First Line of Defense

Primary Care Physicians on Front Line of Mental Health Care

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Cover Story - August 2006  

By  Erin Prather
Associate Editor  

You're halfway through examining a patient when he blurts out that he's so depressed he can barely get out bed to go to work. When you ask him why, he says it's because there is so much evil in the world that he often thinks his whole family would be better off dead.

Clearly, this man desperately needs mental health counseling. But you're a family physician with little training in dealing with mentally disturbed patients. You know he needs to see a psychiatrist soon before an unthinkable tragedy occurs. You remember reading about the San Antonio woman who killed her husband and children in June. Relatives said she had been "disturbed."

If you were in one of the state's larger cities, you could refer the man to a psychiatrist. But you're in a small West Texas town and the nearest psychiatrist is 200 miles away. So it's up to you to help the man as best you can and hope you're not soon hearing about another murder-suicide.

Most of us at one time or another have joked we are "crazy" or "nuts" or "slowly losing our mind." Yet obviously mental illness is no laughing matter, especially when one in every four Americans suffer from a diagnosable mental disorder. The National Institute of Mental Health (NIMH) says mental disorders are the leading cause of disability for people aged 15 to 44 and that many suffer from more than one disorder at a given time.

The Texas Department of State Health Services (DSHS) says only about 25 percent of people with mental disorders obtain treatment.

That does not surprise Laredo family physician Leonides Gonzalez Cigarroa Jr., MD. He says many patients fear being stigmatized when it comes to mental health, and he often has to coax them into discussing their problems.

"Patients are scared to be branded," he said. "There are posters displayed in our clinic that have the warning signs of depression. My staff makes sure they are placed where patients can read them while waiting for me. Sometimes a patient will refer to the poster and open up about their condition. But they are mostly embarrassed to talk about it."

A survey by the American Psychiatric Association found that many people don't know or understand the warning signs, causes, and effective treatment for mental illnesses. The survey showed one-third of Americans mistakenly think emotional or personal weakness is a major cause of mental illnesses, and almost as many think old age is a major cause. (See "Mental Illness Warning Signs and Symptoms .")

In Texas, those who admit they may have a problem often go to their primary care physician for treatment. Not only is there often an established relationship between a primary care physician and patient, but also Texas simply has more primary care physicians than psychiatrists. That makes primary care physicians the first point of contact. Compounding the problem is, according to President Bush's New Freedom Commission on Mental Health, that family doctors may lack the necessary time, training, or resources to provide appropriate treatment for mental health problems. 

The Shortage  

It's obvious when considering the state's population numbers that the supply of psychiatrists has not kept up with demand. A February report by DSHS says its analysis of data from the Health Professions Research Center confirms that Texas has a shortage of mental health professionals. The Texas Medical Board says there were 1,298 general psychiatrists and 190 child psychiatrists in 2005.

As a result, primary care physicians provide a growing percentage of mental health services. An article in the March-April 2005 Journal of the American Board of Family Medicine says primary care physicians are the sole contacts for more than 50 percent of patients with mental illness and have thus been described as the de facto system of treatment for mental health.

Houston psychiatrist Pricilla Ray, MD, a member of the Texas Medical Association Board of Trustees, says this trend is necessary. 

"There are too many patients and not enough psychiatrists to provide care for those who need it. Thanks to medical advances and newer treatments, it's easier for primary care physicians to address the mental health needs of their patients. Due to this and to the lack of access to psychiatrists, patients are often referred to psychiatrists only if their illnesses turn out to be more difficult to treat."

The DSHS report says the number of psychiatry residency programs in Texas has been stagnant for the past 10 years, and it is unlikely the state will be able to address the need for more psychiatrists with that level of training positions. This year, 62 psychiatric residency positions were offered in the state. The report also points says many psychiatrists find it difficult to maintain a viable practice because indigent psychiatric patients are uninsured and even insured patients typically have lower reimbursement for mental health coverage.

The American Academy of Family Physicians says reimbursement for office visits with a mental health diagnosis code is deeply discounted for Medicare patients. Many managed care plans do not reimburse family physicians for psychiatric care, even though they are frequently the ones who diagnose and provide the care. While lack of reimbursement is not the only reason for the documented failures in mental illness detection, it has had an impact on the availability of screening in primary care practices.

TMB says most psychiatrists in 2005 were located along the I-35 corridor from Bexar County to Dallas County, and in Harris and Cherokee counties (Rusk State Hospital is located in Cherokee County). No psychiatrists are available in 181 counties, and there were very few in West Texas or the Panhandle. Many border counties lack an adequate number of psychiatrists as well.

"A patient comes in and I need to decide if this is only depression or if something else is going on," Dr. Cigarroa said. "When feeling unsure, you want to refer the patient to a mental health professional, someone to confirm the diagnosis or determine if it's more serious. The problem is it's very difficult to find a mental health professional. There are the DSHS programs, but unfortunately there is often a three-month waiting list."

NIMH says rural areas present unique barriers to mental health care. Poor access to mental health specialists, geographic isolation, and cultural differences, as well as cost, hinder the quality of mental health care available.

An April 2006 editorial in the U.S. Centers for Disease Control and Prevention's (CDC's) journal Preventing Chronic Disease points out a substantial lag between the onset of mental disorders and their diagnosis and treatment, especially among the poor, poorly educated, and people of color.

Joe Vesowate, DSHS's assistant commissioner for mental health and substance abuse services, says the gap between onset and treatment must be addressed.

"It's time for health care to take a preventative approach to treating mental illness and substance abuse instead of being reactionary. Folks who don't receive treatment can cause harm to themselves and others. Treatment cannot wait until someone is in crisis and at the emergency room, state hospital, or jail.

"We tend to react and focus on the number of inpatient beds in our system and the growing need for crisis services," he added. "What we really need to look at is primary prevention and early symptom management. I hate to put the burden on physicians, but they are seeing the patients, talking to the patients, and often the patients will talk to them."

This year, the U.S. Substance Abuse and Mental Health Services Administration granted $92.5 million to seven states over five years to support the development of state infrastructure to implement the recommendations of President Bush's mental health commission. (See "Commission Seeks Changes in Mental Health System.") Texas received $2,730,000 for the first year. 

The Front Line  

The CDC editorial acknowledges that detecting and managing depression in a primary care practice can pose significant challenges to physicians with too little time and often limited training in mental health care management. However, it says the same principles primary care physicians apply to diabetes and heart disease treatment (referring only complex or treatment-resistant cases to specialty care) should be applied to mental health conditions such as depression.  

Mike Halligan, executive director of Texas Mental Health Consumers, suggests physicians research their local resources in case patients require assistance from a mental health specialist. This is especially true if the physician lives in an area without any or with few psychiatrists.

Dr. Cigarroa says he refers patients to social workers and counselors if available. He cautions physicians to consider their patients' resources when helping them find aid and admits that law enforcement may have to be called if there is no doubt a patient will harm himself or others.

"There are a lot of medications, and physicians must be well informed about what's available. If a physician prescribes a medication and notices no difference, then he or she needs to change the prescription as with any other ailment. Physicians need to be as knowledgeable about mental health as they are about diabetes or other conditions."

TMA offers physicians information about mental health on its  Web site. (See August 2006 MedBytes.)

Mr. Halligan says physicians can go to Texas Implementation of Medication Algorithms on the DSHS Web site, www.dshs.state.tx.us, for guidelines regarding mental health prescriptions.

Many continuing education courses on mental health are available for physicians. The Texas Society of Psychiatric Physicians has meetings throughout the year, and there is a Section on Psychiatry meeting at TexMed every year.

NIMH says untreated mental disorders can lead to more severe, more difficult to treat illnesses and to the development of co-occurring mental illnesses. Dr. Cigarroa says that if patients do not feel well mentally, the chances are they are not going to feel good enough or care enough to take their medication.

"Helping a patient physically is worthless if their mental health is shot and left untreated. I've shown patients their numbers and can tell they just don't give a damn. That's when physicians have to respectfully probe to see what else is going on."

Adds Dr. Ray, "Mental illness can be associated with the worst suffering of all diseases. The command center for the body is the brain, and it has to be healthy for the body to be."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at  Erin Prather.  

SIDEBAR  

Mental Illness Warning Signs and Symptoms

In Adults  

  • Confused thinking
  • Prolonged depression (sadness or irritability)
  • Feelings of extreme highs and lows
  • Excessive fears, worries, and anxieties
  • Social withdrawal
  • Dramatic changes in eating or sleeping habits
  • Strong feelings of anger
  • Delusions or hallucinations
  • Growing inability to cope with daily problems and activities
  • Suicidal thoughts
  • Denial of obvious problems
  • Numerous unexplained physical ailments
  • Substance abuse

In Older Children and Preadolescents  

  • Substance abuse
  • Inability to cope with problems and daily activities
  • Change in sleeping and/or eating habits
  • Excessive complaints of physical ailments
  • Defiance of authority, truancy, theft, and/or vandalism
  • Intense fear of weight gain
  • Prolonged negative mood, often accompanied by poor appetite or thoughts of death
  • Frequent outbursts of anger

In Younger Children  

  • Changes in school performance
  • Poor grades despite strong efforts
  • Excessive worry or anxiety (e.g., refusing to go to bed or school)
  • Hyperactivity
  • Persistent nightmares
  • Persistent disobedience or aggression
  • Frequent temper tantrums

Source: National Mental Health Association, www.nmha.org.

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SIDEBAR  

Commission Seeks Changes in Mental Health System

The President's New Freedom Commission on Mental Health identified the following six goals as the foundation for transforming mental health care in America.

Goal 1: Americans understand that mental health is essential to overall health.  

Recommendations:

  1. Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
  2. Address mental health with the same urgency as physical health.

Goal 2: Mental health care is consumer and family driven.  

Recommendations:

  1. Develop an individualized plan of care for every adult with a serious mental illness or child with a serious emotional disturbance.
  2. Involve consumers and families fully in orienting the mental health system toward recovery.
  3. Align relevant federal programs to improve access and accountability for mental health services.
  4. Create a comprehensive state mental health plan.
  5. Protect and enhance the rights of people with mental illnesses.

Goal 3: Disparities in mental health services are eliminated.  

Recommendations:

  1. Improve access to quality care that is culturally competent.
  2. Improve access to quality care in rural and geographically remote areas.

Goal 4: Early mental health screening, assessment, and referral to services are common practice.  

Recommendations:

  1. Promote the mental health of young children.
  2. Improve and expand school mental health programs.
  3. Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.
  4. Screen for mental disorders in primary health care, across the life span, and connect to treatment and support.

Goal 5: Excellent mental health care is delivered and research is accelerated.  

Recommendations:

  1. Accelerate research to promote recovery and resilience and ultimately to cure and prevent mental illnesses.
  2. Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
  3. Improve and expand the workforce, providing evidence-based mental health services and support.
  4. Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

Goal 6: Technology is used to access mental health care and information.  

Recommendations:

  1. Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.
  2. Develop and implement integrated electronic health record and personal health information systems.

Source: President ' s New Freedom Commission on Mental Health.  

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  SIDEBAR  

Screening for PTSD in a Primary Care Setting

Why should primary care physicians know about post-traumatic stress disorder (PTSD)? Because they are likely to see an increase in traumatized individuals after a natural disaster or terrorist event. Many of these patients will present with physical rather than mental or emotional symptoms. It is recommended that primary care physicians educate themselves about the effects of trauma and routinely screen individuals for trauma after major disasters.

Knowledge about traumatic stress is important for the following reasons:

Trauma often leads to PTSD and other impairment.  

  • In addition to disasters and other traumatic life events, life-threatening medical conditions such as myocardial infarction, severe burns, severe injuries, and cancer can cause or exacerbate PTSD.
  • Patients with PTSD experience a significant degree of functional impairment similar to that observed in patients suffering from major depression.
  • Patients with untreated anxiety report levels of functioning within the range expected for patients with chronic physical diseases such as diabetes and congestive heart failure.
  • PTSD is associated with significant problems in living, including alcohol abuse, marital problems, unemployment, and suicidal ideation. PTSD is also associated with high levels of use of medical services.
  • Traumatic experiences and traumatic stress bring about hormonal, neurochemical, immune functioning, and autonomic nervous system changes that can affect physical health.

PTSD often presents to primary care physicians, but goes unrecognized.  

  • In the private sector, nearly half of all visits instigated by a mental health disorder are to a medical clinic or provider. Of those visits, 90 percent are to primary care physicians.
  • Despite its prevalence, PTSD is likely to remain unrecognized and untreated in primary care patients. Few medical clinics systematically identify trauma survivors who have related mental health problems.

Failure to identify and treat PTSD has adverse effects on the patient ' s physical and mental health.  

  • Traumatic stress is associated with increased health complaints, health services utilization, morbidity, and mortality.
  • Untreated PTSD can impair recovery from medical conditions.

In failing to address the impact of traumatic stress on health, patients and doctors become less likely to achieve desired outcomes.

More information about PTSD is available on the National Center for Post-Traumatic Stress Disorder Web site at  www.ptsd.va.gov. Click on Facts, then Specific, then Trauma, PTSD, and the Primary Care Provider, and finally the fact sheet, Screening for PTSD in a Primary Care Setting.

Source:NationalCenter for Post-Traumatic Stress Disorder   

SIDEBAR  

The Economy of Prevention: Mental Health and Alcohol and Substance Abuse

From Texas Medical Association's Healthy Vision 2010: Diagnosis & Treatment  

According to the National Institute of Mental Health, untreated mental illness costs the United States $300 billion each year; untreated depression alone is responsible for $40 billion of that. The American Psychiatric Association (2005) asserts that mental health treatment can more than pay for itself in terms of increased worker productivity; untreated psychiatric illnesses exacerbate chronic conditions like arthritis, asthma, and diabetes, thus increasing potentially avoidable visits to primary care physicians.

Alcohol and substance abuse pour additional stress onto our already-burdened medical system in Texas. Most people with untreated alcoholism require more general health care, including treatment for illness and injury. Their health care costs are at least 100-percent higher than for people who do not have alcoholism. Untreated alcohol problems waste $184.6 billion per year in health care, business, and criminal justice costs, and cause more than 100,000 deaths, according to the National Institute on Alcohol Abuse and Alcoholism (2000).

Underage drinking costs $3.7 billion a year for medical costs due to traffic crashes, violent crime, suicide attempts, and other related consequences. The total annual cost of alcohol use by underage youth is $52.8 billion. 

August 2006 Texas Medicine Contents
Texas Medicine Main Page  

Last Updated On

July 31, 2019

Originally Published On

March 23, 2010

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