Mind and body: Consults are easier when they're close by

Seeing a benefit to patient care, some primary care physicians are bringing mental health experts into their practices.

By Myrle Croasdale — Posted Feb. 13, 2006

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Getting a psychiatric consultation or therapist appointment for her patients is simple for Kentucky internist Margaret Altman, MD. She walks down the hall to the Caritas Peace Counseling Center, which has these experts on staff.

"It's something that every primary care office needs," said Dr. Altman, who practices with Jefferson Internal Medicine in Louisville. "Either in your office or across the hall, you need someone you can refer to and get patients in to see in a timely fashion."

Physicians are more aware of mental health issues that warrant treatment, physician leaders say. At the same time, they are finding it more difficult to get timely psychiatric consultations. To speed the process and ease the stigma of getting mental health treatment, some physicians are bringing psychiatrists, psychologists and licensed social workers into their offices. Or, as in the case of Dr. Altman, physicians are forming relationships with mental health professionals in the same building.

"A lot of times, I'll walk down the hall with a chart and make the appointment myself," Dr. Altman said. "Once in a while, I will have one of the therapists who's free come back with me and see the person in my exam room."

If patients are particularly upset, Dr. Altman even will walk them down and introduce them to the therapist.

Although there are no data on how many primary care physicians have a behavioral health professional in the office, Russ Newman, PhD, executive director of the American Psychological Assn., believes the practice is increasing.

"The connection between mind and body is better recognized by the public and better attended to by our health care system," he said.

Congress is funding a number of demonstration projects examining the link between physical illness and emotional complications in a variety of settings and populations, Dr. Newman said. Also, some health insurers, such as Aetna, are ending behavioral health carve-outs and bringing those services back under the same umbrella with medical claims.

For physicians who have completed Aetna's depression-screening training program, the health plan will even pay extra for asking questions to determine whether patients need mental health services.

"There's a recognition by Congress and managed care that there is better quality care and cost savings when you integrate the physical and the psychological," Dr. Newman said.

Paul Wick, MD, head of an American Psychiatric Assn. committee on managed care and a psychiatrist in Tyler, Texas, said his large multispecialty group, which includes internists, has integrated services for years. But he said he had noticed that more physicians were integrating psychologists into their primary care fold. Lawson Wulsin, MD, director of the primary care psychiatry residency at University of Cincinnati in Ohio, said the integration had been especially popular in some parts of the country.

"There's some push from above for it to happen, mainly at the policy-making level, and some push from patients," he said. "But there's a fair amount of resistance in the middle from tradition, inertia and insurance companies."

How it works in Louisville

Psychiatrist Michael Harris, MD, believes this integration is a positive experience for patients. He is one of two adult psychiatrists available to physicians in Louisville within the Caritas Physician Group as part of a pilot program to bring mental health care into primary care practices. Two child and adolescent psychiatrists and several psychologists and licensed social workers also are part of the pilot.

The therapists and psychiatrists in the pilot are spread among three primary care practices in the Caritas system, which includes Dr. Altman's office, as well as a large independent pediatric practice. Two other primary care offices are expected be added before June.

"Psychiatry is an especially appropriate specialty to integrate with primary care because of the large overlap in our patient bases," said Dr. Harris, who splits his time between several physician offices and hospital settings. "Even if [primary care physicians] are comfortable managing these disorders, having a psychiatrist in the office takes it to another level."

Dr. Harris handles psychiatric assessments and medication management, referring those needing counseling to therapists on his team.

"If we can work it out, the patient sees the primary care doctor, psychiatrist and counselor all in the same office," he said.

When Dr. Harris started in 2004, it took six months for his schedule to fill, but he's been busy ever since. JoAnne DeLorenzo Maamry, chief executive of Our Lady of Peace, part of Jewish Hospital & St. Mary's HealthCare, which owns the Caritas Physician Group, said there were 8,800 patient visits through the pilot program in fiscal 2003. In fiscal 2004, visits tripled to 25,000, and for fiscal year 2005, they may reach 30,000, Maamry said.

She said the health care system's primary care physicians were eager to participate. The integration effort started after a survey asking them to identify needs showed that 40% to 60% of the doctors' patients had a mental or substance abuse issue that merited intervention. At the same time, physicians said they were having trouble getting timely psychiatric evaluations.

Gaining momentum

The idea of integrating primary care and mental health issues is not entirely new.

Caroline Carney Doebbeling, MD, president of the Assn. of Medicine and Psychiatry, an organization of dual-boarded internists, family physicians and psychiatrists, said the movement might have begun with cancer clinics. She said many major cancer clinics have psycho-oncology programs. Bariatric surgical centers also rely on mental health professionals for patient evaluations before surgery. Dr. Doebbeling, director of psycho-oncology for the University of Indiana Cancer Center, also gets several requests from cardiovascular practices for psychiatric referrals.

For primary care physicians, access to behavioral health experts can be a boon, she said, because depression and anxiety might exacerbate other medical concerns.

"Primary care physicians are often called on to deal with complex patients with multiple somatic complaints," Dr. Doebbeling said. She said integrating mental health into the medical office also helps patients overcome the stigma still attached to mental health treatment.

Patients feel more comfortable going to a familiar office, and getting mental health care in a medical office makes it feel routine, said Howard Feldman, PhD, a clinical psychologist at the Center for Integrative Medicine in Chicago. He sees patients from this practice as well as from other internists within the Northwestern Memorial Physicians Group. Demand is so high that the Center for Integrative Medicine is considering adding a second psychologist.

Theri Raby, MD, medical director and general internist at the Center for Integrative Medicine, will call in Dr. Feldman to meet patients when she refers them for counseling.

Dr. Feldman said this step increases patient compliance by a significant amount. "They get a better understanding of your approach, and we get much better follow-up instead of giving them two names and telling them to call for their own appointment," he said.

Continuity of care is improved, too, physicians and therapists said.

The physician and psychiatrist or psychologist can talk face-to-face instead of waiting to receive a dictated letter, Dr. Doebbeling said.

"Eighty percent of the time, you'll never hear back from the psychiatrist," she said. "At the same time, the patient shows up with no information and will have no clue to what medications they're on."

In cases in which a medication did not produce the hoped-for result or if a patient is going downhill quickly, Dr. Harris said, the primary care doctor can pull the psychiatrist aside, receive an update and see the patient more quickly under the integrated system.

The system also allows Dr. Feldman to work on cases beyond depression. He is able to see patients dealing with chronic disease. A patient with irritable bowel syndrome, for example, will see the naturopath at the center for dietary help, while Dr. Feldman will work with the patient on the stress component of the disease.

"The patient may have enhanced sensitivity to abdominal pain, which triggers anxiety," Dr. Feldman said. "Living a stressful life can impact the GI process. I work with them to give them longer-range skills to deal with the stress, so we can move the person along in the process to get a better medical result. ... It winds up saving physicians time."

Making it work

While such collaboration is appealing, it takes commitment to make it work.

Dr. Harris said the practices where he sees patients have had to hire support staff to handle the large volume of calls and requests for prescription refills his patient base generates.

Dr. Wulsin said the billing side of integration could be a challenge.

"Primary care physicians who have a mental health specialist in their group love it, and their patients love it," he said. "The billing people may not, though, because it can be a more complicated process."

Health insurers' behavioral health carve-outs make the billing process complicated, he said. But in the long run, Dr. Wulsin believes integration is an investment that will pay off.

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Dual residencies

Nearly 1,300 primary care physicians are also psychiatrists. This academic year, 37 residency programs allowed doctors to combine primary care with psychiatry, down from 50 in 1999-2000.

Specialties 2005-06 residency programs Physicians in the field
Internal medicine/psychiatry 17 399
Family medicine/psychiatry 10 113
Pediatrics/child and adolescent psychiatry 10 263

Source: Graduate Medical Education Directories, the American Board of Medical Specialties

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Primary care and mental disorders

Here are highlights from five studies, published in The Journal of Family Practice over the past six years, examining how primary care practices treat mental disorders.

  • Depression in a general medicine practice is as common as hypertension and arthritis.
  • Primary care physicians identify only half of patients who show signs of depression.
  • Physicians who recognize depression in patients ask more questions about a patient's feelings.
  • Primary care physicians prescribe 80% of antidepressants.
  • A combination of cognitive therapy and medication is considered the most effective depression treatment.
  • Nearly half of all patients stop taking antidepressant medication within the first month of treatment.

Sources: The Journal of Family Practice archives

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