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Psychological Symbiosis

In-house behavior health providers give patients real-time access to counselors, improve care for mental health problems, and save physicians time. It’s the ultimate win-win arrangement.

By Cindy Murphy Mcmahon Unique Opportunities, May/June 2008

Maryanne is a 36-year-old professional, married woman with two children. She is having stress-related symptoms during a difficult time in her life, and her internal medicine physician suggests that she could benefit from seeing a psychologist. She has never seen a mental health professional before and her reaction is, “I’m not crazy. I don’t need to see anyone like that.”

Ask any physician if he or she believes that medical care alone will cure a patient. Odds are not too many will be entirely confident of that optimistic, albeit desirable, outcome.

Primary care physicians, although trained to diagnose and treat many mental health issues, often find that behavioral health providers—psychologists, social workers and professional counselors—can augment medical care and help improve a patient’s chance for a more complete recovery.

“There are a lot of medical problems that can’t be treated by just starting a person on medication,” says Jim King, MD, the president of the American Academy of Family Physicians and a private practitioner in Selmer, Tennessee. “A family practice physician is trained to take care of many mental health problems, such as anxiety, depression, even substance abuse and other problems. We take care of a lot of that. And we make referrals for some patients to get services added, like we would for any other specialty or subspecialty in a particular area.”

Patients sometimes need professional help with coping mechanisms, however, whether they are grieving the loss of a loved one or just need someone to help them work through mental health problems. Says King, “They need to spend time talking to someone with that kind of training.”

So, family practice and other primary care physicians refer their patients to see behavioral health professionals. But just because a patient leaves a physician’s office with instructions to see a behavioral health provider—or even with an actual appointment in hand, arranged by the physician’s office—doesn’t mean the appointment will take place. Compliance is out of the physician’s hands.

Partnerships a growing trend

That is one reason some physicians are teaming up, or co-locating, with behavioral health providers (BHPs) in their own medical offices—to ensure that patients will get the support they need to complement their medical treatment.

Such in-house partnering is not new, but interest in this arrangement appears to be growing, although official figures are not available on how widespread the practice is.

A forum on mental health services in primary care sponsored by Georgetown University in July 2006, which focused on children’s health needs, recommended co-location as one strategy to better serve patients and their families. The forum concluded that BHPs, particularly early childhood mental health specialists, should be co-located with primary care providers to screen,

assess, and treat patients, as well as refer them to other services and coordinate care.

The Veterans Health Administration has been increasing the number of co-located mental health professionals in its medical clinics for 15 years, according to Linda Van Egeren, PhD, a clinical psychologist at the Women’s Comprehensive Health Center at the Minneapolis VA Medical Center. Van Egeren was among the first mental health professionals to co-locate at a VA facility when she came there in 1993. She and a mental health clinical nurse specialist work full time at the women’s clinic, and a psychiatrist is onsite about one and a half days per week.

She says that primary care providers end up dealing with patients’ psychological problems whether they are diagnosed or not, adding that, “Mental health care cannot be divorced from primary medical care.

“The point of our model is to ensure that mental health care is perceived as part of health care. It’s a more holistic approach, not the body/mind separation. It is very beneficial to patients because there is less stigma for receiving mental health services.”

Ralph Leonard, MD, is a VA staff physician, board-certified in internal medicine and geriatrics, at the Minneapolis VA Medical Center. He works in a primary care clinic and admits that, initially, he was skeptical of having BHPs located in the clinic.

“I’ll admit I was a bit reluctant to have some of our scarce office space used by others, but we shifted things around and they are such a valuable addition,” Leonard says. The clinic employs psychologists and RN depression case managers. The depression case manager program started about two and a half years ago, while the psychologist started in April 2007. An additional project involves a nurse specialist who screens all patients older than 75 for dementia.

Leonard sees many benefits to the arrangement. Studies show that roughly half of patients discontinue their psych meds within the first month because of side effects or lack of perceived benefit. Depression case managers call patients to find out if they are tolerating new meds and getting adequate response. “They encourage patients to stick with treatment during the first few weeks when benefits are slow to develop. If needed, they inform us if there is a med-related issue,” says Leonard.

Case managers also spend time listening to patients, many of whom have a situation that has precipitated their mood problem, such as a recent loss or posttraumatic stress disorder (PTSD), and “although they suggest some helpful coping mechanisms, I think a major service our depression case managers provide is to be a good listener and supporter,” Leonard says.

At the VA, patients who require cognitive behavior therapy can be seen by the clinic’s psychologists in the course of a regular visit. This initial assessment can occur within an hour of referral, whether the referral is initiated by the patient or clinical staff. “This is very helpful for patients with complex social stressors who we want to help because we do not have the flexibility in our schedules to attend to every issue in detail,” says Leonard. “Our psychologists are also very good at troubleshooting challenging and time-consuming cases, such as those involving dementia.”

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