Despite success in collaboration, PCPs have struggled in treating the mental health in both adults and adolescents as many doubt their own abilities to treat these patients. In a survey led by Danielle Loeb, MD, of the Division of General Internal Medicine at the University of Colorado, researchers examined PCP confidence in treating these patients. Because PCPs treat more than half of all patients with mental illness, a PCP’s confidence in their own ability to diagnose, treat, and provide referrals to specialists is crucial in establishing communication between disparate health care providers, such as psychiatrists or therapists, which creates a team-based approach treating to mental illness.
Loeb designed a series of 3 self-efficacy surveys to evaluate PCP's beliefs about their ability to adopt the role of providing primary care for patients with mental illness, and found that many of the 402 PCPs surveyed harbored doubts about their ability to effectively treat patients with mental illness, and those doubts may negatively affect their interest in establishing team-based care regimens for those patients.
Additionally, a recent study led by Stéphane Saillant, MD, chief-medical for Emergency Psychiatry and Liaison Psychiatry Services at the Neuchatel Center of Psychiatry in Switzerland, member of the Swiss Medical Association’s Federation of Psychiatry-Psychotherapy, shed light on the collaborative approach between PCPs and psychiatric care providers.
Saillant and colleagues retrospectively analyzed 182 reports of psychiatric evaluations conducted between October 2010 and August 2012 in the Primary Care Service of the Geneva University Hospitals. They carried out a set of 4 focus-group discussions with 23 physicians-in-training intended to “explore their experience and perceptions of the joint consultations,” according to the study.
They found that joint consultations were helpful for both patients and health care providers. The researchers pointed out that prior to experiencing joint consultations many physician respondents, who reported that 43.6% of their patients suffered from mental health problems, they perceived difficulties in caring for these patients.
“In order to help doctors, they need to know the mental health professionals to begin with, which is often not the case,” Saillant told MD Magazine. “Psychiatrists must also focus efforts to popularize their activities and work.”
Data revealed that on a scale of 1 to 7 (1 = no difficulty, 7 = very difficult) physicians reported that they did face difficulties in caring for their patients with mental health problems (mean = 4.5, SD = 1.1). Saillant reported that in all 4 of the focus groups physician participants “talked about mental health problems as not part of their area of competence” and that many physician participants reported feeling overwhelmed by, unprepared for, and incapable to respond to patients’ mental health problems.
In spite of that, they discovered that with 68.7% of the 182 patients receiving joint consultations, “the PCP’s initial diagnostic impression” of the patient’s disorder was confirmed. Post joint consultation, 59.9% of patients were returned to PCP care with “no additional input from a psychiatrist” required.
Emily Wood, PhD, with the University of Sheffield in the United Kingdom, who led a 2017 study reviewing PCP treatment of depression with a focus on the barriers to collaborative care, told MD Magazine® that PCP burnout is a concern for those treating patients with mental illnesses.
“Conditions like depression can make a consultation quite lengthy and when you are time pressured, it can seem easier to focus just on diabetes, for example,” Wood said. “Many professionals see depression as the proverbial ‘can of worms’ that they would rather not open.”
Wood and colleagues did a systematic review of 18 studies, which revealed that often a lack of “readiness” for change on an organizational, cultural, or daily practice level was the largest barrier to implementation of collaborative care.
“A huge issue remains the problem that many do not see mental health care as equally important as physical health care,” Wood said. “This is a problem for organizations and the way they are funded but also for some individual PCPs. However, numerous studies have found that presence of depression worsens outcomes for comorbid physical health conditions. Ignoring the depression makes treating the physical health condition harder.”
Many steps are being taken to address this ongoing issue of mental health care in primary care environments, such as changes to the World Health Organization’s (WHO) International Classification of Diseases (ICD-11) regarding mental health and primary care and an examination of the improvements collaborative care can have on adolescent mental health.
ICD-11 FOCUS ON MENTAL HEALTH IN PRIMARY CARE
Although changes to the ICD-11 cover a wide range of diseases, there has been a dramatic shift in the section on Mental and Behavioral Disorders in an effort to address a “mental health gap,” wherein patients suffering from mental health disorders remain diagnosed, but untreated in primary care settings. This led to the creation an additional version of the ICD-11 Mental and Behavioral Disorders section explicitly for use by primary health care providers in clinical settings.
A WHO working group of primary care physicians and mental health professionals is focused on increasing the utility of the ICD-11 for mental health diagnoses and guidance in connection with clinical use in primary care settings. Researchers field-testing the revised PCP-focused tools have reported positive outcomes to clinical tests of screening scales and tools based on the proposed ICD-11 changes to mental disorder classifications.
Wolfgang Gaebel, MD, president of the European Psychiatry Association; Jürgen Zielasek, Dr Med, senior physician at the Clinic and Polyclinic for Psychiatry and Psychotherapy at Heinrich-Heine-University in Düsseldorf, Germany; and Geoffery M. Reed, MD, PhD, senior project officer, Revision of ICD-10 Mental Health and Behavioral Disorders at the World Health Organization in Geneva, Switzerland; published an overview of some of the major changes in the WHO ICD-11 related to mental health.
The group wrote that the ICD-11 is intended as a “freely available and open global resource, usable as a tool for clinical practitioners, researchers, patients, administrators, policy makers, and governments” to ease the clinical burden of identifying, and treating mental health disorders worldwide, stressing the importance of PCP involvement in lifting the global mental health care burden.
In an editorial for Salud Mental, Reed, with colleague Rebeca Robles Garcia, PhD, wrote that “due to the significant treatment gap for mental disorders, as well as the shortage of mental health professionals around the world, it has been proposed that the identification and management of common mental disorders needs to be carried out in primary care settings.”
The revision of ICD-11 for PCP includes what Reed and Robles Garcia stated are the “27 mental disorders considered to be most clinically relevant in these [primary care] settings, either because they are common (such as depression) and/or because it is important that they are recognized by first-contact health care providers.”
Diagnostic tools and screening mechanisms, treatment models, and techniques, and evidence-based guidelines provided in the ICD-11 for PCPs are “specifically designed for implementation in primary care settings” and can “make an important contribution to the development of the capacity of primary care professionals to be more involved in the management of the mental health problems experienced by their patient.”
David P. Goldberg, DM, of the Institute of Psychiatry, Psychology and Neuroscience in London, was chosen to lead the WHO working group focused on mental health and primary care, currently conducting clinical field studies using proposed ICD-11 diagnostic guidelines.
A series of studies, led by Goldberg, have been released in 2017 testing new/revised screening scales, training, and tools based on ICD-11 reclassifications of mental disorders, including 2 that tested a series of screening tools for anxiety, depression, and anxious depression for use by PCPs.
Goldberg told MD Magazine® that he felt the revised classification of mental disorders for PCPs in the ICD-11 may help patients get the care they need. Through training and reclassification, PCPs can improve how they address and diagnose patient symptoms, increase their understanding of the links between psychological and physiological disorders, and improve detection of mental disorders overall.
Goldberg said that the 2 “brief scales for anxiety and depression worked very well, administered by the PCPs themselves.” The screening scales successfully predicted diagnoses with 90% sensitivity and 88.5% specificity, creating a tool that Goldberg and colleagues agree can potentially fill a great need in PCPs for “feasible and accurate screening procedures for depression and anxiety.”
The proposed changes for ICD-11 provide explanations for multiple somatic symptoms across multiple body systems and guide PCPs treatment of patients suffering from such disorders. Goldberg said that he believes the new designations will dissuade PCPs from using the potentially harmful “all in your head” approach to patients exhibiting somatic symptoms.
COLLABORATIVE EFFORTS IMPROVE ADOLESCENT MENTAL HEALTH
According to 2 other examinations, adolescent mental health care can be improved by integration of mental and behavioral health care into primary care settings. The first, done by Laura P. Richardson, MP, MPH, with Seattle Children's Research Institute and the University of Washington's Department of Pediatrics, and co-authors from the University of Pittsburgh and University of California Berkeley, was a systematic review of to identify barriers to integrating mental and behavioral health into primary care.
The second, a review of clinical and preventative services for adolescents, including those affecting mental and behavioral health, reviewed system-level and clinical visit-level strategies to enhance access to preventative care, was conducted by Sion Kim Harris, PhD, of Boston Children's Hospital and Harvard Medical School, and colleagues in the United States and Chile.
Richardson and colleagues pointed out that although an estimated 20% of adolescents and young adults face mental and behavioral health disorders, mental and behavioral health concerns for adolescents often go untreated.
Both studies agreed that more can be done in primary care settings to screen and treat mental and behavioral health for adolescents and young adults, and to identify similar barriers inhibiting optimal preventative health.
“Mental and behavioral health concerns are actually the most salient and frequent health issues that adolescents tend to face,” Harris told MD Magazine®. “In order to have a general health care delivery system that is responsive to adolescents' primary health needs, we need providers and systems that have the knowledge, skills, and structures/ processes to offer adolescents accessible, appropriate, and respectful mental and behavioral health services.”
Richardson’s study assessed a series of 17 studies focusing on collaborative care in 3 primary forms: coordinated care between primary care providers (PCPs) and advisory community-based behavioral specialists; integrated care involving shared treatment plans between PCPs and behavioral specialists; and co-located care comprising medical and behavioral services in the same setting to ease communication efforts and referrals.
The analysis of studies using collaborative care found that all of the studies illustrated the successes of collaborative care for mental and physical health in adolescent patients. However, Richardson and colleagues noted there remains a gap in research on and use of these treatment models in adolescent health care as opposed to adult health care, and the majority of the studies examined were focused on substance use among young adults in college settings.
“There are additional barriers that relate to concerns about mental health confidentiality, which limits communication between mental health and medical providers and medical provider lack of training or comfort in managing behavioral health issues,” Richardson told MD Magazine®. “Additionally, mental health professionals are less likely to be present in medical clinics than other types of providers that primary care providers might collaborate with such as nurses or social workers to provide collaborative treatment for medical conditions.”
A final barrier, according to Richardson, has to do with exposure to effective collaborative models. She said “many providers have not had exposure to collaborative care, and so it is a bit of a black box to them. They don’t know what it can or should look like.”
Harris, similarly, pointed out some barriers to effective care for adolescents centered on PCP delivery of preventative services, including a “lack of knowledge or confusion about guidelines or available tools, lack of time, low self-efficacy (ie, belief by the clinician that he/she can deliver the recommended services), low outcome expectancy (ie, belief that the delivery of services will lead to the desired outcome), and/or lack of motivation to change practice.”
The researchers noted that integrated screening tools that work with extant electronic medical record systems, collaborative support, and “appropriate clinician training” show “particular promise in addressing these barriers.”
“We have found in our research at Boston Children's Hospital that if we give PCPs practical and feasible tools that help them provide these recommended services while overcoming the barriers they face, they really do change their practice, and adolescents actually give higher satisfaction ratings,” Harris said.
Richardson and colleagues agreed that because of the critical role adolescent and young adult care plays in lifelong health behaviors, care management and psychiatric supervision for adolescents must be prioritized, and new avenues of effective care, such as collaborative care models, should be explored based on the observed effectiveness of those care models.