Mind and body: Benefits of integrated health care
For years, Nellene New managed with little more than pills prescribed by primary care providers after a family doctor diagnosed her with depression in 1994. She had no therapist on speed dial, no lengthy discussions with a professional about her mental health.
"I wasn't talking to anybody about any of it," says the 52-year-old Angie's List member from Shelbyville, Ky.
New says she thought she could handle it on her own by merely taking the medication. But by this spring, anger consumed her and she cried almost constantly. As her world darkened, she says she made plans to take her life — even preparing her will.
Most medical providers have at least some training in diagnosing and treating mental health disorders. However, experts worry that primary care providers — already pinched for time — could be overprescribing and under evaluating; and patients often never get the mental health help they need.
It's great primary care doctors are stepping up, says psychiatrist Dr. Ken Thompson, who's a medical director for the Center for Mental Health with the U.S. Substance Abuse and Mental Health Services Administration in Rockville, Md. But, "There is a real concern as to whether people are getting good treatment," he says.
Nearly 60 percent of U.S. mental health drug prescriptions are written by general practitioners, including family doctors and pediatricians, according to a study released last year by Thomson Reuters and SAMHSA.
"The data clearly shows if people are experiencing mental health issues, more often than not, they go to their primary care doctors," says Richard Munger, a researcher and licensed psychologist in Buncombe County, N.C.
'People are integrated'
About 40 percent of Angie's List members who responded to an online poll say they or a family member got mental health medications prescribed exclusively by a family doctor or another primary care provider. That compares with 32 percent who obtained them exclusively from a psychiatrist or another mental health professional.
Another 26 percent say they've gotten medications from both. While some members who took the poll say their primary care providers are adept at prescribing medications to treat mental health issues, others believe the arrangement is woefully inadequate.
A core issue, say family doctors and mental health experts, is traditional medical offices are separate from mental health services.
"People walk around with their heads and their bodies connected," says Thompson, who believes the health care system probably needs to be redesigned, accordingly. "People are integrated even if our service system is not."
Fortunately for New, a work supervisor referred her to an assistance program for employees where she got connected to intensive outpatient therapy. She says she's since been diagnosed with bipolar disorder and now undergoes regular counseling. Talking through problems has helped New deal with life's ups and downs.
"I laugh more, I'm generally happier," says New, who only wishes she would have gotten the bipolar diagnosis and the right combination of medications and talk therapy earlier.
The side effects
Member Shawn Cabot of North Augusta, S.C., wishes she'd gotten a second opinion before following her doctor's orders and taking powerful antidepressant and anti-anxiety medications prescribed by her primary care physician, internist and endocrinologist Mary Luella Martin Thompson.
Cabot says she ended up in the emergency room five times in January 2009 because of problems she attributes in large part to the antidepressant Pristiq. "That's when things went haywire," says Cabot, 53. "When I was hospitalized, they thought I was having a stroke because I couldn't respond."
Cabot concedes she did express feelings of anxiety and depression in 2009 to Thompson, who was helping to manage her thyroid condition. But she says her thyroid was to blame for her feelings, not underlying psychological problems, and other doctors subsequently took her off the mental health medications Thompson prescribed.
Shortly after her hospitalizations, Cabot saw a psychiatrist, Dr. Ben C. Barnard in Augusta, Ga., who advised her to stop taking Pristiq.
Bernard says antidepressants, in most cases, aren't appropriate for patients with thyroid problems: "I would tend to just use something to help them normalize the thyroid," he says and adds that Pristiq mimics the thyroid condition and can compound problems by raising pulse and blood pressure.
Cabot says Thompson didn't discuss side effects associated with Pristiq. Through her office manager, Thompson declined to comment, citing patient confidentiality.
The failure to adequately discuss potential side effects associated with mental health drugs is a common complaint lodged against primary care providers. Dr. Kate Atkinson, a highly rated family physician in Amherst, Mass., concedes she and others in her field may be stretched thinner than psychiatrists and have less time to talk about medications.
"However, I don't always find [psychiatrists] are much better than we are at warning people about side effects — I think that depends in large part on each doctor," she says.
That's not to say Atkinson doesn't see benefit in collaboration. When necessary and with patient permission, she sometimes enlists the help of psychologists in co-managing patient care. "We could make medical care a lot better if we all work together," Atkinson says.
Learning to talk to each other
Jim Endsley of Mack, Colo., certainly wouldn't dispute that. After falling at his trucking job in 2008 and experiencing amnesia from traumatic brain injury, he went to Marillac Clinic in Grand Junction, Colo., for follow-up primary care.
After learning they also offered mental health services, he sought care for memory loss and post traumatic stress disorder related to his fall, which together caused near-constant fear and thoughts of suicide. "It was decided therapy was a viable option for me," Jim says.
Going to the same place for mental and physical health is reassuring because it's a familiar place, says his wife, Nancy, adding that Jim doesn't scare as easily anymore or have thoughts of suicide. He still struggles mightily with memory — he has to be reminded Nancy is his wife — but he's happy again and his logic and reasoning are intact.
"He's got a great sense of humor and he uses it well," Nancy says.
Marillac Clinic executive director Steve Hurd says it's critical to treat mental health issues when the patient is ready and where they're comfortable getting treated, rather than sending them elsewhere.
Experts estimate fewer than 20 percent of patients ever follow through when referred to a mental health professional. Hurd puts the figure at closer to 10 percent and blames the stigma often associated with mental illness, along with worries over cost.
But integrating care isn't an easy fix.
Privacy concerns can bog down communication between providers and mental health professionals, as can ethnocentric training in which specialists learn one discipline, one language, says Dr. Mac Baird, a family physician and family therapist who heads the Family Medicine and Community Health Department at the University of Minnesota in Minneapolis.
"As physicians, we want to be, too much, in charge," says Baird, an authority on integrated care. And, he adds, "We don't know how to talk to each other."
It doesn't help that insurance reimbursement is typically lower for mental health services. So even in integrated practices, there's financial incentive to emphasize the medical aspect — the physician's role — as being the most important part of a patient's care, Baird says.
For now, experts say patients would be well served to have all the health professionals in their lives on one team.
It's all about increasing collaboration, says Denise Levis Hewson, a clinical programs and quality improvement director with Community Care of North Carolina in Raleigh who has studied different models of behavioral health integration in primary care.
"If you are a patient and you already have relationships built, make sure that you let both [your primary care and mental health] providers know you want them to talk to each other," she says.