that GP is the primary prescriber, but they might do 8-20 or more hour-long therapy visits. Now, more info on how many people with DSM-IV diagnoses are receiving talk therapy plus meds (which all the outcome lit says is the most effective) versus just meds (cheaper but also less effective) might change my sense of that summary statement, but my first pass through it says “yeah, they’re just talking about the pill portion of treatment.”

    Anyway. 100% agree that GPs need to be better trained to spot symptoms of mental illness, particularly culturally-related expressions like somatization. They also need to be trained to be alert for gender bias (seeing women’s complaints as more psychological and men’s as more physical). I would bet that, much like the stigma and distorted beliefs doctors carry around about fat people that impacts the quality of the care they give, there are also a lot of GPs with distorted beliefs about mental illness that gets in the way of assessment and diagnosis.

    And then they need to be at least passing familiar with the current research on treatment – for example, the evidence that shows that couple and family modalities are extremely effective with “individual” diagnoses like substance abuse, mood disorders, childhood disorders, etc., so they can make appropriate referrals. There is a tendency, exacerbated by managed care, to shove everyone toward CBT and group modalities because they’re fast and cheap, and because providers aren’t aware of new evidence based treatments (Dialectical Behavioral Therapy, Emotionally Focused Therapy, Multi-Systemic Therapy, etc.)

    I sometimes play private mental “games” with doctors. Will this doctor who is prescribing me antibiotics for my sinus infection mention that it will interfere with the effectiveness of my Pill? Will that doctor to whom I’ve described insomnia, fatigue, and low energy ask me questions intended to clarify if my symptoms might be depression? Will another doctor give me clear action steps for follow-up so I know what to do if my condition improves or gets worse? Will yet another mention “diet and exercise” to me because I’m fat without asking me what my food intake is like and how much physical activity I do? Will this one clarify whether my response of being “sexually active” means with men, women, or both?

    The answers usually leave me despairing about what less well-educated, less vocal, less system-savvy, ESL, etc. patients experience. Sometimes I fill out patient response forms or, as in the case of a GP whose “summary of your visit” sheet recommended weight loss and avoiding fried foods when she had not assessed my diet nor had I allowed her staff to weigh me, send along more substantial info aimed at doctor education. Sometimes I just sigh heavily.

    (That doesn’t even begin to address the issue of what quality of care a referred patient can access, which varies wildly by network. I really loved being a member of K****r P********e, because the care was so well-integrated including electronic records and extremely simple referrals, but it was effectively impossible for me to see a mental health provider with the experience and training I needed, since one region in which I lived relied almost exclusively on group therapy treatment (how will a client with a PhD in a mental health field fare in that setting, I wonder?) and the other relies almost exclusively on pre-licensure interns. But that’s another arm of the problem.)