Beyond parity: primary care physicians' perspectives on access to mental health care

Screening for depression in the primary care population

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.

Value-based financially sustainable behavioral health components in patient-centered medical homes

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

Acceptance of insurance by psychiatrists and the implications for access to mental health care

IMPORTANCE

There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.

OBJECTIVE

To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties.

DESIGN, SETTING, AND PARTICIPANTS

We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not.

MAIN OUTCOMES AND MEASURES

Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings (2005-2006, 2007-2008, and 2009-2010).

RESULTS

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006. Psychiatrists' Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).

CONCLUSIONS AND RELEVANCE

Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.

Primary care providers' initial treatment decisions and antidepressant prescribing for adolescent depression

OBJECTIVE

Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. This study examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network.

METHODS

A cross-sectional survey was administered to 58 PCPs within a large pediatric practice network. PCP reports of initial treatment decisions were compared in response to 2 vignettes describing depressed adolescents with either moderate or severe symptoms. PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics were measured.

RESULTS

Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (odds ratio [OR], 5.50; 95% confidence interval [CI], 2.47-12.2] p < .001). Depression severity did not affect the likelihood of antidepressant recommendation (OR, 1.58 [95% CI, 0.80-3.11] p = .19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR, 1.72 [95% CI, 1.14-2.59] p = .009) and access to an on-site mental health provider (OR, 5.13 [95% CI, 1.24-21.2] p = .02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR, 0.85 [95% CI, 0.75-0.98] p = .02).

CONCLUSION

PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs' antidepressant prescribing.

Behavioral health referrals and treatment initiation rates in integrated primary care: a Collaborative Care Research Network study

Although the benefits of integrating behavioral health (BH) services into primary care are well established (World Health Organization and World Organization of Family Doctors, 2012; Chiles et al. in Clin Psychol-Sci Pr 6:204-220, 1999; Cummings 1997; O'Donohue et al. 2003; Olfson et al. in Health Aff 18:79-93, 1999; Katon et al. in Ann Intern Med 124:917-925, 2001; Simon et al. in Arch Gen Psychiatry 52:850-856, 1995; Anderson et al. in Diabetes Care 24:1069-1078, 2001; Ciechanowski et al. in Arch Intern Med 160:3278-3285, 2000; Egede et al. in Diabetes Care 25:464-470, 2002), research has focused primarily on describing the types of interventions behavioral health providers (BHPs) employ rather than on reasons for referral, treatment initiation rates, or the patient characteristics that may impact them. This study presents the results of a multisite card study organized by The Collaborative Care Research Network, a subnetwork of the American Academy of Family Physicians' National Research Network devoted to conducting practice-based research focused on the provision of BH and health behavior services within primary care practices. The goals of the study included: (1) identifying the characteristics of patients referred for BH services; (2) codifying reasons for referral and whether patients were treated for the referral; (3) exploring any differences between patients who initiated BH contact and those who did not; and (4) assessing the types and frequency of BH services provided to patients who attended at least one appointment. Of the 200 patients referred to a BHP, 81 % had an initial contact, 71 % of which occurred on the same day. Men and women were equally likely to engage with a BHP although the time between appointments varied by gender. Depression and anxiety were the primary reasons for referral. Practice-based research is a viable strategy for advancing the knowledge about integrated primary care.

Mental health, substance abuse, and health behavior intervention as part of the patient-centered medical home: a case study

Currently integrating mental health, substance abuse, and health behavior into Patient-Centered Medical Homes (PCMH) is being advocated with increasing frequency. There are no current reports describing efforts to accomplish this. A theory-based project was developed to integrate mental health, substance abuse, and health behavior services into the fabric and culture of an NCQA-certified level-three PCMH using funding from the Vermont legislature. A mixed methods case report of data from the first 34 months reviews planning, development, implementation, care model, information technology (IT), and data collection, and reports results using the elements of a RE-AIM framework. Early accomplishment of most RE-AIM dimensions is observed. Implementation remains a struggle, specifically the questions of role responsibilities, form, and financing. This effort is a successful pilot implementation of the Primary Care Behavioral Health (PCBH) model in the PCMH with the potential for dissemination toward additional implementation and a model for a comparative effectiveness trial.

Out-of-network provider use more likely in mental health than general health care among privately insured

OBJECTIVE

Previous research has shown relatively high use of out-of-network mental health providers, although direct comparisons with rates among general health providers are not available. We aimed to (1) estimate the proportion of privately insured adults using an out-of-network mental health provider in the past 12 months; (2) compare rates of out-of-network mental health provider use with out-of-network general medical use; (3) determine reasons for out-of-network mental health care use.

METHODS

A nationally representative sample of privately insured US adults was surveyed using the internet in February 2011. Screener questions identified if the participant had used either a general medical physician or a mental health professional within the past 12 months. Respondents using either type of out-of-network provider completed a 10-minute survey on details of their out-of-network care experiences.

RESULTS

Eighteen percent of individuals who used a mental health provider reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider (P<0.01). The most common reasons for choosing an out-of-network mental health provider were the physician was recommended (26.1%), continuity with a previously known provider (23.7%), and the perceived skill of the provider (19.3%).

CONCLUSIONS

Out-of-network provider use is more likely in mental health care than general health care. Most respondents chose an out-of-network mental health provider based on perceived provider quality or continuing care with a previously known provider rather than issues related to the availability of an in-network provider, convenient location, or appointment wait time.

Prevention of postpartum traumatic stress in mothers with preterm infants: manual development and evaluation

Premature birth has been associated with multiple adverse maternal psychological outcomes that include depression, anxiety, and trauma as well as adverse effects on maternal coping ability and parenting style. Infants who are premature are more likely to have poorer cognitive and developmental functioning and, thus, may be harder to parent, both as infants and as they get older. In response to these findings, a number of educational and behavioral interventions have been developed that target maternal psychological functioning, parenting, and aspects of the parent-infant relationship. The current study aimed to both develop and evaluate a treatment that integrates, for the first time, effective interventions for reducing symptoms of posttraumatic stress disorder (PTSD) and enhancing maternal-infant interactions. Conclusions from the study indicate that the intervention is feasible, able to be implemented with a high level of fidelity, and is rated as highly satisfactory by participants. Though encouraging, these findings are preliminary, and future studies should strive to reproduce these findings with a larger sample size and a comparison group.

Mental health collaborative care and its role in primary care settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

A needs-based method for estimating the behavioral health staff needs of community health centers

BACKGROUND

Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed.

METHODS

Using health center staffing data and behavioral health service patterns from the 2010 Uniform Data System and the 2010 National Survey on Drug Use and Health, we estimated the number of patients likely to need behavioral health care by insurance type, the number of visits likely needed by health center patients annually, and the number of full time equivalent providers needed to serve them.

RESULTS

More than 2.5 million patients, 12 or older, with mild or moderate mental illness, and more than 357,000 with substance abuse disorders, may have gone without needed behavioral health services in 2010. This level of need would have required more than 11,600 full time providers. This translates to approximately 0.9 licensed mental health provider FTE, 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider per 2,500 patients. These estimates suggest that 90% of current centers could not access mental health services or provide substance abuse services to fully meet patients' needs in 2010. If needs are similar after health center expansion, more than 27,000 full time behavioral health providers will be needed to serve 40 million medical patients, and grantees will need to increase behavioral health staff more than four-fold.

CONCLUSIONS

More behavioral health is seen in primary care than in any other setting, and health center clients have greater behavioral health needs than typical primary care patients. Most health centers needed additional behavioral health services in 2010, and this need will be magnified to serve 40 million patients. Further testing of these workforce models are needed, but the degree of current underservice suggests that we cannot wait to move on closing the gap.

Rethinking the mental health treatment skills of primary care staff: a framework for training and research

Health care reforms may offer several opportunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are organized on three levels: cross-cutting skills to build therapeutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This framework is intended to help inform future mental health training in primary care and catalyze research that examines the impact of such training.

Delivering psychiatric services in primary-care setting

Psychiatric disorders, particularly depression and anxiety disorders, are common in primary-care settings, though often overlooked or untreated. Depression and anxiety disorders are associated with a poorer course for and complications from common chronic diseases such as diabetes mellitus and coronary heart disease. Integrating psychiatric services into primary-care settings can improve recognition and treatment of psychiatric disorders for large populations of patients. Numerous research studies demonstrate associations between improved recognition and treatment of psychiatric disorders and improved courses of psychiatric disorders, but also with improvements in other chronic diseases such as diabetes. The evidence bases supporting the use of 2 models of integrated care, colocation of psychiatric care and collaborative care, are reviewed. These models' uses in specific populations are also discussed.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

Primary care prescribing psychologists in the Indian Health Service

Some of the largest health care disparities are those related to services for American Indians and Alaska Natives (AI/ANs), who show significantly greater prevalence for diabetes, coronary heart disease, smoking, obesity, heavy alcohol use, depression, and PTSD than the general population. Given the recognition of the behavioral components of all of these conditions, the Indian Health Service, the federal agency responsible for providing comprehensive health care services to AI/ANs, has been focusing on increasing the integration of behavior health and primary care. One innovation has been to hire prescribing psychologists on primary care teams. This paper describes the role of a prescribing psychologist on three treatment teams at an IHS facility in Montana. Prescribing psychologists in the Indian Health Service can serve as valuable members of comprehensive care teams, providing exceptional wrap-around care for some of our most vulnerable and underserved citizens. This model could be an example of how a prescribing psychologist could contribute to primary care clinics in a variety of other settings.

Functional roles and foundational characteristics of psychologists in integrated primary care

Psychologists are presented with unprecedented opportunities to integrate their work in primary care settings. Although some roles of psychologists in primary care overlap with those in traditional psychology practice settings, a number are distinct reflecting the uniqueness of the primary care culture. In this paper, we first describe the integrated primary care setting, with a focus on those settings that have components of patient centered medical home. We then describe functional roles and foundational characteristics of psychologists in integrated primary care. The description of functional roles emphasizes the diversity of roles performed. The foundational characteristics identified are those that we consider the 'primary care ethic,' or core characteristics of psychologists that serve as the basis for the various functional roles in integrated primary care. The 'primary care ethic' includes attitudes, values, knowledge, and abilities that are essential to the psychologist being a valued, effective, and productive primary care team member.

Effective group training for patients with unexplained physical symptoms: a randomized controlled trial with a non-randomized one-year follow-up

BACKGROUND

Although cognitive-behavioral therapy for Unexplained Physical Symptoms (UPS) is effective in secondary care, studies done in primary care produced implementation problems and conflicting results. We evaluated the effectiveness of a cognitive-behavioral group training tailored to primary care patients and provided by a secondary community mental-health service reaching out into primary care.

METHODOLOGY/PRINCIPAL FINDINGS

The effectiveness of this training was explored in a randomized controlled trial. In this trial, 162 patients with UPS classified as undifferentiated somatoform disorder or as chronic pain disorder were randomized either to the training or a waiting list. Both lasted 13 weeks. The preservation of the training's effect was analyzed in non-randomized follow-ups, for which the waiting group started the training after the waiting period. All patients attended the training were followed-up after three months and again after one year. The primary outcomes were the physical and the mental summary scales of the SF-36. Secondary outcomes were the other SF-36-scales and the SCL-90-R. The courses of the training's effects in the randomized controlled trial and the follow-ups were analyzed with linear mixed modeling. In the randomized controlled trial, the training had a significantly positive effect on the quality of life in the physical domain (Cohen's d = 0.38;p = .002), but this overall effect was not found in the mental domain. Regarding the secondary outcomes, the training resulted in reporting an improved physical (Cohen's d = 0.43;p = 0.01), emotional (Cohen's d = 0.44;p = 0.01), and social (Cohen's d = 0.36;p = 0.01) functioning, less pain and better functioning despite pain (Cohen's d = 0.51;p = <0.001), less physical symptoms (Cohen's d = -.23;p = 0.05) and less sleep difficulties (Cohen's d = -0.25;p = 0.04) than time in the waiting group. During the non-randomized follow-ups, there were no relapses.

CONCLUSIONS/SIGNIFICANCE

The cognitive-behavioral group training tailored for UPS in primary care and provided by an outreaching secondary mental-health service appears to be effective and to broaden the accessibility of treatment for UPS.

TRIAL REGISTRATION

TrialRegister.nl NTR1609

Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups

PURPOSE. To examine variations in depression care and outcomes among high-risk pregnant and parenting women from different racial/ethnic groups served in community health centres.

METHODS

As part of a collaborative care programme that provides depression treatment in primary care clinics for high-risk mothers, 661 women with probable depression (Patient Health Questionnaire-9 ≥ 10), who self-reported race/ethnicity as Latina (n = 393), White (n = 126), Black (n = 75) or Asian (n = 67), were included in the study. Primary outcomes include quality of depression care and improvement in depression. A Cox proportional hazard model adjusting for sociodemographic and clinical characteristics was used to examine time to treatment response.

RESULTS

We observed significant differences in both depression processes and outcomes across ethnic groups. After adjusting for other variables, Blacks were found to be significantly less likely to improve than Latinas [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.44-0.65]. Other factors significantly associated with depression improvement were pregnancy (HR: 1.52, 95% CI: 1.27-1.82), number of clinic visits (HR: 1.26, 95% CI: 1.17-1.36) and phone contacts (HR: 1.45, 95% CI: 1.32-1.60) by the care manager in the first month of treatment. After controlling for depression severity, having suicidal thoughts at baseline was significantly associated with a decreased likelihood of depression improvement (HR: 0.75, 95% CI: 0.67-0.83).

CONCLUSIONS

In this racially and ethnically diverse sample of pregnant and parenting women treated for depression in primary care, the intensity of care management was positively associated with improved depression. There was also appreciable variation in depression outcomes between Latina and Black patients.

Diagnostic inflation: causes and a suggested cure

There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.

Strategies to improve the management of depression in primary care

Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

Quality improvement with pay-for-performance incentives in integrated behavioral health care

OBJECTIVES

We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics.

METHODS

We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization.

RESULTS

Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation.

CONCLUSIONS

Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.

General practitioners' management of mental disorders: a rewarding practice with considerable obstacles

Background

Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.

Methods

This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.

Results

At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.

Conclusions

To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

National trends in mental health disability, 1997-2009

OBJECTIVES

I assessed recent trends in mental health disability in the US nonelderly adult population in the context of trends in physical disabilities and psychological distress.

METHODS

Using data for 312 364 adults aged 18 to 64 years from the US National Health Interview Survey, 1997 to 2009, I examined time trends in self-reported disability attributed to mental health conditions, disability attributed to other chronic problems, and significant psychological distress (measured by using the K6 instrument).

RESULTS

The prevalence of self-reported mental health disability increased from 2.0% of the nonelderly adult population in the first 3 years (1997 to 1999) to 2.7% in the last 3 years (2007 to 2009), corresponding to an increase of almost 2 million disabled adults. Disability attributed to other chronic conditions decreased and significant psychological distress did not change appreciably. Change in self-reported mental health disability was more pronounced in adults who also reported disability attributed to other chronic conditions or significant psychological distress but who had no mental health contacts in the past year.

CONCLUSIONS

These findings highlight the need for improved access to mental health services in the community and for better integration of these services with primary care.

Distinguishing symptoms of ADHD from other psychiatric disorders in the adult primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.

Psychiatry and primary care integration: challenges and opportunities

Health systems across the world remain significantly fragmented, affecting access, quality and costs of the care delivered. Strengthening health systems is a global health challenge for all countries: low, middle and high income. According to the World Health Organization the key components of a well functioning health system, namely, leadership and governance, health information systems, health financing, human resources for health, essential medical products and technologies, and services delivery are sine qua non for health systems functioning and strengthening (WHO, 2010). Psychiatry and primary care integration are contributions the house of medicine can make to address fragmentation, access, quality and costs.

Access to mental health care among older adults

Many older adults experience common mental health problems that can have a negative impact on physiological health, functional status, and quality of life. Lack of access to mental health care for community-dwelling older adults is a significant problem. Busy primary care practices, few mental health professionals, inadequate problem recognition, and flaws in the health care system all contribute to restricted access to mental health care. As the population of adults 65 and older continues to grow, the need for mental health care for this group will increase. Strategies to improve access to mental health care must be targeted at the individual level, the provider level, and the system level.

Assault and mental disorders: a cross-sectional study of urban adult primary care patients

OBJECTIVE

This study estimated the strength of associations between self-reported assault and psychiatric disorders among low-income, urban primary care patients who were predominantly female.

METHODS

A sample of adult patients who consecutively presented at an urban primary care practice completed the Life Events Checklist (N=1,157). They were also screened for current major depression, panic disorder, generalized anxiety disorder, and substance use disorders with the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire; for bipolar disorder with the Mood Disorder Questionnaire; and for posttraumatic stress disorder (PTSD) with the PTSD Checklist-Civilian Version. A total of 977 of the respondents reported whether they had ever experienced an assault. Logistic regression was used to model associations between self-reported assault and screen status, controlling for relevant sociodemographic and clinical characteristics.

RESULTS

Twenty-five percent of study participants endorsed a history of physical or sexual assault. Compared with patients without a history of assault, patients with a history of assault had significantly greater odds of screening positive for PTSD (odds ratio [OR]=1.97, 95% confidence interval [CI]=1.19-3.25), alcohol use disorder (OR=2.17, CI=1.07-4.41), and drug use disorder (OR=3.38, CI=1.14-9.98).

CONCLUSION

A history of assault was related to risk of screening positive for PTSD and a substance use disorder. These findings support assessment of trauma history among low-income primary care patients.

Physician identification and management of psychosocial problems in primary care

Often the burden of identifying children with behavioral or developmental problems is left up to the primary care physician (PCP). However, previous literature shows that PCPs consistently underidentify children with developmental/behavioral problems in pediatric primary care. For the current study, questionnaires containing three vignettes followed by questions addressing common psychosocial problems, general questions about their practice and training, and the Physician Belief Scale were distributed to physicians. Results indicated that physicians were better at identifying severe problems, had more difficulty identifying psychosocial problems with mild symptomatology, and tended to refer to a medical specialist or mental health professional more often for severe problems, depression or a developmental problem. Physicians tended to view treating psychosocial problems favorably.

Barriers to physical and mental condition integrated service delivery

OBJECTIVE

To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression.

METHODS

We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs.

RESULTS

All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services.

CONCLUSIONS

Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

The inextricable nature of mental and physical health: implications for integrative care

There is growing evidence that physical health problems are caused and exacerbated by psychological factors. Research indicates that psychological distress leads to physical disease through impairment of the neuroendocrine system and its interface with the body's immune response. However, the current health care delivery system splinters care into "psychiatric" and "physical" health silos. New approaches are needed to assure adequate professional knowledge of behavioral health at basic licensure, to increase the use of advanced practice psychiatric-mental health nurses in primary care settings, to identify and teach behavioral competencies for primary care providers, and to fund the design and evaluation of integrative models of care.

Ethical issues in perinatal mental health research

PURPOSE OF REVIEW

To review the background of current ethical standards for the conduct of perinatal mental health research and describe the ethical challenges in this research domain.

RECENT FINDINGS

Current literature reflects a growing sentiment in the scientific community that having no information regarding the impact of psychiatric treatment on the mother and developing fetus/infant poses dangers that may exceed the risks involved in research. However, without sufficient consensus across the scientific community, both regulatory bodies and perinatal researchers find themselves without a framework for decision making that satisfactorily limits the risks and facilitates the benefits of participation of pregnant and lactating women in clinical research.

SUMMARY

Psychiatric research in perinatal mental health is critically important as it enables clinicians and patients to participate in informed decision-making concerning treatment for psychiatric disorders. Specific areas of concern include fetal safety, maternal risk, the therapeutic misconception, commercial interests, forensic/legal issues, the informed consent process, and study design. Developing guidelines that address ethical challenges and include the views and concerns of multiple stakeholders could improve the access of perinatal women to the benefits of participation in mental health research in addition to providing evidence-based mental healthcare for this subpopulation.