Management of Mental Disorders in Rural Primary Care A Proposal for Integrated Psychosocial Services

,

Original Research

Management of Mental Disorders in Rural Primary Care A Proposal for Integrated Psychosocial Services

J Fam Pract. 1999 October;48(10):813-818

By

Lee Badger, PhD

References

1. Greenberg PE, Stiglin LE, Finklestein SN, Berndt ER. The economic burden of depression. J Clin Psychiatry 1993;54:405-38.

2. Rost K, Wherry J, Williams C, Smith GR. Depression in rural primary care practices: treatment and outcomes. National Institute of Mental Health research conference on mental health problems in the general health care sector; 1992.

3. Philbrick JT, Connelly JE, Wofford AB. The prevalence of mental disorders in rural office practice. J Gen Intern Med 1996;11:9-15.

4. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry 1998;20:12-20.

5. Rost K, Zhang M. Differences in use of services by depressed rural and urban residents. Eighth annual National Institute of Mental Health international research conference on mental health problems in the general health care sector. Washington, DC; 1994.

6. Yuen EJ, Gerdes JL, Gonzales JJ. Patterns of rural mental health: an exploratory study. Gen Hosp Psychiatry 1996;18:14-21.

7. Schulberg HC, Block M, Madonia M. Treating major depression in primary care patients. Arch Gen Psychiatry 1996;53:913-9.

8. Katon W, Robinson P, Von Korff M, et al. A mulifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53:924-32.

9. Mynors-Wallis L. Problem-solving treatment: evidence of effectiveness and feasibility in primary care. Int J Psychiatry Med 1996;26:249-62.

10. Klerman G, Weissman M, Rounsaville B, Chevron E. Interpersonal psychotherapy of depression. New York, NY: Basic Books; 1984.

11. Grusky O, Tierney K. Evaluating the effectiveness of country wide mental health care systems. Community Ment Health J 1989;25:3-20.

12. Rost K, Humphrey J, Kelleher K. Physicians’ management p and barriers to care for rural patients with depression. Arch Fam Med 1994;3:409-14.

13. Lerner R, Blackwell B. The GP as a psychiatric community resource. Br J Prev Soc Med 1975;11:1,-3-9.

14. Flaskerud JH, Kviz FJ. Resources rural consumers indicate they would use for mental health problems. Community Ment Health J 1982;18:107-19.

15. Geller JM. The role of rural primary care physicians in the provision of mental health services: letter to the field #5. Grand Forks, ND: The Center for Rural Health, University of North Dakota School of Medicine and Health Sciences; 1997.

16. Schulberg HC, Saul M, McClelland M, Ganguli M, Christy W, Frank R. Assessing depression in primary medical and psychiatric practices. Arch Gen Psychiatry 1985;42:1164-70.

17. Katon W, Berg AO, Robins AJ, et al. Depression: medical utilization and somatization. West J Med 1986;144:564-8.

18. deGruy FV. Mental health care in the primary care setting. Appendix D. Washington, DC: Institute of Medicine; 1996.

19. Rost K, Zhang M, Fortney JC. One year outcomes among untreated depressed individuals: implications for outreach efforts. National Institute of Mental Health mental health services research conference. Washington, DC: National Insitute of Mental Health; 1995.

20. Blouin A, Perez E, Minoletti A. Compliance to referrals from the psychiatric emergency room. Can J Psychiatry 1985;30:103-6.

21. Jellinek MS, Murphy JM. Screening for psychosocial disorders in pediatric practice. Am J Dis Child 1988;142:1153-7.

22. Sweeney JA, Von Bulow B, Shear MK, Friedman R, Plowe C. Compliance and outcome of patients accompanied by relatives to evaluation. Hosp Community Psychiatry 1984;35:1037-8.

23. Zimmerman MA, Wienckowski LA. Revisiting health and mental health linkages: a policy whose time has come…again. J Public Health Policy 1991;12:510-24.

24. Berry B, Davis AE. Community mental health ideology: a problematic model for rural areas. Am J Orthopsychiatry 1978;48:673-9.

25. Hauenstein E, Saby PB. Functional disability and psychiatric morbidity among young women in rural primary care. Tenth annual conference on mental health problems in the general medical sector. Washington, DC: National Institute of Mental Health; 1996.

26. Acosta F, Yamamoto J, Evans LA. Effective psychotherapy for low-income minority patients. New York, NY: Plenum Press; 1982.

27. Azocar F, Miranda J, Durger EV. The relationship between attachment and dissociation in adult survivors of incest. Women Ther 1996;18:91-105.

28. Hill CE, Fraser GJ. Local knowledge and rural mental health reform. Community Ment Health J 1995;31:553-68.

29. Jeffrey MJ, Reeve RE. Community mental health services in rural areas: some practical issues. Community Ment Health J 1978;14:54-62.

30. Rost K, Smith GR, Taylor JL. Rural-urban differences in stigma and use of care for depressive disorders. J Rural Health 1993;9:57-62.

31. Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19:98-111.

32. Miranda J, Munoz R. Intervention for minor depression in primary care. Psychosom Med 1994;56:136-42.

33. Pardes H. The provision of mental health services in primary care settings. In: Parron DL, Solomon F, eds. Mental health services in general health care. Volume 1. Washington, DC: US Department of Health and Human Services, National Institute of Mental Health, Division of Biometry and Epidemiology and Division of Mental Health Service Programs; 1980.

34. Mechanic D. Mental health services in the context of health insurance reform. Milbank Q 1993;71:349-64.

35. Coleman JV, Patrick DL. Integrating mental health services into primary medical care. Med Care 1976;14:654-61.

36. Coleman JV, Patrick DL, Eagle J, Hermalin JA. Collaboration, consultation and referral in an integrated health-mental health program at an HMO. Soc Work Health Care 1979;5:83-96.

37. Marks E, Broskowski A. Community mental health and organized health care linkages. In: Broskowski A, ed. Linking health and mental health. Beverly Hills, Calif: Sage Publications; 1981.

38. Morrill R. A new mental health services model for a comprehensive neighborhood health center. Am J Public Health 1972;62:1108-11.

39. Broskowski A, Marks E, Budman SH. Linking health and mental health. Beverly Hills, Calif: Sage Publications; 1981.

40. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. Eighth annual National Institute of Mental Health international research conference on mental health problems in the general health care sector. Tyson’s Corner, Va: National Institute of Mental Health; 1994;27-8.

41. Schulberg HE, Block MR, Perel J, Madonia MJ, Scott P, Rodriguez E. The practice of clinical guideline pharmacotherapy for major depression in primary care settings. Seventh annual National Institute of Mental Health international research conference on mental health problems in the general health care sector. Tyson’s Corner, Va: National Institute of Mental Health; 1993.

42. Lader MH, Beaumont G, Bond A. Guideline to the management of patients with generalized aniety. Psychiatr Bull 1992;16:560-6.

43. Eisenberg L. Treating depression and anxiety in primary care. N Eng J Med 1992;326:1080-4.

44. Brochstein JR, Adams GL, Tristan MP, Cheney CC. Social work and primary health care: an integrative approach. Soc Work Health Care 1979;5:71-81.

45. Pincus HA. Patient-oriented models for linking primary care and mental health care. Gen Hosp Psychiatry 1987;9:95-101.

46. Goldberg RJ, Novack D, Gask L. The recognition and management of somatization: what is needed in primary care training. Psychosomatics 1992;33:55-61.

47. Badger LW, Ackerson B, Buttell F, Rand ER. The case for integration of social work psychosocial services in rural primary care practice. Health Soc Work 1997;22:1-10.

48. Health Resources and Services Administration. Mental health providers: supply and distribution. Washington, DC: Health Resources and Services Administration; 1992.

49. Wagenfeld MO, Murray JD, Mohatt DF, DeBruyn JC. Mental health and rural America: 1990-1993. Washington, DC: Office of Rural Health Policy, US Department of Health and Human Services; 1993.

50. Austin CD, McClelland RW. Case management in the human services: reflections of public policy. J Case Manage 1997;6:119-26.

51. Solomon P. The conceptual and empirical base of case management for adults with severe mental illness. In: Williams JBW, Ell K, eds. Advances in mental health research: implications for practice. Washington, DC: National Association of Social Workers Press; 1998;482-97.

52. Orcutt B. Science and inquiry in social work practice. New York, NY: Columbia University Press; 1990.

53. Germain C. Technological advances. In: Rosenblatt A, Waldfogel D, eds. Handbook of clinical social work. San Francisco, Calif: Jossey-Bass; 1983.

54. Hepworth D, Larson J. Direct social work practice: theory and skills. Belmont, Calif: Wadsworth; 1990.

55. Mynors-Wallis L, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. BMJ 1995;310:441-5.

56. Reid WJ. The task-centered system. New York, NY: Columbia University Press; 1978.

57. Reid WJ. Task strategies: an empirical approach to clinical social work. New York, NY: Columbia University Press; 1992.

58. Vanselow NA, Donaldson MS. From the Institute of Medicine: a new definition of primary care. JAMA 1996;273:192.

Mental health facilities and specialized providers are particularly lacking in rural areas. Even when these are available, poverty, negative attitudes toward mental health treatments, and traditional rural values of privacy and autonomy often result in low utilization rates. Consequently, most mental health care in rural America is provided by primary care physicians who are also faced with competing demands, including tensions among limited time and resources, the multiple and complex needs of patients, and economic forces determining reimbursements. We propose that in the best interest of physicians and their patients, fully integrated psychosocial services in rural primary care settings would reduce the burden of time-consuming mental health care, conform to patient preference for immediate on-site care, reduce nonproductive medical care use, and eliminate duplication of effort by physicians and mental health professionals. The treatment model we propose would provide multiple arenas for psychosocial intervention—with the individual, the family, and the community—based on the patient’s self-identified needs. The integration of psychosocial services within primary rural care is readily available, economically feasible, and urgently needed, but physicians must take the lead to implement this collaborative treatment partnership.

Eleven million Americans and their families bear the emotional and financial pain of depression,¹ the most prevalent mental health disorder affecting the general population. Many of them are affected chronically, and the sequelae of depression—suicide, addiction, and emotional turmoil—continue to plague family members for generations. The greatest need for help may be in rural America, where patients have rates of major depression equal to or higher than their counterparts in metropolitan areas^2-4 and are as many as 9 times more likely to be hospitalized.^5,6 Unfortunately, many of those suffering from major depression do not receive treatment, even as pharmacologic and psychologic interventions are proving to be efficacious.^7-10 Mental health facilities and specialized providers are particularly scarce in rural areas. Even when they are available, poverty, negative attitudes toward mental health treatments, and traditional rural values of privacy and autonomy result in low utilization rates.^2,11,12 Rural primary care patients overwhelmingly prefer that mental health treatment be provided in the primary care setting.^13-15 Not surprisingly then, the greater part of mental health care in rural America is provided by primary care physicians who confront the complex task of weighing the social, psychological, and biological factors influencing their patients’ requests for medical help.

Challenges to mental health care in rural communities

Diagnosis

There are few greater challenges in rural primary care than the detection, diagnosis, and treatment of depression and related mood disorders. Poorly defined symptoms, diffuse somatic complaints, subthreshold symptoms, and high medical comorbidity may confound diagnosis. Primary care physicians’ severe time constraints fuel a well-documented and disturbing practice paradox: More than one half of all people suffering from mental disorders seek help through primary care, yet the majority of their conditions—from 50% to 80%—are not diagnosed or are misdiagnosed, and therefore these patients are not treated for their disorders.^16,17 Some of these unrecognized cases may not fit traditional diagnostic criteria, and the patients may not benefit from disorder-level treatments.¹⁸ However, patients who suffer from major depression, a disorder for which the diagnostic criteria are applicable, unquestionably need attention and care. It is especially distressing that more than two thirds of the rural patients treated for depression in primary care still meet criteria for major depression 5 months later.^2,19

Treatment

Accurate diagnosis of depression is only one part of the challenge faced by rural primary care physicians. After a diagnosis is made, significant questions still remain as to who will treat the patient for this disease, what treatment will be offered, and where that treatment will take place. Referral to specialty mental health services is one option for overburdened physicians, particularly those more comfortable with treating the biomedical aspects of disease than the psychosocial ones. Rural patients can be particularly resistant to referral,¹² however, and their physicians have reported that the effectiveness of referral to specialty care is frequently unsatisfactory because of the few referral sources in rural areas,¹¹ the resulting long waiting lists, and inadequate follow-up.¹² Consequently, from 30% to 74% of patients refuse to follow through when referral is suggested.^20-23 Many rural communities, moreover, are so removed from mental health clinics and mental health specialists that referral is not even an option.

Patient Perceptions

In addition to these structural barriers, mental health treatment of rural patients is especially difficult. These patients often do not recognize their problems as psychiatric,^12,24,25 and they do not want treatment that focuses on psychiatric symptoms.^24,26,27 Rural residents do not usually recognize the “mind-body” split, but rather intuitively integrate mental health, social health, and physical health,²⁸ which is precisely why they prefer to obtain their care in the primary care setting. In addition, many rural residents often will not seek or use mental health services because of the lack of anonymity in treatment, the stigma associated with treatment, and the value they often place on independence and privacy.^{2,11,12,15,29,30} In rural primary care, physicians are especially challenged to provide medical treatment within the press of competing demands, including tensions among limited time and resources, the multiple and complex needs of patients, and a formidable combination of government policies and economic forces determining insurance regulations and fee reimbursements.^18,31 Other primary care practice personnel, such as nurses and physician assistants, infrequently have the necessary training to diagnose and treat mental disorders, and almost never have the time to routinely carry out mental health care. It is unlikely, furthermore, that this situation will change in the future.