Background of psychosocial services in rural primary care
Many persons concerned with the delivery of health care services have encouraged a change in our current system to increase the likelihood of responsibly meeting the critical mental health needs of rural primary care patients.32-34 Several models have been proposed, but few have been tested. For example, formal linkages between rural health and mental health professionals in the United States were attempted on a small scale in the 1970s, when community mental health workers were assigned to primary care practices, usually for 1 half-day per week.35-38 Although linkage did show early promise,39 the model was abandoned in the early 1980s with the advent of block grant funding,23 and formal outcome evaluations were not carried out. However, one of the authors (L.W.B.) has personal experience that linkage was frequently unacceptable to rural patients because of the association of the linkage worker with the mental health clinic. Other exploratory collaborative arrangements have ranged from simple referral agreements to fully integrated health/mental health teams working together on-site. The potential significance of these efforts for rural practice, however, awaits empirical scrutiny. In metropolitan and group primary care settings, several primary care trials of co-located collaborative care are currently underway and show great promise.40,41 In smaller and more isolated rural practices, however, these models are neither practical nor affordable. Consequently, they are unlikely to emerge as a solution to rural mental health needs in the future.
One recommendation being proposed with increasing frequency is that every family physician have a staff member trained to provide psychological treatment.9,23,35,36,42-46 This innovation moves in the right direction, but any approach failing to accommodate both patients’ preferences for care and their environmental challenges is unlikely to succeed. Physicians report, for example, that depressed patients in primary care tend to have multiple psychosocial and environmental service needs, such as counseling, education, financial assistance, help with life transitions, and other concrete services.47 Psychological treatment alone, particularly treatment experienced as “psychiatric,” does not provide an acceptable goodness of fit with many rural patients and their problem definitions. In a study of 600 low-income and minority patients with mental disorders, for example,15 categories of requests for treatment were generated from patient interviews, and none was related to psychiatric symptomatology.26,27 Nearly all requests focused instead on getting help in solving life problems. Identifying “problems in living,” a broader concept than psychiatric diagnosis, is apt to appeal more to rural patients and physicians alike. A treatment strategy employing a psychosocial orientation, therefore, is more likely to match the framework for help that physicians and patients in rural settings prefer.
Integrated services
We propose that psychosocial services be fully integrated within the primary care practice setting to enhance the treatment of rural patients with mental health disorders. This type of integration is in the best interest of physicians and their patients. Access to critically needed treatment is improved, patient preference for immediate on-site care is provided, psychiatric labeling and social stigma are reduced, and the burden of time-consuming mental health care is lifted from the physician. A broad psychosocial approach, embracing environmental as well as intrapsychic sources of patient distress, best matches the kinds of life problems found among rural patients with mental health disorders, such as depression.
On-site provision of integrated psychosocial services within the primary care practice also removes barriers to treatment access. Patients can be seen quickly, and their psychosocial needs can be addressed by someone who is viewed as a primary care employee, eliminating the stigma of outside mental health consultation. (These advantages will only be realized, however, if sufficient services with per practice flexibility are made available to meet the demand.) Cognitive psychological therapies that focus on life problems and employ problem-solving strategies can be seamlessly infused into a classic case management model recognizing environmental and psychosocial needs of patients. Psychosocial providers can therefore act to mobilize personal, interpersonal, and community resources as they maintain a life problem framework that is more acceptable to these patients than psychiatric referral. The integration of psychosocial services into primary care also permits greater opportunity for exploration of comorbid syndromes and psychological disorders that might otherwise be overlooked in the fast-paced culture of primary care.
Advantages of integration
In a survey conducted by Badger and colleagues,47 primary care physicians from the rural southeastern United States reported strong support for the integration of psychosocial services into their practices and endorsed a vast array of case management services as potentially useful. In a series of focus groups held in 1997 and 1998, a more geographically diverse group of more than 50 rural primary care physician members of the Ambulatory Sentinel Primary Care Network felt that fully integrated psychosocial services would be far more acceptable and beneficial to both patients and physicians than most existing systems of collaboration or referral. They strongly supported a model of integrated services that included a partnership between the physician and the psychosocial care provider, who they felt should be a full-time employee of the practice with shared participation in the treatment protocol, medical record keeping, and responsibility for comprehensive patient care.