Many patients with mental health issues go to their primary care doctor either because they assume their symptoms are medical or simply because it is their only doctor. However, primary care doctors are not trained in mental healthcare and do not have the necessary time to address mental health concerns.
How would you feel if a mental health professional came to chat with you while you were sitting in the doctor’s office? Would it remove some of the stigma of calling a shrink? After all, you didn’t seek out this mental health professional. You did not even have to make an appointment to see them.
As a social work graduate student, I interned in an emergency room where collaborative care was the standard. The doctors asked the social workers to speak with patients who seemed anxious or depressed and we sought out families in the pediatric emergency room who appeared to need support, psychoeducation or resources. Providing mental health services in an emergency room, a pseudo-primary care setting, was inspiring, effective and valuable. I did not know it was a unique role — I thought it was the norm.
Fortunately, I am not the first person to believe the concept of collaborative care is practical, logical, beneficial and could revolutionize the future of health care.
To advance the field of integration, the Agency for Healthcare Research and Quality (AHRQ) created the Academy for Integrating Behavioral Health and Primary Care. It is a government agency devoted to integrating behavioral health and primary care. AHRQ’s vision for the Academy is to support the collection, analysis, synthesis, and dissemination of actionable information for providers, policymakers, investigators, and consumers.
The integration of behavioral health and primary care has a promising future, but there are also many barriers. Mental health parity and the Affordable Care Act have helped provide coverage for mental health conditions and substance use disorders but, not surprisingly, funding, insurance and legislation remain major obstacles.
The Substance Abuse and Mental Health Services Administration Center for Mental Health Services published a 2008 document discussing these barriers, including state Medicaid limitations on payments for same-day billing; lack of reimbursement for collaborative care; absence of reimbursement for services provided by non-physicians; disallowance of reimbursement when bills list only mental health diagnoses; level of reimbursement rates in rural and urban settings; difficulties in getting reimbursement in school-based health center settings; and lack of reimbursement incentives for screening and providing preventative mental health services in primary care settings (Kautz, Mauch, & Smith, 2008).
So how do we climb over these barriers?
Some states are trying out pilot projects. Massachusetts expanded children’s access to mental health screening through statewide health care reform. Minnesota is working to overcome professional shortages in rural areas through telepsychiatry (Behrens, Lear, & Price, 2013).
Many pediatric practices are sharing space with mental health professionals, a shift aimed at improving access to hard-to-obtain mental health services. One example from an Oregon primary care doctor involved a 17-year-old who fell on his head snowboarding (Foden-Vencil, 2013). After trying many doctors and emergency room visits for his headaches, his family ended up at a clinic where they saw a pediatrician and a psychologist. The pediatrician treated him for his brain injuries and the psychologist helped him with coping skills. His parents also received support from the psychologist.
Having a mental health clinician in a doctor’s office takes away the stigma of having to go see a therapist. It also takes away the stress of having to schedule another appointment and take time away from people’s already busy schedules. In Massachusetts, roughly one in four pediatricians in private practice works in a setting that includes some type of mental health service (Wen, 2013).
This Massachusetts model is one example of a national trend toward more coordinated services, centered on primary care doctors working closely with specialists to keep patients healthier and, preferably, to lower overall cost. Hopefully, parents will receive the message that treating children’s depression and behavioral issues are as important as treating their asthma and other medical problems.
Since primary care is the first place most patients go when experiencing symptoms, primary care physicians and pediatricians have been the subject of most studies and pilot projects. However, in my opinion, one important doctor is being ignored from this discussion, the OB-GYN.
I hope future pilot projects place social workers, psychologists and psychiatrists in OB-GYN offices, which essentially are women’s primary care during pregnancy through the first year postpartum. Women with postpartum depression and anxiety would benefit considerably from quality care in a collaborative model.
Behrens, D., Lear, J.G., & Price, O.A. (2013). Improving Access to Children’s Mental Health Care: Lessons from a Study of Eleven States.
Foden-Vencil, K. (2013, October 22). Oregon Experiment Puts Therapists On Primary Care Teams. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/Stories/2013/October/22/Oregon-primary-care-mental-health.aspx
Kautz, C., Mauch, D., & Smith, S. A. Reimbursement of mental health services in primary care settings (HHS Pub. No. SMA-08-4324). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2008.
Wen, P. (2013, March 18). Children’s access to mental care in Mass. is growing. The Boston Globe. Retrieved from http://www.bostonglobe.com/lifestyle/health-wellness/2013/03/17/growing-number pediatrician-offices-therapist-down-hall/5G1QIpo7WFfeCmWY7G1glN/story.html