Data from the National Comorbidity Survey-Replication (NCS-R) indicates that only about 40% of those with a diagnosable DSM-IV condition will receive treatment in a given year. Of those who do receive some treatment, more get care from a primary-care physician (22.8%) than from a psychiatrist (12.3%) or a non-psychiatrist mental health professional (16%). More recent investigation has revealed that primary-care providers may in fact be filling in gaps in coverage in areas under-served by mental health care professionals. In these cases, the PCPs are providing psychotherapy as well as writing scripts for psychopharmacological compounds. Because of their ever-evolving role in providing mental health services, some researchers have begun to look at the quality of care provided by PCPs. While there is room for improvement, the early reports are encouraging.
A recently published study in the Annals of Internal Medicine looked at primary-care physicians' adherence to guidelines for mental health care in primary-care settings. The team, composed of researchers from RAND, Florida State University, UCLA, Johns Hopkins School of Medicine, and Veterans Affairs, examined to what degree doctors from 45 primary-care practices followed guidelines set forth by the Agency for Healthcare Research and Quality. The team's general consensus is that PCPs do an excellent job of identifying the acute signs of depression and informing their patients about the disease, but that the doctors could vastly improve their treatment of some issues associated with depression including suicidality, alcoholism, and issues specific to seniors, who represent one of the largest groups receiving mental health care in primary-care settings.
Psychiatric News spoke with Lisa Rubenstein, M.D., coauthor of the study, who offered some ideas for improving care:
"Primary care physicians talk to their patients about depression and follow up in the early phase [after diagnosis], but many are not able to perform intensive assessments of patients' comorbidities and treatment adjustments if the patient does not respond," said Rubenstein on the barriers to better adherence to guidelines. "A full depression assessment takes 20 to 40 minutes, which can't be done in a 15-minute office visit or with lab tests." She suggested practical approaches, such as training nurses and other personnel to perform evaluations, as a way to improve the quality of depression treatment in primary care settings.
With such a high percentage of depression treatment taking place in primary-care settings, it is important to make sure that patients are receiving a high quality of care. While some markers point to success, others are areas for improvement. Interestingly, it is insurers and other coverers of medical care, like the VA, that have the most to gain from improved mental health services by PCPs. By managing mental health problems up front, ballooning costs from associated disorders and conditions can be avoided. Certainly pushing PCPs to adhere to practice guidelines could help, as could more continuing medical education opportunities about mental health or support services provided through online systems. By whatever means this help is offered, it will be important that PCPs continue to embrace the treatment of mental health and work toward improving the quality of care they offer.
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