Mental Health Care Services by Family Physicians (Position Paper)

EXECUTIVE SUMMARY

Mental illness is highly prevalent in the United States and is associated with an increased risk of morbidity and mortality. There are significant gaps in the provision of mental health care services in the U.S., especially related to vulnerable populations. Family physicians are well-equipped to provide mental health services and are one of the primary sources for mental health care in the U.S. The American Academy of Family Physicians (AAFP) supports the following:

  • Family physicians are well-prepared to provide many mental health services and should continue to
        lead and participate in these services to improve access, quality, and outcomes.
  • Family physicians should work with behavioral and mental health professionals whenever possible to
        ensure the best care for their patients. This can range across a continuum, including collaboration
        and partnerships, co-locating services, or even full integration within one single care plan.
  • Graduate medical education in family medicine emphasizes the direct link between physical and
        mental health, and should continue to offer behavioral and mental health training as part of the
        core curriculum.
  • Family physicians should educate themselves about mental health practices, including staying
        up-to-date on screening recommendations for mental health; behavioral health and primary care
        integration models; trauma-informed care, telemedicine and telepsychiatry; and mental health
        disparities and high-risk populations.
  • Family physicians should advocate for the elimination of the stigma that accompanies poor mental
        health, as well as support policies that improve access to behavioral and mental health services.
  • Advocating for the maintenance and expansion of state, federal, and private insurance funding
        of mental health care services for all.
  • Advocating for the establishment of payment mechanisms that: adequately reimburse primary care
        physicians for providing mental health care services; and allows adequate funding of mental health
        care services provided in co-located practices to ensure its continued availability in the primary care
        physician’s office.
  • The development of new treatment strategies to increase the number of patients who receive
        appropriate treatment and follow-up through both primary care and mental health specialty care
        providers, and through the use of new technologies, such as telehealth.

BACKGROUND

Mental illness, which includes a range of mental health conditions that affect one’s mood, thinking, and behavior, is one of the most pervasive causes of disease and disability worldwide. The prevalence of mental illness has important public health ramifications, affecting roughly 20% of all adults,1 and is the leading cause of disability in the U.S., accounting for 18.7% of years of life lost to disability and premature mortality.2 While mental illness is common in all parts of society, there are disparities, with American Indian and Alaska Natives (28.3%) experiencing higher rates than white (19.3%), black (18.6%), Hispanic (16.3%), or Asian (13.9%) adults.1 Mental illness has a substantial economic impact,  accounting for $179 billion in health care spending in 2014, which is projected to increase to $238 billion in 2020.3

Challenges exist for providing high-quality mental health care services in the U.S., mainly arising from the fragmentation of medical care and mental health care.4 Mental health services are not distributed evenly throughout the U.S. and many communities lack access to these services.5 Roughly two-thirds of primary care physicians are unable to connect their patients to outpatient mental health services.6 This results in the need for primary care physicians to assume a leading role in the management of mental health care services.5 Primary care physicians serve as primary managers of psychiatric disorders in one-third of their patient panels5 and two-thirds of patients with depression receive treatment for their depression in the primary care setting.5

Family medicine, which promotes the integration of the behavioral and physical models of illness, serves a vital role in providing mental health care services. Transformations within primary care, most notably the patient-centered medical home (PCMH), have called for reintegration of mental health care into routine comprehensive care through a team-based approach.7-9 Integration can take place across a continuum, including collaboration and partnerships, co-locating services, or full integration within one single care plan.10 The current lack of integration is a barrier to improving the quality, outcomes, and efficiency of care delivery for those struggling with both mental and physical illness.11,12

This paper explores the various issues family physicians face regarding mental health and mental health care services, clarifies the family physician’s role, and provides direction to the AAFP to advocate for a better system for addressing mental health in the U.S. The paper covers topics related to: incorporating mental health care services in primary care; health disparities and high-risk populations; tobacco use as a risk factor for excess morbidity and mortality in the population experiencing mental illness; and payment.

ROLE OF THE FAMILY PHYSICIAN

While psychiatric and other mental health professionals can play an important role in the provision of high-quality mental health care services, primary care physicians are the main providers for the majority of patients. Most people with poor mental health will be diagnosed and treated in the primary care setting.13 Mental illness also complicates other medical conditions, making them more challenging and more expensive to manage.13 Together, this makes mental health an important issue for primary care physicians.

Family physicians are well-positioned to address their patient’s mental health issues. The behavioral sciences and mental health are central tenets of the specialty of family medicine,14 and family physicians receive high-quality training in these areas. The Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) for Family Medicine has stringent standards for education in family medicine residencies for mental health, including that residency programs: have faculty dedicated to the integration of behavioral health; teach residents to diagnose, manage, and coordinate care for common mental illnesses and behavioral issues in patients of all ages; require that residents demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, and their application to patient care; and structure their curriculum so that behavioral health is integrated within student’s total educational experience.15

INCORPORATING MENTAL HEALTH SERVICES IN PRIMARY CARE

Screening for Mental Illness
Screening for mental illness is not new to family medicine but has more recently been linked to quality metrics and payment. Screening for mental illness can be an important strategy for decreasing morbidity,16 as well as preventing adverse maternal and child health outcomes associated with perinatal depressive symptoms, postpartum depression, or maternal suicide.17-20 While important, screening in a busy practice can seem overwhelming, but practices can leverage technology, empower staff, and utilize wellness visits to complete this screening.21

Family physicians should be aware of screening recommendations for their patients, recognizing that identification of mental health issues is integral to ensuring appropriate treatment and reduction of complications. Mental health clinical recommendations and guidelines developed or endorsed by the AAFP are outlined on the AAFP’s website (http://www.aafp.org/patient-care/browse/topics.tag-mental-health.html).

Primary Care and Behavioral Health Integration
Integrating mental health into primary care settings, as well as the blending of primary and preventive medicine into traditional mental health settings, represents a more holistic approach to treatment than the traditional consultative and referral models. Integrating primary care and mental health services increases access for patients by making mental health services available in their regular primary care clinics. When integrated into primary care, mental health providers can impact the care of more patients than in the specialty mental health referral sector.22 In the primary care setting, mental health providers take on a more consultative and team-based role and focus on helping primary care providers treat mental health disorders. In this context, mental health providers typically reach more patients, and have shorter and more problem-focused encounters than in the context of traditional specialty mental health.

Collaborative Care – A model for Primary Care and Mental Health Integration
The Collaborative Care Model, supported by various organizations including the American Psychiatric Association, is a model for the successful integration of primary care and behavioral and mental health.23 At its core, the idea of collaborative care is anchored in team-based care, often in the context of a medical home, and steered by primary care physicians. It involves behavioral health specialists and consulting mental health professionals delivering evidence-based care that is patient-centered. Evaluations of this model of care are ongoing, particularly in the adult population.

The collaborative care model includes four core elements: 1) team driven, 2) population focused, 3) measurement guided, and 4) evidence based. These four elements, when combined, can allow for a fifth guiding principal to emerge—accountability and quality improvement. Collaborative care is team-driven, led by a primary care clinician with support from a “care manager” and consultation from a psychiatrist who provides treatment recommendations for patients who are not achieving clinical goals. Other mental health professionals can contribute to the Collaborative Care Model. Collaborative care is population focused, using a registry to monitor treatment engagement and response to care. Collaborative care is measurement guided with a consistent dedication to patient-reported outcomes and it utilizes evidence-based approaches to achieve those outcomes.  Care remains patient centered with proactive outreach to engage, activate, promote self-management and treatment adherence, and coordinate services.23

Telemedicine and Telepsychiatry
Telemedicine is the process of providing health care from a distance using technology. Telepsychiatry, a subset of telemedicine, can involve either direct or indirect interaction between a psychiatrist and the patient, where a psychiatrist supports a primary care physician and other health care providers. Several telehealth models exist for providing mental health services. A promising model is Project ECHO (Extension for Community Healthcare Outcomes). A model such as this seeks to enhance access to mental health and substance-use disorder treatment via remote and telehealth training and practice support for primary care clinicians, particularly in rural and underserved areas.24,25 Telemedicine for mental health is a growing interest in primary care and telehealth initiatives for mental health care are expanding rapidly. While the research is limited on this topic, there are a growing number of studies assessing the benefits, comparative effectiveness with face-to-face visits, and cost comparisons. Family physicians who wish to integrate mental health care services in their practice, but have limited access, should consider learning more about this topic.

Trauma-informed Care
An estimated 60% of adults in the U.S. have experienced a traumatic event at least once in their lives.26 Exposure to trauma, such as intimate partner violence, sexual abuse, rape, neglect, terrorism, war, natural disasters, and street violence predisposes those affected to poor physical and mental health outcomes.27

Trauma-informed care, an approach to engaging individuals with a history of trauma that recognizes their traumatic experiences, and how it affects their lives, is a promising practice that may facilitate healing and help prevent the consequences of exposure to trauma.28-32 The principles of trauma-informed care include: realizing that there is a high prevalence of trauma and it has serious effects; recognizing the signs and symptoms of trauma; responding to the high prevalence by integrating knowledge about trauma into practices, procedures, and policies; and avoiding retraumatizing individuals by using best-practices in screening and history taking.27

While still in its infancy in family medicine, trauma-informed care is gaining support and evidence of its benefits are accumulating.33 Family physicians who have learned about trauma-informed care have increased measurements of “patient-centeredness” after completing a continuing medical education (CME) course.34 Family physicians will undoubtedly hear more about trauma-informed care and should take advantage of training opportunities in its principles and practice.35

HEALTH DISPARITIES AND HIGH-RISK POPULATIONS

Health Disparities
While mental health conditions can affect everyone, regardless of culture, race, ethnicity, gender or sexual orientation, some populations experience those conditions at a higher rate.

  • American Indian and Alaska Natives (28.3%) experience higher rates of mental illness than white
        (19.3%), black (18.6%), Hispanic (16.3%), or Asian (13.9%) adults.1
  •  Individuals from the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community are
        two or more times as likely as heterosexual individuals to have a mental health condition1 and
        LGBTQ youth are two to three times more likely to attempt suicide than heterosexual youth.1       
  • Nearly one-fifth (18.5%) of the veterans who returned from serving in either Iraq or Afghanistan
        suffer from either major depression or post-traumatic stress disorder.36
  • The prevalence of mental illness is similar for individuals living in either rural or metropolitan areas, but
        the mental health care needs are more often unmet in rural communities due to inadequate
        services.37

Disparities in mental health illness and mental health care are related to coverage and availability of care, quality of care, rates of health insurance, stigma, cultural insensitivity, racism, bias, homophobia, discrimination in treatment settings, and language barriers.1

College Students
Approximately 20 million students are enrolled in U.S. colleges and universities.38 Mental health concerns, such as non-suicidal self-injury and serious suicidal ideation, have risen in this population over the past several years.39 According to the Center for Collegiate Mental Health’s 2017 Annual Report, 52.7% of students attended counseling for mental health concerns; 34.2% took a medication for mental health concerns; 9.8% were hospitalized for a mental health concern; 27% purposely injured themselves without suicidal intent; and 34.2% seriously considered attempting suicide, with 10% making a suicide attempt.39 In fact, some data suggest that suicide may be the most common cause of death in college students.40

Attention-deficit/hyperactivity disorder (ADHD) is another prevalent disorder in college students that family physicians may encounter. ADHD’s prevalence is estimated to be between 2-8% among college students, and this condition is frequently associated with other psychiatric comorbidities and increases individuals’ risk of psychosocial and substance-use problems.41

TOBACCO USE – A RISK FACTOR FOR EXCESS MORBIDITY AND MORTALITY

Tobacco use is prominent among individuals living with mental illness. Thirty-six percent of adults with any mental illness use tobacco products, compared with 25.3% for adults without a mental illness.42 In addition, people who have any mental illness are only half as likely to quit smoking compared to individuals without a mental illness.43 One study found that nearly half of all deaths were tobacco-related for persons who received substance abuse services, or who received both substance abuse and mental health services.44 Therefore, addressing tobacco addiction among individuals living with mental illness is an important strategy for decreasing preventable mortality and morbidity among individuals living with a mental illness.

The AAFP has position papers that detail substance abuse and addiction (http://www.aafp.org/about/policies/all/substance-abuse.html) and tobacco prevention and cessation (http://www.aafp.org/about/policies/all/nicotine-tobacco-prevention.html).

PAYMENT

Historically, primary care physicians have encountered barriers to receiving full reimbursement for office visits for mental health diagnoses. This limitation in reimbursement interfered with the family physician’s ability to offer comprehensive care and management of mental health conditions, as well as the ability to integrate, from a business perspective, with behavioral health services. However, new coverage policies adopted by the Centers for Medicare & Medicaid Services (CMS) are more promising and may incentivize primary care physicians to provide treatment for mental and behavioral health conditions.45 These policies, effective January 1, 2017, emphasize collaborative care, where primary care physicians are expected to work in partnership with a behavioral health care manager, and consult with mental health specialists. While targeting populations with Medicare, these policies may also encourage private insurers to offer similar options and may incentivize more family physicians to offer behavioral and mental health care to other populations.

Health care for all people with mental illness should be “affordable, nondiscriminatory, and includes coverage for the most effective and appropriate treatment.”46 Coverage for mental illness should be equal in scope to coverage for other illnesses and all clinically-effective treatments appropriate to the needs of individuals with mental illness should be covered.

CONCLUSION

Family physicians play an important role in the provision of mental health care services in the U.S. and are well trained to provide many types of mental health care services. It is imperative that family physicians work to integrate with mental and behavioral health care providers to better meet their patients’ needs when possible. A variety of models and resources exist to assist them with filling the existing gaps in the provision of mental health care services in the U.S., especially related to vulnerable populations. In this manner, family physicians can work to meet both the physical and mental health care needs of their patients.

REFERENCES:

1. National Alliance on Mental Illness. Mental health by the numbers. https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers(www.nami.org). Accessed January 22, 2018.

2. Murray CJL, Atkinson C, Bhalla K, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591.

3. Substance Abuse and Mental Health Services Administration. Projections of national expenditures for mental and substance use disorders, 2010-2020. 2014.  https://store.samhsa.gov/shin/content/SMA14-4883/SMA14-4883.pdf(store.samhsa.gov). Accessed January 22, 2018.

4. Simon GE, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry. 1995;52(10):850.

5. Xierali IM, Tong ST, Petterson SM, Puffer JC, Phillips RL, Bazemore AW. Family physicians are essential for mental health care delivery. J Am Board Fam Med. 2013;26(2):114-115.

6. Cunningham PJ. Beyond Parity: Primary Care Physicians’ Perspectives On Access To Mental Health Care. Health Aff. 2009;28(3):w490-w501.

7. Petterson SM, Phillips RL, Bazemore AW, Dodoo MS, Zhang X, Green LA. Why there must be room for mental health in the medical home. Am Fam Physician. 2008;77(6):757.

8. Blount A. Integrated primary care: organizing the evidence. Fam Syst Heal. 2003;21(2):121-133.

9. deGruy FV, Etz RS. Attending to the whole person in the patient-centered medical home: the case for incorporating mental healthcare, substance abuse care, and health behavior change. Fam Syst Heal. 2010;28(4):298-307.

10. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759-769.

11. Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med. 2005;352(24):2515-2523.

12. Abed Faghri NM, Boisvert CM, Faghri S. Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions. Ment Health Fam Med. 2010;7(1):17-25.

13. DeGruy F. Mental health care in the primary care setting. Primary Care: America’s Health in a New Era. Institute of Medicine. Committee on the Future of Primary Care. National Academies Press. 1996.

14. Fischetti LR, McCutchan FC. A contextual history of the behavioral sciences in family medicine revisited. Fam Syst Heal. 2002;20(2):113-129.

15. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine. 2017.https://www.acgme.org/Portals/0/PFAssets/ReviewandComment/120-17-FamilyMedicine-2017-11-13-R&C.doc.pdf(www.acgme.org). Accessed January 22, 2018.

16. LeFevre ML, U.S. Preventive Services Task Force. Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;160(10):719.

17. Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on maternal mental health: perinatal depression and anxiety. Obstet Gynecol. 2017;129(3):422-430.

18. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-713.

19. Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL. Trends in postpartum depressive symptoms — 27 states, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep. 2017;66(6):153-158.

20. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol. 2011;118(5):1056-1063.

21. Savoy M, O’Gurek DT. Screening your adult patients for depression. Fam Pract Manag. 2016;23(2):16-20.

22. Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. https://www.milbank.org/wp-content/uploads/2016/04/EvolvingCare.pdf(www.milbank.org). Accessed January 22, 2018.

23. American Psychiatric Association Academy of Psychosomatic Medicine. Dissemination of integrated care within adult primary care settings. file:///Users/mike/Downloads/APA-APM-Dissemination-Integrated-Care-Report.pdf. Accessed January 22, 2018.

24. Mehrotra A, Huskamp HA, Souza J, et al. Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Aff (Millwood). 2017;36(5):909-917.

25. Sockalingam S, Arena A, Serhal E, Mohri L, Alloo J, Crawford A. Building provincial mental health capacity in primary care: an evaluation of a Project ECHO mental health program. Acad Psychiatry. 2017.

26. National Council for Behavioral Health. Trauma-informed approaches learning communities. https://www.thenationalcouncil.org/consulting-best-practices/areas-of-expertise/trauma-informed-care-learning-community/(www.thenationalcouncil.org). Accessed January 22, 2018.

27. Agency for Healthcare Research and Quality. Trauma-informed care.  https://www.ahrq.gov/professionals/prevention-chronic-care/healthier-pregnancy/preventive/trauma.html(www.ahrq.gov). Accessed January 22, 2018.

28. Oral R, Ramirez M, Coohey C, et al. Adverse childhood experiences and trauma informed care: the future of health care. Pediatr Res. 2016;79(1-2):227-233.

29. Decker MR, Flessa S, Pillai R V., et al. Implementing trauma-informed partner violence assessment in family planning clinics. J Women’s Heal. April 2017:jwh.2016.6093.

30. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698-709.

31. Hegarty K, Tarzia L, Hooker L, Taft A. Interventions to support recovery after domestic and sexual violence in primary care. Int Rev Psychiatry. 2016;28(5):519-532.

32. Sales JM, Swartzendruber A, Phillips AL. Trauma-informed HIV prevention and treatment. Curr HIV/AIDS Rep. 2016;13(6):374-382.

33. Schiff DM, Zuckerman B, Hutton E, Genatossio C, Michelson C, Bair-Merritt M. Development and pilot implementation of a trauma-informed care curriculum for pediatric residents. Acad Pediatr. 2017;17(7):794-796.

34. Green BL, Saunders PA, Power E, et al. Trauma-informed medical care: CME communication training for primary care providers. Fam Med. 2015;47(1):7-14.

35. Ravi A, Little V. Curbside Consultation. Providing trauma-informed care. Am Fam Physician. 2017;95(10).

36. Tanielian T, Jaycox LH, Schell T, et al. Invisible wounds. Mental health and cognitive care needs of America's returning veterans. RAND Corporation. 2008. https://www.rand.org/pubs/research_briefs/RB9336.html(www.rand.org). Accessed January 22, 2018.

37. Substance Abuse and Mental Health Services Administration. Results from the 2015 National Survey On Drug Use And Health: detailed tables. Prevalence estimates, standard errors, P values, and sample sizes. 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf(www.samhsa.gov). Accessed January 22, 2018.

38. National Center for Education Statistics. Fast facts. Back to school statistics.  https://nces.ed.gov/fastfacts/display.asp?id=372(nces.ed.gov). Accessed January 22, 2018.

39. Center for Collegiate Mental Health. 2017 Annual Report. https://sites.psu.edu/ccmh/files/2018/01/2017_CCMH_Report-1r3iri4.pdf(sites.psu.edu). Accessed January 22, 2018.

40. Turner JC, Ke 384 ller A. Leading causes of mortality among American college students at 4-year institutions. Conference Paper: American Public Health Association 139th Annual Meeting and Exposition. Washington, D.C. 2011.  https://apha.confex.com/apha/139am/webprogram/Paper241696.html(apha.confex.com). Accessed January 22, 2018.

41. Unwin BK, Goodie J, Reamy B v., Quinlan J. Care of the college student. Am Fam Physician. 2013;88(9):596-604.

42. Centers for Disease Control and Prevention. Tobacco use among adults with mental illness and substance use disorders. https://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm(www.cdc.gov). Accessed January 22, 2018.

43. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥ 18 years with mental illness — United States, 2009-2011. MMWR. 2013;62(05):81-87.

44. Bandiera FC, Anteneh B, Le T, Delucchi K, Guydish J. Tobacco-related mortality among persons with mental health and substance abuse problems. PLoS One. 2015;10(3):e0120581.

45. Press MJ, Howe R, Schoenbaum M, et al. Medicare payment for behavioral health integration. N Engl J Med. 2017;376(5):405-407.

46. National Alliance on Mental Illness. Public policy platform of the National Alliance on Mental Illness. Twelfth Edition. 2016. https://www.nami.org/getattachment/Learn-More/Mental-Health-Public-Policy/Public-Policy-Platform-December-2016-(1).pdf(www.nami.org). Accessed January 22, 2018.

(2001) (2018 COD)