Michaele Dunlap, PsyD
Michael G. Conner, PsyD
Dave Johnson, RCSW
Virtually everywhere you look, researchers and policy makers are quoted to say that 80% of mental health problems are treated by physicians in primary care settings. Mental health professionals believe it is more accurate to say that physicians attempt to treat mental health problems in primary care.
Nationally and regionally major hospital systems and hospital-owned medical clinics are required and incentivized to integrate physical care with care for the mental and behavioral well-being of patients. Do Healthplans want integrated care because it improves outcomes and population health? Have the various experiments with integration demonstrated improvements? How often is patient distress or self-harming behavior misdiagnosed of undiagnosed?
Screening for mental and behavioral health issues is becoming a Standard of Care in medical practices. When emotional or behavioral problems are identified, intervention is ethically and clinically required. Are appropriate interventions happening? Where are all the psychotherapists who are ready and willing to take referrals?
The majority of front line medical providers are in clinical contact for a very few minutes with individual patients. How can integration and appropriate intervention happen? Is the typical medical response of medication appropriate? Physicians who actively refer to community psychotherapists are often those less likely to medicate. But where are all the psychotherapists if as many as 16 to 32% of patients see their physician and report physical symptoms that have no underlying organic cause and are actually the result depression, anxiety or psychological trauma that are undetected.
Depending on how success is measured, primary care providers may unwittingly discourage patients from seeking psychotherapy when patients don’t respond to, or refuse to use, medication that was offered or when the patient ignores a medical provider’s brief counsel to make a behavior change.
As physicians take on the tasks of screening and treating depression, anxiety etc. in primary care, how many patients are discouraged from seeking further care because of medication side effects, or from being treated for a wrong diagnosis? Situational or trauma-based depression and anxiety do not respond effectively to medication.
If there is a psychotherapist in the medical setting as the integrated care provider there is usually severe limitation on patient-therapist contact. Brief counseling may be effective in some situations in others it can be counter-productive.
The perception that integrated care has positive outcomes may be an artifact of patients’ discouragement. Patients who do not seek other help after the integrated care encounter may have come to believe that no help is available or possible.
Symptoms of depression, anxiety, rage, grief etcetera, and people’s self-harming behavior have many different “causes;” and can respond positively to many different therapeutic interventions. Decades of research on emotional and behavior change processes demonstrate that effective therapy involves those willing to engage in an intervention process and therapists with whom help-seekers have affinity.
Community psychotherapists are justifiably cautious about referrals from primary care clinics when there has been a failed or too-brief “integrated response” to the patient’s emotional and/or behavior problems. Such referrals may come with patient resentment for being passed on in an abrupt manner, patient distrust of helpers, a high no-show rate and greater patient morbidity* in all definitions of the word. If distressed emotions and self-harmful behavior are associated with medical problems, there needs to be sufficient “dose of contact” with psychotherapists who are trained to treat those problems.
*morbidity (mor-BIH-dih-tee) Refers to having a disease or a symptom of disease, or to the amount of disease within a population. Morbidity also refers to medical problems caused by a treatment.