Topic 5: Primary Care Collaborations and Training Projects


Relevance to the Underserved Issue

Research indicates primary care physicians (PCPs) provide the majority of mental health care in the United States. Unfortunately, most PCP's are not fully prepared to diagnose and treat mental illnesses.


Summary of Key Information

According to the 1999 Surgeon General's Mental Health Report, one in five adults will experience a diagnosable mental illness in any given year 1-7. When people do seek treatment for mental health concerns, research indicates that they most often do so with their family physician. In fact primary care physicians provide the majority of mental health care in the United States 8-9. According to the American Academy of Family Physicians, "among diagnosed patients, 42 percent with clinical depression and 47 percent with generalized anxiety disorder (GAD) were first diagnosed by a primary care physician 10. Estimates are that 11 percent to 36 percent of primary care patients have a psychiatric disorder, and research indicates that only one-half of those patients are diagnosed 6-7,11-15. Further, "32 percent of undiagnosed, asymptomatic adults indicate that they will first turn to their primary care physician for help with a mental health issue 10 and only 4 percent would approach a psychiatric professional 10.

The following barriers have been identified as roadblocks to the successful implementation of efforts related to the provision of mental health care by primary care physicians in collaboration with psychiatrists:

  1. Psychiatrists not available to PCPs: Primary care providers report that psychiatrists are not available for consultation in the same way that, for instance, endocrinologists are. Mental health carve outs by insurers have exacerbated this problem. Psychiatrists often see patients for a long period, and incentives for PCP's to see these patients are different than for other medical specialties. The fundamental question is whether psychiatric practices are willing to change in order to provide ongoing support to PCP settings.
  2. Concern about quality of care: There are problems associated with inadequate treatment of depression in PCP settings. The average number of visits for depression treatment in PCP settings is 4, (while it's 14 in psychiatric settings.)

Furthermore there are practical considerations ie. (reimbursement, coding). There are reimbursement concerns (real or perceived) related to PCPs' treatment of depression. PCPs are reticent to put a diagnosis of depression in the chart due to the lack of reimbursement for administration of a screening exam (although Aetna is changing this, see below); the lack of understanding about how to code to get paid for depression treatment; and the inherent time constraints associated with short PCP appointment visits (generally 15 minutes for treatment of "entire body" including mental health issues).


Model Programs and Collaborative Projects

ICARE Partnership North Carolina Project

Many North Carolinians have inadequate access to mental health, developmental disability, and substance abuse services (MH/DD/SAS), and their services for physical and behavioral health are poorly coordinated. Primary care providers (PCPs) often must try to address unmet behavioral health needs with insufficient specialty back-up and information resources. The ICARE Partnership seeks to increase access to quality, evidence-based behavioral health care services for North Carolinians. The North Carolina Psychiatric Association is an Advisory Member of the ICARE Partnership. http://www.icarenc.org/


Massachusetts Child Psychiatry Access Project (MCPAP)   

The Massachusetts Child Psychiatry Access Project (MCPAP) is a new, interdisciplinary healthcare initiative that assists primary care providers (PCPs) who treat children and adolescents for psychiatric conditions.  Its goal is to help PCPs diagnose and treat these patients more effectively, thereby increasing access to effective psychiatric care for children and adolescents. The project provides PCPs with timely access to psychiatric consultations and, when indicated, to transitional services for behavioral health care. It teams child psychiatrists, social workers, and care coordinators with the PCPs who are providing psychiatric services.  The project is available to all families and children whatever their insurance status, and provides outpatient/non-emergency services. For additional information, contact Martha Page, MCPAP Project Manager, at the Massachusetts Behavioral Health Partnership, 617-350-1923 or Martha.Page@valueoptions.com  or go to the project website at: http://www.mcpap.org/.


MacArthur Foundation Initiative on Depression and Primary Care at Dartmouth and Duke

Many of the efforts developed draw from the MacArthur Foundation Initiative on Depression and Primary Care at Dartmouth and Duke. This initiative features a "three-component model." The three components are 1) primary care physicians as lead responders; 2) nurse managers to follow up and help with monitoring; and 3) consultation with psychiatrists. The model makes use of the nine-question Patient Health Questionnaire (PHQ-90, see below) and encourages primary care physicians to increase their understanding of depression and how to treat it, to ask for assistance and consultation with psychiatrists, and to refer cases to psychiatrists when appropriate. The MacArthur toolkit on the model can be found at: http://www.depression-primarycare.org/clinicians/


Depression Care Improvement Study (APA, AAFP, ACP): Making use of the PHQ-9: Measurement-based Depression Treatment

Given the significant number of patients who present with depression symptoms in the primary care setting, and the prevalence of treatment in that setting, the American Psychiatric Association (APA) believes it is important to try and improve the quality of depression care at the primary care level, including appropriate consultation with and referral to psychiatrists. The APA, American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) have worked together on this issue through a project called the Collaborative Initiative to Improve Care for Patients with Depression. The initiative seeks to improve diagnosis and treatment through the use of a validated depression screening instrument in primary care settings.

There is a good deal of quality research regarding the use of depression screening tools, including a wealth of information on their effectiveness when used by primary care physicians, often in conjunction with other protocols, such as ongoing monitoring and medication management. In the past, when such interventions were employed and delivered to patients, depression treatment outcomes improved by more than 50 percent. However, their use has been generally limited to research projects - and once the study stopped, so did the interventions. The APA, AAFP, and the ACP now want to leverage their constituencies to drive systemic change and achieve permanent incorporation of these protocols into the primary care practice.

The APA, AAFP, and ACP agreed on using the nine-question Patient Health Questionnaire (PHQ-9) for this project. The PHQ-9 covers nine criteria for depression, consistent with the DSM-IV. (the PHQ-9 can be found at http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/). It assesses symptoms and allows the physician to track each component using a metric for determining if the patient is responding to treatment - and being treated to remission. It should be noted that the tool assesses the patient's suicide risk/ideation, which may help address physician concerns about potential liability regarding the recently highlighted issue of antidepressant use and suicide risk. The PHQ-9 is being combined with other interventions that assist primary care physicians in treating depression, including regular monitoring, medication management, and psychiatric consultation. In addition to assisting the PCP in assessing and monitoring depression treatment, the use of a common metric facilitates communication between PCPs and psychiatrists, are improving patient outcomes.


Aetna Takes the Three-Component Model to Next Level by Paying for PHQ

Aetna has piloted a program that takes the Macarthur Foundation Initiative's three-component model to the next level by reimbursing primary care physicians for administration of the PHQ-9. Early results are promising, but there are concerns related to how the amount of penetration of a given practice by Aetna beneficiaries will affect a physician's willingness to participate. A physician generally either implements a new protocol for all his/her patients or provides no intervention. Further, physicians are generally unaware of their patients' specific insurance coverage (although their office administrative staff generally has this information). Doctors must see a large enough number of Aetna beneficiaries in order for it to make sense for them to begin administrating the PHQ-9. Aetna plans to make its depression initiative national. A New York Times article on the Aetna effort can be accessed at this link: http://www.nytimes.com/2005/11/02/business/02depress.html?ex=1179374400&en=bc6179d8ba7bac45&ei=5070


The New York City Initiative: Using the PHQ-9 in the Public Sector

In New York City, health officials have introduced a depression screening tool for physicians working in public hospitals. In conjunction with the Health and Hospitals Corporation, the city is working toward a goal of having every primary-care physician in the city hospital system begin screening using the PHQ-9. The city launched the campaign using public education, encouraging the public to ask their doctors about a simple test for depression. The public education campaign featured messaging at bus shelters and on ATM receipts. More information about this program can be found at: http://www.nytimes.com/2005/04/13/health/13depress.html?ex=1179633600&en=61d640e3a62c23de&ei=5070


Relevant Web Resources

References

  1. Callahan EJ, Jaen CR, Crabtree BF, et al. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice." J Fam Pract 1998;45(5):410-8.
  2. Eisenberg L. Treating depression and anxiety in primary care. Closing the gap between knowledge and practice. N Engl J Med 1992;326,(16):1080-4.
  3. Klinkman MS. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19(2):98-111.
  4. Saravay SM, Cole SA. Mental disorders in the primary care sector: a potential role for managed care. Am J Manag Care 1999; 4(9):1319-22.
  5. Schulberg HC, Katon W, Simon GE, et al. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry 1998;55(12):1121-7.
  6. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995;4(2):99-105.
  7. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry 1996; 153(5):636-44.
  8. Gallo JJ, Coyne JC. The challenge of depression in late life: bridging science and service in primary care. JAMA 2000;284(12):1570-2
  9. Williams JW Jr. Competing demands: does care for depression fit in primary care? J Gen Int Med 1998;13(2):137-9.
  10. National Mental Health Association. America's mental health survey, May 2000. Conducted by Roper Starch Worldwide, Inc. www.roper.com/Newsroom/content/news189.htm.