Psychiatrists and mental health professionals in the Department of Veterans Affairs (VA) touted the value of integrating primary care and mental health services at a recent meeting.
The occasion was the Third National Primary Care/Mental Health Conference, which was sponsored by the National Center for Post-Traumatic Stress Disorder of the Department of Veterans Affairs in Washington, D.C., on October 7 and 8. The center promotes research into the causes and diagnosis of posttraumatic stress disorder (PTSD), with a focus on education and consultation.
VA Undersecretary for Health Robert H. Roswell, M.D., set the tone for the meeting in his keynote address, saying, "[It] is vitally important to create systems that address the ‘whole patient’—the mind, the body—in a coordinated, systematic way."
The VA has data, he pointed out, that show that when primary care services are integrated with mental health services, clinical outcomes and patient satisfaction are improved.
Roswell said, "The VA ranks well among the few organizations committed to implementing and testing truly integrated primary care/mental health models of care."
Integration of services is particularly important for patients with PTSD because, according to Roswell, "PTSD is the most common undetected anxiety disorder in primary care that has a major adverse impact on illness severity, chronicity, medical utilization, and increased overall costs to the medical system."
Research from the National Center for PTSD shows that high users of primary care services are twice as likely to have PTSD as low service users.
Mary Schohn, Ph.D., presented data linking diagnoses frequently made in primary care settings with mental disorders. She is the chief clinical officer of the Behavioral Health Care Line of Veterans Integrated Service Network (VISN) 2. (VISNs are regional health care networks that were created in 1996 as a result of PL 104-262, which promoted deinstitutionalization.)
Schohn said that individuals with diabetes, for example, are twice as likely as nondiabetics to be clinically depressed.
In cardiology patients, comorbid depression appears to be the best predictor of cardiac events during the 12 months following the diagnosis of cardiac problems.
She reported that 35 percent to 40 percent of veterans in a VA primary care setting have a diagnosis of depression, PTSD, or alcohol-related disorder.
Scott Murray, Ph.D., director of the Behavioral Health Care Line, described the model of integrated care implemented in VISN 2.
Mental health care staff, which includes psychiatric nurse practitioners, psychologists, and social workers, are assigned to all primary care teams. Psychiatrists are allocated as needed.
The staff help the primary care provider identify mental health problems, serve as gatekeepers for referrals, provide brief psychotherapy interventions, and offer wellness groups.
Murray reported that use of the General Health Questionnaire, a 12-item, self-administered screening test, has resulted in a 10 percent increase in the number of patients identified in the primary care setting as needing mental health services.
VISN 2 staff developed disease-management programs in PTSD, substance abuse, hypertension, diabetes, and chronic pain.
As a result of the integration of services, the number of patients seen in mental health clinics decreased, and the number of patients seen in "lifestyle groups," such as those living with chronic illness, increased.
Kirk Strosahl, Ph.D., spoke about adapting integrated care into VA primary care settings based on his experience with health care organizations around the country. He is director of research and training for the Mountainview Consulting Group in Moxee, Wash.
Strosahl expanded on his comments in an interview with Psychiatric News.
"The primary care system has become the de facto mental health system," he said. Managed care and other factors have reduced the availability of mental health services. The result is that more patients with mental health disorders are seeking care for physical symptoms from primary care physicians.
"By the time they receive any kind of medical attention, those disorders often have become severe," Strosahl said. He added that primary care physicians frequently have neither the time nor training to treat the disorders adequately.
He advocates an integrated model in which a team manages patient treatment. The mental health care team member provides consultation and training to the physician, engages in short-term co-management of mental health problems, and provides patient education.
The treatment approach encourages patients to develop responsibility for their own education and care.
Strosahl hopes that federal efforts will promote integration of care. In addition to the VA, the Air Force and the Department of Health and Human Services (HHS) are advocating integrated-care models. HHS’s Bureau of Primary Health Care is implementing an initiative to integrate behavioral health care services in 90 percent of its community health centers within five years. ▪
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