For years we have heard arguments that splitting mental health from the biomedical sciences was harmful1,2 and that repairing this split, at least in the primary care setting, would result in better and perhaps less expensive care.3 But contemporary primary medical care is structured so that even conscientious, sympathetic, psychologically minded primary care physicians (PCPs) have an extraordinarily difficult time expanding their scope of practice to include the full biopsychosocial range of their patients’ problems as part of normal business.
Many investigators have pursued this problem. They have studied the effects of patients’ disorders being diagnosed before the examination and providing the PCP with those diagnoses4; of providing simple diagnostic tools for mental health diagnoses5; of providing PCPs with diagnoses augmented with management suggestions or algorithms6; of introducing professionals into the primary care setting who can manage mental health disorders in conjunction with the PCP7,8; and of removing these patients to special settings for individual or group treatment.9 The National Institute of Mental Health, the MacArthur Foundation, several pharmaceutical companies, and the Robert Wood Johnson Foundation are investing enormous amounts of money in research trying to figure out how to find and treat depression—the most common mental health disorder in primary care—as it occurs in this setting. We can anticipate similar efforts for other common mental health conditions.
What have we learned from all this? We know that PCPs generally agree that these are important health conditions that should be addressed, but the competing demands of a busy practice render simple physician education and physician-administered diagnostic instruments of transient and marginal benefit. Interventions that add resources to the practice, such as cognitive behavioral therapists, pharmacotherapists, psychiatric consultants, or group therapy sessions consistently show improved outcomes, but it is still unclear whether these benefits apply to the majority of affected primary care patients or selectively to only the subset of patients who meet research inclusion criteria. It would appear that the most effective interventions, involving the introduction of additional personnel into the system of care, do result in lower overall medical expenditures,10,11 but these savings are less than the cost of the interventions themselves. There is no medical cost offset to justify the programs of integrated care that have been studied, and we are looking instead at cost-effectiveness equations.
Recently the usual care of mental disorders, particularly depression, in the primary care setting has come under closer scrutiny. Some patients who meet the criteria for major depression are treated, and some are not. Of those treated, some are treated adequately, and some are not. Some researchers are reporting that all these patients—untreated, inadequately treated, and fully treated—seem to experience similar clinical outcomes and incur similar medical costs.12,13 This finding is hard to digest and suggests that we need to better understand what normally occurs between PCPs and their patients who have mental health disorders.
A Cost-Offset of Diagnoses?
In normal practices we encounter PCPs whose mental health care diagnostic behavior distributes along a continuum. Does the distribution of this behavior relate to a corresponding distribution in the cost of care? The answer, either way, sharpens subsequent research. It helps us know what kind of benefits we can expect from attention to mental conditions, and it gives us hints about where we might look for the underlying reasons. In this issue of the Journal Campbell and colleagues14 report the results of a large study designed to answer one aspect of this question. They report that PCPs who most frequently make mental health diagnoses are caring for the patients who incur the lowest medical expenditures. This initially suggests that in the usual care setting, there is a cost-offset effect associatedwith taking a biopsychosocial approach to primary care and that we are justified in encouraging primary care clinicians to make mental health diagnoses. But the situation is far more complicated than that, and the chain of inferences that lead from the study findings to this conclusion is long and tenuous. Alternative explanations must be entertained. We should look at this study a little more closely.
The patient and physician sample in the study by Campbell and coworkers is large and representative, and the utilization data is most likely complete and accurate. We have no reason to believe that these physicians practice a drastically different form of primary care than PCPs elsewhere in the country. Thus we can accept with reasonable confidence that the findings accurately represent primary care practice in Rochester, New York, and probably elsewhere in the United States. This requires corroboration, but provisional acceptance is justified.