State Leadership Conference
A middle-aged man fails to manage his diabetes because of depression. A recently widowed woman complains of repeated, inexplicable chest pains. A young man caring for his mother with Alzheimer's disease reports insomnia and panic attacks.
All these cases have obvious psychosocial underpinnings, yet their treatment often stops with a physician more at ease with the physical than the psychological, said Margaret Heldring, PhD, at the 2006 State Leadership Conference (SLC).
The problem? The health-care system is set up to isolate and treat a single physical malady, so providers often overlook key mental and psychosocial health problems that can spur, interact with or exacerbate physical problems. And when providers do make mental health referrals, patients often don't pursue them, added psychologist Col. Larry C. James, PhD, chief of the psychology department at the Tripler Army Medical Center in Honolulu, at an SLC session on the intersection of psychological and physical health.
The solution? Integrated mental and physical health care, where multidisciplinary providers treat the whole patient from the get-go and track their progress long term, said session speakers. In fact, the President's New Freedom Commission on Mental Health recommended such integration in 2003, and the Institute of Medicine called for it as recently as last year, Heldring noted.
"The problem is there's a big gap between what patients are bringing and what providers are trained to provide and what the system is set up to reimburse," said Heldring. "In response to health-care fragmentation, the vision is integration of psychology and behavioral health into all health care, especially primary care and public health."
She noted that APA Past-president Ronald F. Levant, EdD, helped propel that mission with his 2005 "Health Care for the Whole Person" Initiative. In fact, Heldring, founder and president of the health advocacy organization America's Health Together, chaired the APA task force that put Levant's initiative into action.
The task force made inroads by enlisting a host of professional associations, including the American Public Health Association, the American Nurses Association and the American College of Obstetricians and Gynecologists. However, psychology has more work to do-through national and local policies-to realize an integrated health-care vision, argued Heldring, James and fellow panelist Helen L. Coons, PhD, at the SLC session. Nationally, they said, legislators need convincing that good physical health and sound mental health are interlinked. Locally, they said, patients and providers need psychologists to practice across the hall, not across town.
Talking the talk
SLC speakers noted a number of treatment shortfalls psychologists can highlight to persuade policy-makers and the public of the need for more comprehensive health care:
Mental health demands overwhelm primary care. General practitioners deliver 50 percent of mental health services, said James, and they prescribe close to 70 percent of psychotropic drugs. In addition, he said, well over half of primary-care visits involve psychosocial concerns. For example, psychological distress precipitates obesity, hypertension, asthma, diabetes and sleep disorders, to name a few conditions commonly seen in primary care.
Treatment is fragmented. Given the enormous volume of behaviorally based disorders-and physicians' predominantly physical focus-these conditions tend to be undertreated in primary care: Patients receive spotty education and advice, and as a result, their compliance with medical and behavioral treatments is low, said James. In addition, providers often overlook psychological disorders, and when they do recognize them, only 20 percent of patients follow through on their mental health referrals, according to research. What's more, informal studies by James at Walter Reed Army Medical Center suggest that patients who do pursue mental health referrals take, on average, 14 months to do so.
Armed with such data, James retooled psychological services at Walter Reed and at Tripler, moving them from separate outpatient clinics to the primary-care offices.
Costs are higher. Untreated behavioral and psychosocial problems take a toll on patients' physical health, placing an increased burden on primary care and driving up its costs, noted Heldring. She cited two studies to support her point: People with depression spend twice as much on health care as people without the condition, according to research published in 2005 in the Journal of General Internal Medicine (Vol. 20, No. 2, pages 160-167) and led by Roger G. Kathol, MD. In another study, by Jeremy A. Chiles, PhD, and colleagues that appeared in Clinical Psychology: Science and Practice (Vol. 6, No. 2, pages 204-220), when patients with mental health disorders underwent targeted psychological treatment, they reduced their health-care costs by 17 percent. Control participants increased their costs by 12.3 percent.
Walking the walk
Besides convincing lawmakers to integrate health care nationally, psychologists can also help make it happen locally, said SLC panelists. To do that, they advised psychologists in medical settings to:
Be accessible. Just like in real estate, the key to success in medical psychology is "location, location, location," said James. Position yourself on the same hall as primary-care providers so you can treat patients on their first visit. Be available for consultation and "take down the 'Do not disturb' sign,'" advised James. Traditionally, psychologists have discouraged interruptions during patient sessions, but that doesn't work in collaborative health care, he said.
As Coons put it, "Do the curbside consult-be available, visible and flexible." Coons does this herself. Through her private practice, Women's Mental Health Associates, she provides a range of clinical services in women's primary care, obstetrics, gynecology, reproductive endocrinology and oncology settings. For example, among other tasks, she prepares women for labor and delivery, evaluates couples considering fertility options, treats women with chronic medical conditions, and helps women deal with cancer.
Fit with the medical model. To work effectively on medical teams, you must know physiology and psychopharmocology well, advised James. Look the primary-care part by wearing the white lab coat, calling patients "patients," attending morning report, and walking rounds with other providers.
Collaborate. Move from a sole practitioner mentality to a team health outlook, and be prepared to work with a range of providers, such as nurse practitioners, social workers and physical therapists, advised Coons. In her work in reproductive health clinics, for instance, she shares patient education materials, relaxation aids and DVDs on genetic counseling with gynecologists, nurse practitioners and other staff. She also joins with them to lecture, write articles and grants and team teach-activities, she said, that promote the careers of all involved, as well as the comprehensive care of patients.
Putting such comprehensive care in a policy context, session chair Randy Phelps, PhD, noted that APA's Practice Directorate, of which he is deputy executive director and administrative director, has worked for more than a decade to integrate psychology into primary care and other health-care settings, building on recommendations made in 1996 by the APA Committee for the Advancement of Professional Practice's Primary Care Task Force. The advocacy efforts have involved creating tools to facilitate integration and reducing barriers to psychology's broad participation throughout the health-services delivery system.
For example, said Phelps, the directorate pursued a multiyear advocacy effort to create health and behavior CPT codes (see "New codes give psychologists more treatment flexibility"), which took effect in 2002. The codes enabled billing for psychological services provided to patients with a physical health diagnosis. The directorate also has facilitated demonstration projects that integrate psychological and physical health-services delivery, for example, in treating breast cancer and cardiovascular disease. In addition, the directorate successfully placed an APA Fellow in the U.S. Department of Health and Human Services Primary Care Policy Fellowship in all eight years of the program thus far.