Families, Systems, & Health 2014, Vol. 32, No. 1, 12–13
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000020
COMMENTARY
Turning Toward Treating the Seriously Mentally Ill in Primary Care Suzanne Daub, LCSW
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
The National Council for Behavioral Health, Washington, DC
Twenty years ago, I took a job as the Director of Social Work at a Federally Qualified Health Center. I didn’t know a thing about primary care, and when I watched the primary care clinicians work, what I saw blew my mind. Twenty years ago, I assumed if you had a mental health problem, you would go to therapy. At the health center, I met Ed, whose diabetes was out of control, and who asked me, “Why would I go see a therapist? I just caught a little depression.” Ed was suspicious of all medication, so he walked around with a dangerously high blood pressure. Ed’s doctor didn’t address his depression. I met Vorrie, whose depression was so severe that she could barely make it out of bed. Vorrie found alcohol and Percocet far more effective than antidepressants. Her clinicians were clearly struggling, saying, “I’m not trained to deal with this type of problem. These people take up way too much time.” Fortunately, I joined the Collaborative Family Healthcare Association and I learned how to support the primary care providers through collaborative care. This changed how I practiced and stands as the most meaningful work I’ve done in my life. Last year, after 18 years at that same health center, I joined the staff of The National Council for Behavioral Health. About one week into the job, I learned an astounding fact: people who suffer from a serious mental illness die 25 years earlier than those without one. Why? Suicide is a big factor, accounting for 30% to 40% of early deaths. But, 60% to 70% of early deaths result from preventable and treatable medical conditions such as smoking, obesity,
substance abuse, and inadequate access to medical care (Parks et al., 2006). I felt so ashamed that this information was new to me. People with serious mental illness will tell you that they do not feel welcome in primary care. Recently, I saw a behavioral health consultant approach a medical provider about treating a sleep problem. The provider’s response: “That’s psych, I’m not dealing with it.” I’ve heard behavioral health consultants plead, “She’s psychotic. Her mental health center won’t take her insurance and they told her ‘Go see your primary.’” The primary care provider replied, “Send her to the crisis center, I don’t prescribe those meds.” And it’s not just the primary care providers; the behavioral health consultant wasn’t thrilled with this very symptomatic person showing up at the health center either. He was unnerved by the psychosis and annoyed that the community mental health system was “pushing the patient to primary care.” In these situations, the mental health issue triggers us and we miss the opportunity for a broader discussion with the patient about their overall health. And all the patient hears is “get out of my exam room.” In primary care, time is short and work is abundant. This leads us to provide structured algorithmic care. But serious mental illness does not fit neatly into an algorithm; it demands relationship-based healing. I think we are simply uncomfortable with the symptoms of serious mental illness, and this results in avoidance, both individually and as a system. How can we possibly address this health disparity if the affected population isn’t part of the conversation? We have gone so far as to create another model of integration—“reverse integration”—in which primary care clinicians practice in mental health centers. Certainly reverse integration increases access for some, but what about the many people with mental illness who are not seen in mental health care settings. Does
Correspondence concerning this article should be addressed to Suzanne M. Daub, LCSW, Senior Consultant, Department of Health Integration and Wellness, National Council for Behavioral Health, 1701 K Street NW, Washington, DC 20006. E-mail: [email protected] 12
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
TREATING THE SERIOUSLY MENTALLY ILL
community-based primary care have a responsibility to address the physical health needs of the seriously mentally ill? If our answer is yes, I think we need to start by acknowledging our discomfort, listening deeply to the voices of people with severe mental illness, and learning how to intervene effectively to improve their health. People with serious mental illness can live longer, and we have a rare opportunity to be part of the tipping point.
13
Reference Parks, J., Svendsen, D., Singer, P., & Foti, M. E. (2006). Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors, Medical Directors Council. Received November 17, 2013 Revision received December 9, 2013 Accepted December 15, 2013 䡲
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000020
COMMENTARY
Turning Toward Treating the Seriously Mentally Ill in Primary Care Suzanne Daub, LCSW
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
The National Council for Behavioral Health, Washington, DC
Twenty years ago, I took a job as the Director of Social Work at a Federally Qualified Health Center. I didn’t know a thing about primary care, and when I watched the primary care clinicians work, what I saw blew my mind. Twenty years ago, I assumed if you had a mental health problem, you would go to therapy. At the health center, I met Ed, whose diabetes was out of control, and who asked me, “Why would I go see a therapist? I just caught a little depression.” Ed was suspicious of all medication, so he walked around with a dangerously high blood pressure. Ed’s doctor didn’t address his depression. I met Vorrie, whose depression was so severe that she could barely make it out of bed. Vorrie found alcohol and Percocet far more effective than antidepressants. Her clinicians were clearly struggling, saying, “I’m not trained to deal with this type of problem. These people take up way too much time.” Fortunately, I joined the Collaborative Family Healthcare Association and I learned how to support the primary care providers through collaborative care. This changed how I practiced and stands as the most meaningful work I’ve done in my life. Last year, after 18 years at that same health center, I joined the staff of The National Council for Behavioral Health. About one week into the job, I learned an astounding fact: people who suffer from a serious mental illness die 25 years earlier than those without one. Why? Suicide is a big factor, accounting for 30% to 40% of early deaths. But, 60% to 70% of early deaths result from preventable and treatable medical conditions such as smoking, obesity,
substance abuse, and inadequate access to medical care (Parks et al., 2006). I felt so ashamed that this information was new to me. People with serious mental illness will tell you that they do not feel welcome in primary care. Recently, I saw a behavioral health consultant approach a medical provider about treating a sleep problem. The provider’s response: “That’s psych, I’m not dealing with it.” I’ve heard behavioral health consultants plead, “She’s psychotic. Her mental health center won’t take her insurance and they told her ‘Go see your primary.’” The primary care provider replied, “Send her to the crisis center, I don’t prescribe those meds.” And it’s not just the primary care providers; the behavioral health consultant wasn’t thrilled with this very symptomatic person showing up at the health center either. He was unnerved by the psychosis and annoyed that the community mental health system was “pushing the patient to primary care.” In these situations, the mental health issue triggers us and we miss the opportunity for a broader discussion with the patient about their overall health. And all the patient hears is “get out of my exam room.” In primary care, time is short and work is abundant. This leads us to provide structured algorithmic care. But serious mental illness does not fit neatly into an algorithm; it demands relationship-based healing. I think we are simply uncomfortable with the symptoms of serious mental illness, and this results in avoidance, both individually and as a system. How can we possibly address this health disparity if the affected population isn’t part of the conversation? We have gone so far as to create another model of integration—“reverse integration”—in which primary care clinicians practice in mental health centers. Certainly reverse integration increases access for some, but what about the many people with mental illness who are not seen in mental health care settings. Does
Correspondence concerning this article should be addressed to Suzanne M. Daub, LCSW, Senior Consultant, Department of Health Integration and Wellness, National Council for Behavioral Health, 1701 K Street NW, Washington, DC 20006. E-mail: [email protected] 12
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
TREATING THE SERIOUSLY MENTALLY ILL
community-based primary care have a responsibility to address the physical health needs of the seriously mentally ill? If our answer is yes, I think we need to start by acknowledging our discomfort, listening deeply to the voices of people with severe mental illness, and learning how to intervene effectively to improve their health. People with serious mental illness can live longer, and we have a rare opportunity to be part of the tipping point.
13
Reference Parks, J., Svendsen, D., Singer, P., & Foti, M. E. (2006). Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors, Medical Directors Council. Received November 17, 2013 Revision received December 9, 2013 Accepted December 15, 2013 䡲
