Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

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Original Research

Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

J Fam Pract. 2001 January;50(1):41-47

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Although the prevalence of virtually all biomedical, psychosocial, and psychiatric illnesses is greater in the underprivileged, special attention needs to be paid to addressing cognitive, psychosocial, and psychiatric issues. The high prevalence of mental disorders may lead to chronic disability,³⁴ perpetuating poverty. Mental illness complicates the management of chronic medical illness and increases risks for illness and death.³⁵ Diminished sense of control of life compromises self-care^36,37 and well-being.³⁸

The majority (90%) of Marillac patients preferred their medical providers and mental health providers to communicate with one another about their health care. These patient preferences combined with research supporting the use of collaborative designs represented a compelling argument for system redesign. The findings of this study helped secure 4 years of funding from the Robert Wood Johnson 2000 Local Initiative Funding Partners Program to match funding from local contributors lead by the Colorado Trust. These funds will pay for on-site counselors, case managers, psychiatric and substance abuse assessments, group treatments, and ongoing training to create stronger linkages with a variety of community agencies (The Mesa County Coalition on Health). Marillac has adopted Collaborative Family Health Care,³⁹ a model emphasizing teamwork between biomedical, nursing, and psychosocial providers, and that views the patient^40,41 and family^42-44 as crucial in treatment design and implementation. System adjustments emphasized the management of chronic illness⁴⁵ with a focus on the psychosocial needs of this population.⁴⁶ More details of these changes are described elsewhere.⁴⁷

Limitations

The major limitation of our study may be lack of generalizability to other indigent primary care populations. More studies are needed that examine the prevalence of mental illnesses and relationships with functional status and disability in poor, urban populations with and without health insurance. Most subjects in our study are white and speak English. The prevalence and nature of mental disorders among urban diverse primary care patients may differ from the profiles we have described. In our study the method used to assess medical comorbidity relied on patient report. Patients may have under-reported or over-reported physical illness. Some symptoms reported on the PHQ could be caused by medical illnesses, and many may be medically unexplained.⁴⁸ In the PHQ study, mental health professionals interviewed patients to validate survey findings. We assume that responses from this low-income population are valid, but future studies may want to further validate the PHQ in indigent samples. Our data probably underestimate overall prevalence of mental disorders in Marillac patients, because the number of disorders detected by the PHQ is limited. The Marillac population was younger (18-64 years) than the PHQ-3000 sample (19-99 years). An older population may have a different prevalence of mental disorders, levels of functional status, and service use. The relationships among these variables may also be different.

Conclusions

We found an indigent uninsured primary care adult population to have an extremely high prevalence of current mental disorders. Also, in addition to the expected decrease in functional status for those with severe mental disorders, the functional status of the entire clinic population was quite low. A sizable portion of the literature suggests that much of this diminished health-related quality of life might be the expression of an impoverished existence. Beyond financial poverty and limited education, the chronically poor person suffers from a higher prevalence of mental illness and a limited sense of being able to control the future. Patient preferences support provider and policy recommendations for the integration of mental health and primary care services. These health care designs may increase our potential to improve the health of those with the greatest need.⁴⁹

Acknowledgments

Between August 1998 and July 1999 Mr Mauksch was on leave from the University of Washington Department of Family Medicine as a consultant in collaborative care to the Marillac Clinic. Funding for his position came from the Brownson Memorial Fund, the Victim/Witness Assistance and Law Enforcement Fund—21st Judicial District of Colorado, the Sisters of Charity, and St. Mary’s Hospital.

We wish to thank the Marillac Clinic medical assistants, administrative staff, community volunteers, and clinicians who contributed to this study in many essential ways. Because no additional financial support was used to fund this study, the role of the entire clinic community was critical for its successful completion.

The authors thank Jurgen Unützer, MD, for help in selecting an instrument to measure medical comorbidity.

Related Resources:

The Collaborative Family HealthCare Coalition www.cfhcc.org
The Institute for Healthcare Improvement-Information on “Improving Care for People with Chronic Conditions,” a national congress with a focus on asthma and depression www.ihi.org
Anxiety Disorders Association of America www.adaa.org
National Depressive and Manic Depressive Association www.ndmda.org