Mental Health Services in General Health Care A Conference Report, Volume I (1979) / Chapter Skim
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IV. Summaries of Major Presentations
IV. Summaries of Major Presentations
Pages 41-120
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From page 41... ...
primary care settings. But we know that much of the variance in reported rates is directly related to differences in research methodology We will examine some of the effects of methodology on prevalence rates, citing study results from the literature in which single prevalence measures are usually used, as well as results from some recent NIMH-sponsored studies in which multiple measures were used within and across sites e Results from the latter studies, which permit person-based and visit-based rates to be compared, will also be reviewed.
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From page 42... ...
2/ While this estimate is relatively crude, it does provide a general framework for understanding the scope of the problem. Regarding the division of responsibility in the current service system for the care of those with mental disorders, as shown in Figure 1, we have identified some 21 percent in the specialty mental health sector, another 54 percent as being seen only in the outpatient primary care sector (pith 6 percent specialty overlap)
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From page 43... ...
3/ studies of four ___ between 1.3 and ~ Figure 2 shows some of the prevalence rate ranges in primary care settings, grouped by case identification method. Starting with the person-based, more epidemiologically oriented studies, the first method of case identification is routine reporting of mental disorder diagnoses on clinical records of general practitioners.
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From page 44... ...
11/ Similarly, in their recently completed study in Marshfield, Wisconsin, Hoeper, et al, using the SADS-L standardized psychiatric interview, reported some 26.7 percent of patients identified with an RDC diagnosis of mental disorder. 5/ The final method of case identification is patient self-report on psychiatric symptom questionnaires.
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From page 45... ...
These settings included the Bunker Hill Health Center in Boston, the Columbia Health Plan in Columbia, Maryland, and the Marshfield Clinic, which has both a fee-for-service and prepaid practice program. The rates across settings ranged from .4 to 4 percent of visits.
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From page 46... ...
2 1.8 Fee For Service 6.5 3.6 1.8 Bunker Hill Health Center 6.4 3.2 2.0
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From page 47... ...
Thus, results from the Marshfield study, in which multiple case identification techniques were used in one site, confirm the methoddependent effects noted earlier across many studies and sites: relatively low rates when GP reporting is used, and relatively high rates when self-reports of standardized psychiatric interviews are used. Elucidating precisely the prevalence of mental disorders in primary care practice is but one of the important research tasks required to guide future policy and program development.
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From page 48... ...
48 identification which includes elements of symptom questionnaires in routine history taking; and more detailed structured interviews which can be used when there is doubt about diagnosis or treatment. In short, a combination of descriptive, analytic, and methodolo gically oriented studies is needed to improve understanding of the mental health service role of primary care providers, to aid them in carrying out that role, and to guide the informed development of services policy related to that role.
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From page 49... ...
London, Oxford University Press, 1966. Locke, B.Z., Gardner, E.P.: Psychiatric disorders among the patients of general practitioners and internists.
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From page 50... ...
Jacobson, A.M., Leet, R., Goldner, N.: 14. Burns, B.J., Orso, C., Utilization of Health and Mental Health Outpatient Services in Organized Medical Settings: Final Report, Bunker Hill Health Center of Massachusetts General Hospital, 1978.
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From page 51... ...
Research Psychologist, Primary Care Research Section, Applied Biometrics Research Branch, Division of Biometry and Epidemiology, National Institute of Mental Health Rockville, Maryland Efforts to provide more closely integrated health and mental health services particularly within primary care settings have taken a number of forms in community and neighborhood health centers and health maintenance organizations. A current Federal emphasis encourages closer ties between existing neighborhood or community health centers (CHCs)
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From page 52... ...
Frequent communication between the BHHC and the CMHC developed around coordination of specialized services including those for CMHC inpatients, and the mental retardation and children's programs. Within the neighborhood health center, there was active interaction between general health and mental health providers.
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From page 53... ...
Collaborative research Formal communication among providers Multi-problem families with health and mental health problems are frequently presented Open intake system by mental health service Health provider requests for advice on managment of patients Medical records, various task forces Series on alcoholism, child development, infant-parent relationships Modeling assessment approaches for health providers Pre-school screening, obesity group, medication clinic Pediatric nurses counseling adolescent mothers meet with psychiatrist regularly A pediatrician attends the child mental health intake meeting A study of internists' patterns for prescribing tranquilizers
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From page 54... ...
First, accessibility and acceptability of mental health services delivered by both health providers and specialty mental health providers within BHHC were demonstrated. During 1975, 15.7 percent of Health Center patients received a provider-reported diagnosis of mental disorder, a high rate as compared with other studies of routine recording of mental disorder by providers.
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From page 55... ...
Frustrated with the length of mental health treatment for chronic mental illness and long-term psychosocial problems, some health providers felt that mental health providers should spend less time with patients and be more authoritative and directive. In later years, as a result of both organizational growth and decreased grant support, other issues developed.
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From page 56... ...
Although the Bunker Hill Health Center may not be typical of community or neighborhood health centers with respect to the extensive integration of its outpatient health and mental health services, or the level and complexity of linkages influencing the health/mental health interface, at least some of the following recommendations which emerged for this experience should be applicable to other settings and populations: A scarcity of mental health resources, a high level of need for mental health services within a general medical population, and the availability of new resources combine to make a health/ mental health effort feasible. As in all organizational or programmatic innovations, the support of strong leadership, and sanction by the boards (of directors or trustees)
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From page 57... ...
Initial clarity of the agreements for fiscal support of the mental health services can provide some "assurance" that as the health center mission evolves, mechanisms for supporting mental health services in a health care system will also continue to evolve. Physical proximity alone (co-location)
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From page 58... ...
New England Journal of Medicine 295:140145, 1976. Burns, B.J., Orso, C.L., Jacobson, A.M., et al: Utilization of health and mental health outpatient services in organized medical care settings: Bunker Hill Health Center of the Massachusetts General Hospital.
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From page 59... ...
The requirements necessary for the provision of adequate mental health services in a primary care setting are adequate training for the provider, allotment of significant time to provide the service, and~appropriate remuneration for the time spent and the quality of service offered. In my case, the subsequent training after pediatrics residency and my Air Force tour of duty consisted of a one-year fellowship, entitled "The Psychiatric Aspects of Pediatrics," with Dr.
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From page 60... ...
In the near future, we may consider hiring a psychiatric social worker who has considerable experience in medical and school settings as an addition to our staff. An active approach to mental health delivery in the primary care setting begins with the first well child visits.
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From page 61... ...
We often have done rather extensive workups prior to referral sometimes out of necessity, when the family was unwilling to accept such a workup in any other setting. The feedback to us is that, in comparison with the typical referrals from primary care settings where such screening is omitted, the patients we refer appear to be more appropriate cases, are better motivated, and are more likely to follow through on recommended therapies.
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From page 62... ...
Most parents, when presented with the need for this type of care and the possibility that their health insurance will pay for at least part of it, report ignorance of the coverage and even ignorance about how to obtain appropriate information. Unfortunately, these results seem to vary only slightly when the family itself or an employer is responsible for the premiums.
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From page 63... ...
It has been our impression that mental health services are most appropriately offered in a primary care setting. The requirements to make this a viable option are attitude and training of the provider, appropriate scheduling, and adequate remuneration.
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From page 65... ...
We have found that 72% of our patients with emotional problems are cared for by primary physicians alone, and are not seen by mental health personnel. The organizational model for mental health services at CHCP recognizes and supports the key role of primary physicians as mental health providers by including mental health clinicians as members of the primary care team.
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From page 66... ...
The CHOP program in psychiatry is thus oriented to the human problems of patients under the care of primary physicians, as well as to patients referred to mental health clinicians for specialized care. Mental health problems require the resources of many professional groups within the health field as well as in other social support agencies.
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From page 67... ...
At CHCP, most of the non-medical mental health clinicians are psychiatric social workers, but we have included a clinical psychologist on one team in medicine and a psychiatric nurse practitioner on another. We have found that professional differences become less important than the functional similarities shaped by similar job demands.
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From page 68... ...
This gets worked on over time with the development of mutual understanding between primary care and mental health providers of each other's capabilities and limitations, and understanding which may get sorely tried in unusual cases, and which is constantly retested and renewed. The ratio between primary care and mental health caseloads is important.
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From page 69... ...
The mental health program at CHCP attempts to bridge the gap between the two approaches to the care of patients with emotional problems.
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From page 70... ...
. ~ ~ Social work in a pediatric primary health care team In a group practice program.
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From page 71... ...
Are they really interchangeable? When given a choice, patients prefer not to be referred to specialized mental health and specifically psychiatric services, even within the HMO system.
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From page 72... ...
Coleman, but I am concerned that the assumptions that underlie that organization have not been tested, perhaps because they satisfy economic considerations. The economic considerations are necessary, but alone are not sufficient to establish the guidelines by which the most efficient and efficacious mental health services may be provided to subscribers.
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From page 73... ...
The latter clearly provides more promise in terms of improving family practice training ~ , , _ ~ O (The full text of Dr. Goldberg's paper appears in Section VII.)
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From page 75... ...
In addition, psychiatric illness is related to patient distress, functional level, and overall medical utilization. SETTING The study was conducted in Marshfield, a central Wisconsin town of 17,000.
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From page 76... ...
4/ RESULTS Table 1 displays the prevalence of psychiatric disorder as measured by three different criteria. Utilizing the SADS-L as the criteria for mental disorder, the weighted estimate of the prevalence of RDC psychiatric disorder in the adult primary care population was 26.7%.
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From page 77... ...
FREQUENCY, AVERAGI: (~IQ, AND AVERAGE GAS BY THE MOS T PREVALENT RDC DIAGNOSIS IN THE WEIGHTED SAMPLE RDC Diagno si s Frequency* Percent Mean (;HQ Mean GAS Major Depression 14 5.8 11.9 62.3 Minor Depression 8 3.4 6.0 73.4 Intermittent Depression 12 5.0 5.1 71.
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From page 78... ...
3. There is an overall increase of medical utilization in the adult primary care population who have a RDC psychiatric illness.
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From page 79... ...
Review of the charts of the RDC identified patients in our study indicated that as Houpt, et al, 1/ described, some had psychiatric disorder only, some had a coexistent medical and psychiatric illness, and some had lifestyle patterns of behavior which either related to the onset of the illness or complicated treatment; that is, non-compliance with therapeutic regimens. Many were also experiencing social and environmental stressors _/ at study entry.
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From page 80... ...
Since 1965 numerous English 16/,17/ and United States _/,15/,17/,18/,19/ studies have demonstrated the_ _ _ consistency of the finding of greater ambulatory medical utilization by persons with diagnosed psychiatric disorder than persons without diagnosed psychiatric disorder. In this study, when identification by RDC for psychiatric illness is utilized, this differential in medical utilization holds true.
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From page 81... ...
Should providers focus their therapeutic efforts on distress or dysfunction or a combination of the two? Finally, evaluation procedures need to use scales which measure functional level, distress, and deviant behavior so that therapeutic outcomes can be measured.
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From page 82... ...
4. Hoeper, EW, Nycz OR, Cleary PD: Final Report NIMH Contract Number: DBE-77-0071, The quality of mental health services in an organized primary health care setting.
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From page 83... ...
14. Hoeper, EW, Nycz, GR, Wenzel, FJ: Impact of mental disorder on medical utilization.
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From page 85... ...
(The full text of Dr. Hankin's paper appears in Section VII.)
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From page 87... ...
Department of Preventive Medicine Rush-Presbyterian -- St. Lukes Medical Center Chicago, Illinois I think that I have, in fact, very little to tell you that will be new to you about the epidemiology of suicide or the need for a preventive role on the part of the primary care physician.
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From page 88... ...
Recently bereaved females had a mean age of 54, but there was an interesting bimodal distribution with an older group in the 60 to 75 year age range. We classified those of "stable marital status," whether single or married, and those
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From page 89... ...
|., We went on therefore to look at a group across both the above who were "recently bereaved." Nineteen of the first group, those of stable status, and 33 of the those of altered marital status, 52 deaths in all, were recently bereaved; out of our total of 250, onefifth of all. If you look at the causes given, less than half were associated with bereavement by death.
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From page 90... ...
The recently bereaved did not differ from other groups in relation either to suicidal threat or suicidal attempt, although suicidal threat occurred three times more frequently. Lastly, we looked at the existence of contact with the psychiatric services in this group.
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From page 91... ...
In this context, too, I want to mention the work of the primary care team, from secretaries through practice nurses, social workers, and so on.
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From page 92... ...
92 In another direction, expectation of role is a major problem: a recently bereaved father is typical. He is widely invited, he is well supported, he is fine everywhere except with his daughter.
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From page 93... ...
Division of Primary Care and Family Medicine Harvard Medical School Boston, Massachusetts Primary care practice provides special opportunities for the prevention, diagnosis, and treatment of mental disorders, through decreased stigma associated with the patient's mental illness, greater likelihood of familiarity with the patient's social context, and greater potential for long-term followup. However, studies traditionally have shown that most general practitioners, while they may recognize the emotional situations of their patients, are not qualified to treat mental health problems -despite characteristics of the primary care therapeutic relationship that should enable physicians to treat many mental disorders more effectively than can specialists.
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From page 95... ...
This discussion is based upon my experience in two very different settings, a neighborhood health center and a large multispecialty group practice. The focus of this presentation will be on problems rather than on the benefits of this form of practice which have been so well described by other speakers.
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From page 96... ...
A population-based focus may also have an impact on direct patient care in that recognition of patients who may be able to use psychiatric services but are ambivalent may lead to use of outreach techniques like home visits. In addition, the psychiatrist in primary care who sees all the patients of the medical practice as potential clients must be flexible in making therapeutic contracts which reflect the patient's ambivalence.
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From page 97... ...
97 loss of identity at a personal level may lead to a loss of identity at an institutional and national level. Psychiatric studies often seem soft and services are difficult to measure in terms of clear outcome; thus, the push towards linkage must be tempered by a realization that the unique identity and goals of psychiatry should not be lost by a simple reductionism.
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From page 99... ...
Data for Saskatchewan during 1977-78 show the following trends: 1) Overall, 13.3% of the total Saskatchewan population received psychiatric services -- 18,400 from specialized mental health hospitals or clinics, 10,100 from general hospitals, and 94,600 from private practitioners.
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From page 100... ...
(The full text of Dr. Richman's paper appears in Section VII.)
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From page 101... ...
First, one of the hopes of those who propose including significant mental health coverage in primary care settings is that it will serve to reduce medical utilization and hence reduce costs. But the very assumption that mental health services should reduce the utilization of other medical services needs to be examined closely.
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From page 102... ...
Medical utilization is often chosen as the indicator of convenience. It is not a simple variable, but rather a congeries of hospital days, doctor visits, procedures done and medicine prescribed.
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From page 103... ...
Among the factors to which medical utilization is sensitive are the following: 1. The tendency in our society to "medicalize" life problems; the "selling of medicine" as holding the key to health, happiness, sexual success and social popularity (Aday and Andersen, 1978; Eisenberg, 1977~.
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From page 104... ...
This list is not exhaustive and many of the factors can be further sub-divided. Since medical utilization is sensitive to so many factors it would be all the more noteworthy if the availability and use of
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From page 105... ...
Again, since psychotherapy and medical utilization are each complex and messy variables, these complexities, if they could be assumed to vary randomly, might be expected to wash out any true relationships that more refined studies might reveal. Thus, if studies conducted at the present state of the art do reliably show a relationship, they would argue for remarkably robust effects.
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From page 106... ...
influences resulting from patient and doctor awareness of the research, they may compensate with superior experimental controls. Archival Time-Series Studies of the Impact of Psychotherapy on Medical Utilization Sixteen studies that examined patients' medical records for a period of time before and after entry into psychotherapy were located in the published and unpublished literature through April, 1979.
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From page 107... ...
107 for all persons in the group under observation; e.g., in absolute time, one month pre-therapy is April 1977 for each person in the group. The importance of this distinction derives from the susceptibility of relative time series to invalidation from the effect of regression to the mean.
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From page 109... ...
on the effects of psychotherapy on medical utilization were found in three areas: alcoholism, asthma, and recovery from medical crisis (surgery and heart attack)
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From page 110... ...
When effect sizes are calculated separately for these two types of outcome, the comparison slightly favors larger effects for the more medically relevant indices, at +.45 versus +.40. A subset of the outcome indicators is particularly important for its cost offset implications.
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From page 111... ...
Most of the archival studies of the effects of psychotherapy on medical utilization are flawed by problems of experimental design. A critical, quantitative review of 15 such studies that takes account of these flaws indicates a likely reduction of between O and 19% in medical utilization and costs.
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From page 112... ...
and Follette, W.T. Psychiatric services and medical utilization in a prepaid health plan setting, (Part II)
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From page 113... ...
and C~'mrnings, N Psychiatric services and medical utilization in a prepaid health plan setting.
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From page 114... ...
and Hastrup, J Effects of psychological treatment on medical utilization in a multidisciplinary health clinic for low income minority children.
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From page 115... ...
Relationships between mental health treatment and medical utilization among low-income MexicanAmerican patients: Some preliminary findings. Medical Care, 15(5)
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From page 116... ...
and Wiens, A.N. Changes in medical problems and utilization of medical services following psychological intervention.
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From page 117... ...
Effects of medical utilization and diagnosis on general medical care utilization in a prepaid clinic setting. Report by Western Interstate Commission on Higher Education (WICHE)
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From page 119... ...
(The full text of Dr. Shepherd's paper appears in Section VII.)
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