Psychiatrists Team Up With Primary Care Docs to Reach More Rural Patients
Abstract
Psychiatrists at Marshall University work closely with primary care residents, empowering them to provide basic mental health care to their patients.
Stephen Petrany, M.D., has seen the repercussions of poor access to mental health care in West Virginia firsthand. “I can’t tell you how many times over the years I’ve gotten a call on a Friday night from somebody who has decided they want to take their life, and there was nobody to turn to,” said Petrany, a professor and chair of the Department of Family Medicine at Marshall Health in Huntington, West Virginia.
West Virginia is the only state located entirely within the Appalachian region, an area with disproportionately higher rates of common mental disorders compared with the rest of the United States, according to APA’s fact sheet on the mental health disparities of Appalachian people.
In this hall of Marshall Health’s Family Medicine Unit, psychiatrists provide care to patients and educate family medicine residents.
According to a 2018 report by the University of Michigan School of Public Health Behavioral Health Workforce Research Center, West Virginia had the tenth lowest number of psychiatrists in the country. Many people in rural areas seek mental health care through their primary care doctors, but most residents in primary care specialties receive little training in diagnosing and treating mental disorders.
To help alleviate the problem in West Virginia and the surrounding areas, psychiatrists at Marshall Health and Marshall University’s Joan C. Edwards School of Medicine have emphasized integrating and collaborating with primary care providers to share their expertise in treating people with mental disorders.
“There’s no way psychiatrists alone could ever meet the need,” said Kelly Melvin, M.D., an associate professor of psychiatry at Marshall’s School of Medicine. “The research tells us that anywhere from 10% to up to 40% of primary care visits have, as the primary complaint, a mental health issue. That’s huge. That’s almost half your day, yet you have so few tools in your toolbox.”
Combining Forces With Family Medicine
Adam Schindzielorz, M.D., an assistant professor of psychiatry at Marshall, sits at a station in Marshall Health’s Family Medicine Unit. Nothing would indicate that he isn’t another family medicine physician, or that he’s actually running a half-day clinic once a week to help patients with their mental health needs.
Providing Collaborative Care in Nursing Homes
Suzanne Holroyd, M.D., a professor and chair of the Department of Psychiatry and Behavioral Medicine and residency program director at Marshall University, has taken collaborative psychiatric care out of the clinic.
Holroyd is the program director for Marshall University’s Geriatric Psychiatry Fellowship Program, which allows her to get back to one of her favorite treatment settings: nursing homes.
Numerous studies have shown that about 80% of patients in nursing homes have a diagnosable psychiatric illness, she said, oftentimes dementia or depression. But they often don’t get the treatment they need.
“What I’ve learned over the years of working in the nursing home is that it’s one of the most rewarding places to work,” she said. The difference before and after the psychiatry team enters the nursing home is amazing, she said. Before, patients may be sitting in their wheelchairs, staring down at the floor for hours at a time. But after, they’re smiling, dancing, holding hands, and the staff is happy, too. Incidents of violence occur less frequently, as well, she said.
“Surprisingly, we often remove more medicines than we add,” she said. “Because primary care doesn’t have that psychiatric background, they don’t really know what to do when people are screaming and hitting, so they just go to medicines that are sedating.”
The psychiatric team removes those sedating medications and instead treats disorders like depression or bipolar disorder.
The program is still young and has recently expanded into a state nursing home, which is often where the severely mentally ill are transferred when they cannot get accepted into a private nursing home.
“I think the reason I love geriatrics is because of how much the patients change,” she said. Family members often assume that their loved one’s negative behavior is just a result of aging. “I’ve had patients who were diagnosed with dementia who were just overmedicated. We peeled off those medications and found there was a human in there,” she said. “It’s incredibly rewarding work.”
Four years ago, Melvin and his colleagues launched the Department of Psychiatry’s half-day clinic in the Department of Family Medicine so psychiatrists could see patients alongside family medicine residents. The goal was to help residents learn how to competently manage patients with common mental conditions on their own, better understand how and when to refer patients to a psychiatrist, and gain a firmer understanding of how to help patients navigate mental health systems of care, Melvin said.
And offering it in the same space as other family medicine services not only helps patients who may be wary of seeing a psychiatrist feel more comfortable, it also allows for easy communication and coordination between psychiatry and family medicine.
Over the years the clinic has changed slightly in how it operates, and it is currently run by Schindzielorz. Typically, after he reviews the patient’s case, he meets with the resident to talk about interview techniques and what the resident has or has not asked the patient. Once the resident has seen the patient, Schindzielorz will then discuss the assessment and treatment with the patient. “It’s been very successful so far,” he said.
“Appalachia has a dearth of access to care,” Schindzielorz said, and primary care practitioners have the necessary knowledge to treat a lot of patients’ mental health needs. Integrated care, especially in an academic environment, empowers primary care residents to treat these patients as well.
“As a family doctor, more than half of my patients come in with psychosocial behavioral issues,” Petrany said. “It’s very important that our family medicine residents graduate with the skills they need to address psychosocial behavioral issues, which are very commonly presented in the primary care setting.
“Just having Adam [Schindzielorz] here on Monday afternoons makes me sleep easier,” Petrany said.
Spreading Psychiatric Knowledge
Marshall University’s Joan C. Edwards School of Medicine’s mission statement specifies that the school focuses on rural health. That’s one reason collaborative care between psychiatrists and other primary care physicians is so important at the school. By ensuring that psychiatrists spend time in other departments, such as family medicine, oncology, and pediatrics, not only do patients have greater access to mental health care, but residents can also carry that knowledge into the rural settings where they may eventually work.
Marshall’s Department of Psychiatry is working to establish more clinics with a model similar to that used in family medicine. Currently, other departments use different models, such as co-locating psychiatrists in the oncology clinics to coordinate care. Such a setup encourages easy access to mental health care for patients and allows coordination between physicians, but it does not have the same emphasis on teaching, Melvin explained.
In the oncology clinic, Scott Murphy, M.D., assistant professor of psychiatry, sees patients who are referred to him. Often, these patients have already seen the psychologist who works in the unit, but they may need medications in addition to therapy to help with their depressive symptoms.
“Sometimes, because it’s oncology, they’re seeing symptoms that they don’t quite know what to make of,” Murphy said. Cancer treatment, and cancer itself, is complicated, and many factors can potentially cause psychotic symptoms or issues with speech in patients, for example. “That’s why it’s really nice to give a solid mental status exam and do some cognitive evaluation to differentiate: is it steroids, is it chemotherapy, is it a brain tumor?”
Hillary Porter, D.O., an assistant professor triple-boarded in psychiatry, pediatrics, and child and adolescent psychiatry, works with residents in the Pediatrics Department to address their patients’ psychiatric needs.
She helps residents feel comfortable tackling patients’ mental health challenges on their own and only referring patients for additional evaluations if they require a higher level of care. “It’s opened up the opportunity for us to teach the pediatric residents what we feel they should be or could be responsible for,” she said.
Empowering Primary Care Physicians
For Marshall’s psychiatrists, spending time with primary care physicians can feel especially rewarding. Over time, they have seen residents and attendings take the initiative to make basic decisions about psychiatric treatment for their patients, without feeling the need to consult with a psychiatrist first. “It’s really nice to see them becoming comfortable doing it,” Porter said.
Sometimes, she continued, primary care physicians simply don’t know what questions to ask their patients or how to explain a diagnosis. “I then try to empower them to have those conversations with their patients,” she said.
Medical students are often taught that basically every field of medicine will involve treating patients with common mental health disorders, said Suzanne Holroyd, M.D., a professor and chair of the Department of Psychiatry and Behavioral Medicine and residency program director at Marshall University. “But they kind of skate through psychiatry in medical school,” she continued. “I think that’s part of the excitement for them when they learn from our psychiatrists. They’re finally getting their specialty’s version of what they can do to help their patients.”
Integrated care gives primary care physicians a lexicon, Schindzielorz said. “There’s a lot of concern, anxiety, and frustration when dealing with these chronic patients and nothing seems to work and you don’t know what steps to take,” he said. “Then, all of a sudden, when you have tools that start to make sense, a lot of the anxiety is dispelled.”
Once, Porter spoke with a pediatrician who said that half of his day involves addressing his patients’ mental health concerns. “And they get 15 minutes per appointment, at best,” she said. “I can’t imagine taking my day and shoving that into a half day, and then throwing in some well-child checks and vaccinations. That’s not conducive to good mental health. If they’re feeling more confident and a little more empowered, maybe that 15 minutes will feel like it’s much more useful.”
That’s one of the advantages of incorporating integrated care into an academic setting, Melvin explained. There are a lot of different models of integrated care, and they provide a lot of advantages, such as improving access for patients, reducing stigma, and eliminating the need for multiple trips to several physicians. “But, in this type of setting, it’s that teaching and cross education that happens, which I think is one of the most positive effects,” he said.
“The number one category of illness causing disability worldwide isn’t heart disease, stroke, or lung disease. It’s mental health [disorders] and addiction,” he continued. “We have to break out of these silos and work alongside primary care providers. That’s the only way we’re going to be able to meet that need.” ■
