Mental and Behavioral Disorders in Primary Care: Bridging the Gap

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[edit] Mental and Behavioral Disorders in Primary Care: Bridging the Gap

Steven A. Cole

Mental disorders in primary care are common, the source of significant suffering and disability, and often unrecognized or undertreated. Furthermore, primary care physicians often find that patients with mental or behavioral disorders can be personally troubling to them and emotionally difficult to manage. This section of the text focuses on these common conditions, with particular emphasis on the basic principles of assessment and management for the primary care practitioner.

Although each of the other chapters in the section reviews a particular problem in depth, this introductory chapter takes a broader perspective. Regardless of the specific psychiatric diagnosis, most patients with mental and behavioral disorders in primary care present the following difficulties for the practitioner:

• Somatic presentation
  
• Difficulty understanding and accepting that mental disorders usually cause physical suffering
  
• Reluctance to accept a psychiatric diagnosis because of stigma
  
• Reluctance to accept psychiatric consultation/referral/collaboration because of stigma
  
• Emotional reactivity (anger, sadness, anxiety)
  

This chapter explores pragmatic strategies to address these problems on a generic rather than a case or disease-specific level. Because the common denominator of difficulty rests on the somatic presentation of mental and behavioral disorders, the assessment and management of unexplained physical complaints will be discussed. These skills function to bridge the gap between disabling and unexplained physical symptoms and the accurate diagnosis and effective treatment for underlying mental or behavioral disorders.

Unexplained physical symptoms account for the vast majority of the presenting complaints in primary care.^[1] Many of these complaints are short-lived and are probably the result of multiple biologic and psychosocial etiologies. However, when these unexplained physical symptoms are recurrent, do not fit into recognizable pathophysiologic patterns, and refer to multiple organ systems, the likelihood that the patient suffers from a mental disorder increases dramatically.^[2]

Mental disorders in primary care practice represent significant sources of reversible suffering and disability. Depression alone has been noted by the World Health Organization as the fourth leading cause of medical disability in all ages worldwide. Among individuals aged 15 to 44, it is the single leading cause of medical disability.^[3]

In addition, poorly recognized and inadequately treated psychiatric disorders contribute to excess general medical utilization. Early recognition and treatment of mental disorders in primary care can lead to significant improvement in patients' well being and to decreased spending on unnecessary utilization. In addition, patients with mental disorders often present significant frustration for physicians; the physicians struggle with the interpersonal demands of patients who experience the physical discomforts associated with psychiatric disorders, but who do not understand or accept the psychiatric explanation for their distress.

Because of the stigma associated with mental illness, patients with mental disorders often get their only health care from nonpsychiatric physicians. Only about 50% of individuals with mental disorders will get any help at all for their disorders. About 18% of all these individuals go only to primary care physicians for help for their problems and 17% to mental health specialists. Only 3% of the individuals with mental disorders get help from both primary care physicians and mental health specialists.^[4] It is likely that this small percentage will increase dramatically as comanagement and collaborative care strategies between primary care and behavioral health specialists increase in the era of managed care and disease management.^[5]

Epidemiologic research now documents that many of these disorders are overlooked in busy office practices. Even when they are recognized, the disorders are often inadequately treated or the outcome is suboptimal. The public health message is clear. Medical schools, medical societies, and health care organizations are now devoting increasing resources toward appropriate identification and treatment of medical patients with psychiatric disorders. The barriers to effective integration, unfortunately, remain considerable.^[6]

Whether these mental disorders occur alone or in the context of other comorbid physical illnesses, the current health care environment now expects primary care physicians to accrue the knowledge and to master the skills necessary to treat uncomplicated mental disorders or to successfully refer more complicated disorders to behavioral health specialists. This section of the text covers the knowledge base necessary for physicians to diagnose and treat the most common and uncomplicated mental disorders in their medical practices: depression, anxiety, alcohol and substance abuse, somatoform disorders, and eating disorders.

Unfortunately, although “book” knowledge of these disorders is certainly necessary, it is not sufficient for the primary care physician to take adequate care of his or her patients. Improved care for psychiatric disorders in primary care depends on the development of certain patient management skills, including the ability to:

• Obtain relevant psychosocial data on all patients
  
• Observe and appropriately respond to a patient's verbal and nonverbal cues of emotional distress
  
• Transition the data-collection process from the biologic domain to the psychosocial
  
• Collect sufficient data to make accurate psychiatric diagnoses
  
• Educate the patient to accept a paradigm shift from a general biomedical to biopsychosocial frame of reference
  
• Deliver care in a complex biopsychosocial frame of reference for patients who suffer from both general medical and psychiatric morbidity
  
• Refer, consult, and collaborate effectively with behavioral health specialists when needed
  

The rest of this chapter will briefly discuss these seven skills necessary to efficiently assess and manage mental disorders in busy primary care practices. Physicians who desire further training may develop these skills by attending workshops and courses on interviewing skills that are discussed more fully in Chapter 2 .

[edit] PATIENT MANAGEMENT SKILLS

[edit] Obtain Psychosocial Background Data on All Patients

Psychosocial data relating to current life stresses and supports are essential for the effective management of all chronic conditions in primary care (see Chapter 2 ). In the assessment and management of persistent unexplained physical symptoms, one of the very first objectives of the physician should be to ascertain background psychosocial data (e.g., “Tell me a little about what's happening now in your life, at home and at work” or “What kind of stresses are you under lately?”).

[edit] Observe Patients Closely and Respond to Verbal and Nonverbal Cues of Emotional Distress

Verbal and nonverbal signals of emotional distress often go unacknowledged in the busy practice of primary care. In the face of unexplained physical symptoms, however, these cues become especially important. When the physician observes, for example, that a patient's head and eyes are downcast, shoulders shrugged, and words punctuated by increased sighing, or if there are tears in the eyes, the physician should use skills of reflection and legitimation, through such comments as “I can see that you feel distressed” (reflection) or “I understand why you feel so distressed. Most people would feel the same way” (legitimation).^[7]

Sometimes physicians observe these signs, but are reluctant to acknowledge the feelings because they fear unlocking a Pandora's box of emotions. Acknowledging the patient's emotional distress may lead to the expression of more feelings (e.g., crying) or to more data about life stresses. In the busy office practice, physicians may sometimes consciously avoid this type of inquiry.

The avoidance of these emotional issues is generally a strategic, as well as humanistic, mistake. From the humanistic point of view, patients generally want to be heard and understood by their physicians. Ignoring signs of emotional turmoil leads patients to feel that they are neither understood nor cared about. This leads to patient dissatisfaction, poor partnership, and poor adherence.

From a strategic point of view, addressing emotional concerns early increases overall interviewing efficiency. Skillful attention to the emotional domain of the physician-patient encounter saves time—always in the long run, and almost always in the short-term. The alliance with the patient is secured and less time is wasted on unproductive exploration of other complaints. When emotional cues are ignored, Pandora's box rarely stays closed—it usually builds up pressure from the lack of understanding and explodes in dysfunctional, unpredictable, and inefficient ways. The bane of many physicians mercilessly emerges: the end-of-the-interview, hand-on-the doorknob “Oh, by the way, doctor …” comment occurs in at least 20% of all interviews and always causes physicians time and emotional distraction.

In contrast, the skilled interviewer moves gracefully from the physical realm of discourse to the psychosocial and emotional domain, without the catastrophe of unlocking Pandora's box. Focusing the discussion on emotional and psychosocial problems in an empathic way is as important an interviewing skill for the primary care physician as focusing the discussion on physical symptoms.

[edit] Move the Data-Collection Process from the Biologic Domain to the Psychosocial

Inquiry about the impact of symptoms on the patient's quality of life can provide a graceful transition. If and when patients with unexplained physical complaints acknowledge distress, it becomes important for physicians to collect information that can rule in or out mental disorders. Transition statements can be helpful in this regard (e.g., “I understand that your stomach pain is your central problem. However, I think I can also help you better if I find out a little more about other symptoms you may be having” or “How has your stomach pain affected your life in general? How are you sleeping … how is your energy … how is your mood … how are things going at home and at work?”).

[edit] Collect Sufficient Information to Make an Accurate Psychiatric Diagnosis

The disorders described in this section represent medical syndromes that can be diagnosed with relatively clear-cut inclusion and exclusion criteria. It is important that primary care physicians understand the importance of accurate diagnosis in order to implement effective treatment strategies. Because some disorders have labels that are the same as some of their symptoms (e.g., depression causing a depressed mood), it is not hard to confuse the presence of symptoms with the presence of a treatable disorder. Better outcomes will be achieved if rigorous attention is paid to understanding and applying evidence-based diagnostic criteria.

[edit] Educate the Patient to Accept a Paradigm Shift From a General Biomedical to Biopsychosocial Frame of Reference

This is the most difficult transition skill that primary care physicians must possess to function efficiently and effectively with patients who present with psychiatric disorders and unexplained physical complaints. These physical complaints are experienced as true physical discomfort; hence if a physician is perceived as trying to “explain away” the physical complaints as secondary to mental disorders, the patient generally and understandably feels discounted and angry, telling the physician that the problem is “not in my head!”

Since the patient does, in fact, experience the problem physically, the physician needs to fully understand and empathize with the patient's frustration. The physician can usually improve the alliance by emphasizing his or her recognition of this experience. It is also often easier to avoid the mind/body dualistic split (i.e., viewing the problem in either the body or mind). Rather, when the physician explains that the problem is in both domains (the body and the emotions), patient acceptance of psychosocial assessment and management usually increases. For example, the following might be said to the patient who suffers from stomach pain and a major depression: I certainly understand that you are suffering with these stomach pains. They are certainly not “in your head.” At the moment, unfortunately, I do not have a definite answer and all your lab tests and other studies are normal at the present time. I am not concerned at the present time that I am missing an important physical problem. I will watch you closely, prescribe appropriate symptomatic treatment, and send you for other medical tests as necessary.

In the meantime, however, I also think you are suffering from a lot of stress and a related depression. I would like for you to work with me in thinking about appropriate treatment for that condition as well. In my experience, when we find effective treatment for the depression, the stomach pain often becomes more manageable and somewhat less troubling.

This approach often works better than arguing that the stomach pain is caused by a depression. For patients who experience actual physical pain, accepting the possibility that treatment of a mental disorder can actually cure a distant physical pain requires an extraordinary leap of faith because it flies in the face of the patient's own bodily experience and interpretation of reality. From a strategic point of view, it is usually better to maintain an agnostic wait-and-see approach concerning the possible relationship between an unexplained physical symptom and a treatable mental disorder such as depression.

[edit] Operate in a Complex Biopsychosocial Frame of Reference for Patients Who Suffer From Both General Medical and Psychiatric Morbidity

Many patients with chronic medical problems also suffer from comorbid mental disorders (e.g., many patients with coronary artery disease and Parkinson's disease also have depression). It is essential that physicians avoid colluding in or promoting the “fallacy of good reasons.” That is, physicians should not reinforce the maladaptive point of view that their patients may have “good reasons to be depressed.” The good reasons argument misserves patients who might otherwise receive effective treatment to reduce suffering, increase quality of life, and quite possibly decrease morbidity and mortality. Patients in severe life stress or with severe physical illness may indeed have good reasons to be sad, but do not have good reasons to explain away and avoid effective treatment for a clinically significant psychiatric disorder (e.g., depression or anxiety).

[edit] Refer, Consult, or Collaborate Effectively with Behavioral Health Specialists in the Treatment of Mental Disorders

Disease management studies now suggest that patient outcome improves when primary care patients receive some collaborative care from mental health specialists.^[8] Thus, although many patients with uncomplicated mental disorders can be effectively treated in the primary care setting, patients with significant psychiatric and medical comorbidity may need referral, consultation, or collaboration with mental health specialists.

Many patients, unfortunately, do not readily accept referral, consultation, or collaboration with behavioral health specialists. Consultation involves a one-session assessment that has limited impact on patient outcome. Collaborative care, or comanagement, on the other hand, involves serial consultation or ongoing specialty input, which facilitates the shaping of a treatment plan, over time, consistent with the patient's developing need and individual response to treatment. Collaborative care does improve outcome.

Effective and increased collaboration, however, will require overcoming many barriers to integrated care. Therefore, in the interest of developing collaborative care models, it is important that primary care physicians help decrease the stigma and reluctance of patients to accept appropriate help, when needed. Empathy, reassurance, and offers of continued support can be helpful in this regard. For example, a physician might say: As you know, I am interested in helping you feel better and overcome this depression. However, I will need some help in making sure that I am treating the correct condition with the correct management strategy and medications. I understand your reluctance, but I really think I can treat you better if you would accept a consultation from a psychiatrist (psychologist/social worker/nurse) colleague of mine who has seen many of my patients. After you see him, I will talk to him about how we can treat you most effectively.

[edit] BRIDGING THE GAP

Mental disorders in primary care are common, disabling, and often unrecognized and undertreated. Patients with these disorders are complex and often frustrating for physicians to manage. Much of this difficulty stems from problems related to shifting the frame of reference from the physical/biomedical realm of discourse to a biopsychosocial one. This chapter presents seven basic skills that can help a physician bridge this gap, in the interest of improving the alliance with the patient, to improve assessment, treatment planning, and, ultimately, outcome.

[edit] REFERENCES