Why It's Essential to Integrate Behavioral Health and Primary Care

Why It's Essential to Integrate Behavioral Health and Primary Care

There is a lot to be gained by integrating behavioral health treatment into medical settings. We know that illnesses tend to be highly overlapped. In fact, more than two thirds of mental health patients also need other medical treatment as well. Given that the illnesses are combined, so should our care. The returns on improving patient lives are significant. 

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Models of Telemental Health

Models of Telemental Health

Telemental health services are delivered in a range of settings to patients with varying degrees of mental illness. Whether it be hospitals, assisted living homes, primary care physician offices or even patient homes, telemental health services can be integrated into most, if not all, clinical practice systems. Aside from clinical settings, patients can access care right from their homes with direct to consumer platforms that function as virtual provider offices. 

The following is a description of two types of telemental healthcare: the clinic-clinic model and the clinic-home model.

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Bipolar Disorder in Primary Care

bipolar disorder in primary care

We know from conversations with many of the primary care practices we serve that the Bipolar Disorders (BP) are among the psychiatric conditions for which primary care clinicians often seek psychiatric support. The table to the right presents data from the National Institutes of Health regarding prevalence of BP in the general population. 

Drilling down a bit, research also indicates that prevalence of BP in a primary care patient panel may be somewhat higher than in the general population (somewhere between .5 - 4.3% across studies), suggesting that in a patient panel of about 2,200 unique patients, as many as 108 of them might benefit from treatment for BP (Cerimele, et al. 2014).

Also, and probably of particular note, is the finding that many patients with BP report symptoms to their primary care providers that might well lead to a different diagnosis and to (probably ineffective) treatment of a different psychiatric condition. For example, Chiu, et al., (2011) found that among patients in primary care settings who reported past or current symptoms of depression, anxiety, substance abuse or attention deficit disorder, 27.9% screened positive for BP on a standardized and validated screening measure.

Data like those suggest the considerable importance - in terms of accurate diagnosis and guideline-concordant treatment - of screening, decision support, and psychiatric involvement for patients with known or suspected BP in the primary care setting, or for patients who report symptoms of other psychiatric conditions which don't seem to quite fit your sense of the patient. For a look at a validated and widely used screen for Bipolar Disorder, click this link to the Mood Disorders Questionnaire (MDQ)

Contact us for information regarding how to bring our psychiatrists and psychologists into your organization.

An Epidemic of Patient Non-Compliance

Since the early '90's it's been thought that a majority of patients who are prescribed antidepressant medications fail to take them as directed. HEDIS data from that time suggested that only about 48% of patients prescribed medication were still taking it at six weeks, and only about 21% were still taking it at 12 weeks.

There is a widely held belief that there is better compliance with selective serotonin reuptake inhibitors (SSRIs) as compared with tricyclic antidepressants because of their faster onset of therapeutic action, greater efficacy, and better tolerance. To test that theory, researchers conducted a multi-center, randomized, parallel-group, open-label comparison of dothiepin (a Tricyclic) and fluoxetine (a SSRI) and compared compliance across the two groups.

As shown in the table below, seventy six percent of the fluoxetine patients (N=58) and 64% of dothiepin patients (N=49) were compliant with treatment at or above the 80% level over the 12-week study - a significantly greater degree of compliance for the SSRI group. These data represent a more precise estimate of compliance than do HEDIS data. They are suggestive of an overall higher level of antidepressant medication adherence than previously thought, with a compliance advantage for the SSRI's. 

However, to my eye, the more interesting aspect of this study is the finding that between one-quarter and one-third of patients who were prescribed antidepressant medication stop taking it during the first three months of treatment.

As Yogi Berra famously said, "If people are determined to stay away from the ballpark, you just can't make them." Twelve weeks or fewer is too short a time frame to treat depression effectively and prevent its recurrence.

Data such as these are particularly disappointing since it is well established that more than 80% of patients with depression can be treated effectively when there is treatment adherence.  Over 70% of prescriptions of antidepressant medications in the U.S. are written by primary care practitioners. And when treatment is consistent with best practice guidelines, that is good all the way around.

However, for the one-quarter to one-third of patients who don't comply with treatment recommendations, or for those patients who don't show a significant treatment response within six weeks, referral to a 1DocWay psychiatrist or psychologist can be essential to engaging patient compliance or modifying treatment strategy.

Contact us to learn more about how 1DocWay telepsychiatry and telepsychology can help improve patient compliance.

Mental Health Concerns in Primary Care Settings: More Frequent than You Think

A substantial number of patients seen by a primary care physician (PCP) each day come into the office with significant psychiatric or psychological concerns - either as the primary reason for the visit or co-existing with other medical conditions.

A study conducted by the Centers for Disease Control and Prevention indicated a large proportion of PCP visits (20.4%) are directly related behavioral health. In fact, the likelihood of patients having mental health related issues escalates as patients age. Patients who are 75 or above are 25.3% more likely to present mental health related issues than patients who are under 12.

Some behavioral health conditions are relatively easier to diagnose than are others. Some can be readily addressed in primary care while others lie out of primary care physicians’ areas of expertise. Some can be solved within the time constraints of the typical PCP schedule, while others cannot.

Telepsychiatry services are provided to relieve the burden of the primary care physicians. Videoconferencing equipment brings psychiatrists and psychologists into clinics to treat patients who might have behavioral health conditions that are difficult to diagnose or treat in a timely manner.

THE TABLE ABOVE SHOWS THE PROPORTIONS OF PRIMARY CARE VISITS THAT HAVE A SIGNIFICANT BEHAVIORAL HEALTH COMPONENT ACROSS AGE GROUPS, AND REFLECTS THE PROGRESSIVE INCREASE IN THAT PROPORTION AS PATIENTS GROW OLDER. 

THE TABLE ABOVE SHOWS THE PROPORTIONS OF PRIMARY CARE VISITS THAT HAVE A SIGNIFICANT BEHAVIORAL HEALTH COMPONENT ACROSS AGE GROUPS, AND REFLECTS THE PROGRESSIVE INCREASE IN THAT PROPORTION AS PATIENTS GROW OLDER. 

If you work in a primary care setting it is important to bear in mind that anywhere from one in ten to almost one in three patients you see in your clinic on a daily basis might benefit from referral for behavioral health services. Telepsychiatry technology is an optimal way to bring that behavioral health service into your clinic, where your patients will be most comfortable receiving it, and to integrate it with your overall medical management of your patients.

Anxiety Disorders are Underdiagnosed and Undertreated in Primary Care

As with depression, the rate of undetected or undertreated anxiety in primary care is substantial. The twelve month prevalence of anxiety disorders in the general community is 19.3%, and is several fold greater in primary care settings (1).

In a three site investigation of university-affiliated primary care practices, researchers found that only 33% of patients diagnosed with anxiety had received any counseling for the condition, and only 25% had received counseling from a mental health professional (the remaining 8% had been counseled by the primary care team only).

Further, only about 10% of these patients received counseling that included multiple elements of cognitive behavioral therapy, the recommended best counseling practice for anxiety disorders. Finally, only 40% of those thus diagnosed received appropriate anti-anxiety medication, and only 25% received those medications at minimally adequate dosage and duration (2).

Of particular note is that these indicia of under-diagnosis and under-treatment of anxiety disorders were found in the primary care practices of university health systems known for their leadership in the area of behavioral health and primary care integration.

Also as with depression, undiagnosed or under-treated anxiety increases patients' utilization of health care services, increases diagnostic testing and hospitalization, consumes large amounts of PCP time, increases misuse of alcohol and prescription and street drugs, and compromises management of co-existing chronic illnesses like diabetes, CHF and COPD (3).

Abundant data point the way to effective management of psychiatric illness in primary care, and to integration of the two disciplines. The remaining challenge - and it is substantial - is translational: Getting what we know from the research setting embedded more firmly and generally in the world of day to day practice. For decision support regarding diagnosis and treatment of the various anxiety disorders, visit the Anxiety Disorders Guideline area of the Federal Agency for Healthcare Research and Quality (AHRQ - Anxiety Guidelines).

(1) Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H-U, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8–19 (2) Stein, MB, Sherbourne, CD, Craske, MG, Means-Christiensen, A, Bystrinsky, A., Katon, W, Sullivan, G, Roy-Byrne, P: Quality of care for primary care patients with anxiety disorders. The American Journal of Psychiatry 2004; 161(12), 2230-2237. (3) Roy-Byrne PP, Stein MB, Russo J, Mercier E, Thomas R, McQuaid JR, Katon WJ, Craske MG, Bystritsky A, Sherbourne CD: Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. J Clin Psychiatry 1999; 60:492–499