Mental Health Problems in Primary Care: Progress in North America
Kathryn M. Magruder, M.P.H., Ph.D.*,**; Derik E. Yeager, M.B.S.**
* Mental Health Service, Veterans Affairs Medical Center, 109 Bee Street, Charleston, SC 29401-5799
** Department of Psychiatry and Behavioral Sciences and Department of Biostatistics,
Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425. USA
ABSTRACT
Background and Objectives: Research in the last decade has acknowledged that primary care plays a pivotal role in the delivery of mental health services. The aim of this paper is to review major accomplishments, emerging trends, and continuing gaps concerning mental health problems in primary care in North America.
Methods: Literature from North America was reviewed and synthesized.
Results: Major accomplishments include: the development and adoption of a number of clinical guidelines specifically for mental health conditions in primary care, the acceptance of the chronic care model as a framework for treating depression in primary care, and the clear adoption of pharmacologic approaches as the predominant mode for treating depression and anxiety. Emerging trends include: the use of non-physician facilitators as care managers in the treatment of depression in primary care, increasing use of technology in the assessment and treatment of mental health conditions in primary care, and dissemination and implementation of integrated mental health treatment approaches. Lingering issues include: the difficulty in moving beyond problem identification and initiation of treatment to sustaining evidence-based treatments, agreement on a common metric to evaluate outcomes, and the stigma still associated with mental illness.
Conclusion: Though there now exists a solid and growing evidence base for the delivery of mental health services in primary care, there are still significant challenges which must be overcome in order to make further advances.
Key words: Mental Health, Primary health Care, United States.
The last decade has seen considerable progress in North America in both practice and research regarding mental health problems in primary care. This is evident in a number of evidence-based practice patterns that have been implemented and that reflect an integrated approach to providing mental health care in the primary care setting. As well, there are emerging trends which build on this increasingly solid evidence base. Despite significant gains, there are still some issues which should be resolved in order for the most patients to receive the full benefit of treating mental health problems in primary care. This paper summarizes the accomplishments of the past decade, emerging trends which will likely be influential in the provision of care in the coming decade, and lingering challenges.
]]>Major Accomplishments
Important milestones in the past decade are reflected in a number of ways, but can be summarized by a few major accomplishments and trends. In general, these areas reflect consolidation and vetting of considerable research evidence. Major successes have been with screening and treatment initiation.
Illustrative of this are the screening recommendations by the United States Preventive Health Task Force1. These recommendations are largely oriented to the prevention of common primary care medical conditions and are "graded" based on the quality of supporting research evidence. In the 1996 2nd edition of the Guide to Clinical Preventive Services, six mental health conditions were considered (dementia, depression, suicide risk, family violence, problem drinking, and drug abuse); problem drinking was the only condition with a recommendation for screening. As of this writing, only depression has been added to the list, based largely on new studies that demonstrate treatment effectiveness in primary care2,3; nevertheless, this addition reflects advances in research and a major shift in thinking from prior editions and presages recommendations for other mental conditions in primary care (e.g., post-traumatic stress disorder, or PTSD).
There are now several clinical practice guidelines, based on research evidence and expert consensus, which have been developed specifically for mental health problems in primary care. These include VA/DoD guidelines for the assessment and treatment of major depression (MDD), PTSD, and substance use disorders4, as well as AHCPR/AHRQ guidelines for MDD5 and attention deficit/hyperactivity disorder6,7. The development of these guidelines and their growing acceptance demonstrate that it is possible to address effectively some common mental health conditions in primary care.
Another clear advance has been the development and acceptance of the chronic care model8,9. Borne out of concern that traditional primary care is more oriented to acute illness and that a major overhaul of primary care is necessary in order to respond to chronic illness (which constitutes the major focus of primary care practice), the chronic care model (and its variations) has focused on six inter-related aspects of primary care: self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources. It has proven to be a good structure for improving treatment of depression. This multi-faceted approach, with heavy emphasis on specialty collaboration, patient education, self-monitoring, and frequent follow-up (by trained nurses) as adjunctive components to pharmacologic treatment, has been successful in multiple venues10,11. The success of this model is largely due to the fact that depression is approached similarly to other chronic illnesses for which primary care providers have responsibility, and the system is designed to support chronic disease management. This model has helped to integrate successfully depression treatment strategies in primary care settings.
In the last decade, pharmacologic treatment of has become the norm for treatment of depression12. Given the ease with which these medications can be prescribed (low abuse potential, few side effects, easy dosing schedules), antidepressant use in primary care has dramatically increased from 2.6% of visits in 1989 to 7.1% of visits in 200013. This has driven an increase in rates of treatment for depression -- particularly in the general medical sector where rates of treatment were 2.59 times higher between 1990-92 and 2001-0314. Because the primary care sector is so large, the increase in treatment rates translates into an overall population increase in treatment and access to care. Primary care providers are thus diagnosing a higher percentage of their caseload with a mental disorder15. Trends are similar for the treatment of attention deficit/hyperactivity disorder (ADHD)16.
Emerging Trends
With the consolidation of therapeutic evidence and primary care organizational and delivery models, a major challenge is expeditious implementation. Cross-training nurses and other health professionals using technology-assisted screening, diagnosis, and follow-up tools, and using the internet in therapy and follow-up are some of the trends that are apt to take hold in the coming decade.
]]> Technological advances have improved the way medical professionals retrieve information (electronic medical records, hand-held computers) while also improving interaction and communication with patients (telephones, cellular telephones, email, and internet) for the purpose of screening, diagnosing, and monitoring mental health disorders. As patients and providers become more comfortable with these technologies, and the research base builds demonstrating at least equivalent effectiveness compared to "usual" operations, we can expect to see increased use of such technologies in the management of mental health problems in primary care. For example, electronic medical records can provide easy access to comprehensive medical notes as well as feedback and treatment options for clinicians. Feedback such as clinical reminders and treatment recommendations can be generated offsite or delivered immediately in the form of computer-generated treatment prompts in order to improve initial management of depression in primary care17.More use of the telephone to conduct initial mental health screens as well as treatment follow-up can prove efficient as well as expand treatment options for those who live in rural areas or do not have access to computers or web-based assessments and/or treatments. While the use of this technology in other areas of health care is well established18, its application in the area of mental health is burgeoning. See, for example, the study by Simon et al.19, which showed improved depression outcomes following a telephone-delivered protocol that included feedback coupled with care management, that by Hunkeler et al. 20 which demonstrated improvement in depression with nurse tele-health care and peer support, and that by Dietrich et al.21 which showed improved treatment response with supervised telephone support.
Many screeners and diagnostic assessments, such as the Primary Care Evaluation of Mental Disorder or PRIME-MD22, 23, that have been developed specifically for use in primary care settings have since been adapted for computer-administration. Other, more recent tools, such as the Drug Abuse Problem Assessment for Primary Care or DAPA-PC24, were designed specifically to be administered via computer. While currently popular in the areas of depression and substance abuse, the audience for assessment tools is expanding for a number of reasons, including: convenience, privacy, high patient satisfaction23, decreased provider time, improved validity and reliability25, and decreased expense. As patients become more familiar with inputting medical information on computers, this technology may eventually replace standard mental health assessment practice.
Even more exciting is the use of the Internet as both a supplemental and an independent treatment modality. Web-based behavioral treatment is gaining favor among practitioners26 and may benefit patients who may not otherwise seek or receive treatment27. The efficacy of using the Internet as a self-management tool for military veterans in primary care with PTSD is currently under investigation in a randomized trial funded by the National Institute of Mental Health28 and the Department of Defense (study number not yet assigned). Given the current utility of the Internet as a tool for providing evidence-based treatment for depression29 and PTSD30,31 and the fact that it is one of the first places that many people turn to learn about symptoms and health conditions, it is likely to emerge as a dominant health care trend in future decades.
While the integration of technology into primary care has the potential to improve quality of care for mental health conditions, technology alone is insufficient. The use of trained nurses or psychologists as care managers to augment medical therapeutics has been shown to be effective in terms of depressive symptomotology32-34. Given the time involved in patient education and follow-up, such individuals will almost certainly be a part of any primary care team that expects to manage mental health problems successfully and efficiently.
Several large scale studies have demonstrated that it is feasible to disseminate depression management programs into primary care practice with resultant improved outcomes21,32-34. Sustainability and implementation under non-research conditions may prove more difficult, as these programs typically increase costs of care35. Combining such programs with technological innovations (e.g., computerized screening, telephone follow-up) as is currently being done with the Translating Initiatives for Depression into Effective Solutions program36 of the U.S. Veterans Administration may help to improve the cost to benefit ratio. Furthermore, as technology improves (as well as patient and provider comfort levels), we can expect to see better integration of technology into depression care management packages with resultant cost reductions.
Challenges
Despite the gains made in the past decade, there are still some hurdles to overcome. A challenge for researchers is to develop a better system for benchmarking mental health outcomes in primary care. The National Committee for Quality Assurance (NCQA) uses the Health Plan Employer Data and Information Set (HEDIS) as a set of standardized performance measures to provide performance information on managed health care plans to consumers and purchasers37. This widely respected system currently relies on process measures (e.g., presence, duration, and dosing of anti-depressant prescription; number and timing of follow-up visits), whereas in other areas of medicine it is possible to measure medical outcomes (e.g., blood pressure, HgA1c). Thus, a major challenge for this field is to agree on a measure that reflects outcomes that have been tied to successful interventions.
While improvements have been made in rates of treatment of mental health problems in primary care14, a persistent challenge remains the number of patients in primary care with mental disorders who do not receive treatment. Approximately 50% of those who could benefit from treatment still go untreated38,39, and even fewer receive adequate treatment39. The reasons are multi-factorial, including: stigma40,41, inadequate systems to support treatment decisions11, inadequate mental health benefits42, and inadequate training of providers for long-term treatment43.
]]>Conclusion
Significant gains in treating mental health problems in primary care have been primarily in the areas of screening and treatment initiation. While effective structures have been developed to support effective mental health treatment in primary care, their widespread implementation and adoption may be hindered by cost issues. As technological advances gain acceptance, we can expect reduced costs and increased integration of treatment approaches while potentially reducing stigma. As treatments and technology continue to improve, we can expect considerable advances in the treatment of mental health problems in primary care.
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Address for correspondence: Received 16 January 2007
Accepted 14 March 2007