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Marcie Hopkins, University of Utah Health
improvement
Mental Health Care Should Begin in Your Clinic: An Approach for Integration
While mental health access through insurance coverage has improved, efficient screening and placement is key to getting patients into mental health care. By taking deliberate steps to integrate depression screening into primary and specialty care office visits, patients are more likely to access mental health resources.
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ental health care can be difficult for patients to access. Along with the increased demand for mental health services, the typical clinical setting for mental health care can be difficult to navigate for new patients.  

Psychiatrists spend most of their time in direct, one-on-one patient care, including lengthy assessments, leaving less time to screen new patients. Though mental health services are now better covered by insurance companies, there are still financial barriers to care as many private practice psychiatrists take cash-only payments.  

Without many advanced practice providers like nurse practitioners in psychiatry, there’s simply no way to meet the demand for care without new strategies. 

New strategies to screen for depression 

Through the Mental Health Integration initiative and system-wide Major Depressive Disorder Value Stream, we are working to improve patient access to mental health care by integrating psychiatric care into primary and specialty care clinics. Not only can more patients be screened for depression, but they can get earlier access to care. 

When people come to a mental health professional for depression, they typically self-identify as depressed. But many other people don’t recognize their depression. Instead, they go to their primary care physician for the physical manifestations of depression such as fatigue, malaise, pain or gastrointestinal symptoms. 

These patients, who are experiencing the physical symptoms, are the ones who should be screened at their primary care physician’s office in order to determine a diagnosis and begin treatment.  

Since 2016, we have administered 280,000 depression screenings within our specialty and primary care clinics. Of those screened, 68,000 scored as having moderate, moderately severe or severe depression.  

The goals of Major Depressive Disorder Value Stream

The Major Depressive Disorder Value Stream can help improve screening and follow-up for people with disorders like depression. The three goals of this program are: 

  1. Increase rate of screening 

  2. Increase follow-ups for patients 

  3. Increase clinical improvement 

We can use different strategies to reach each goal. For instance, we can improve rate of screening by integrating screenings into EPIC, which is more widely utilized than the current evaluation system. EPIC can also alert physicians to positive screens, which could improve follow-up. 

Most patients who undergo screening and test positive will receive a prescription treatment and recommendations immediately, during that same appointment. But more follow-up is still needed beyond a list of therapists that are covered by their insurance company. While follow-up for patients doesn’t necessarily mean an appointment with a mental health professional, it can mean referral to other resources within the community that can help them as well as a check-in to see if they are improving on medication.  

Discussing depression with patients

Physcians may feel uncomfortable discussing depression but I encourage any physician who has a patient screen positively for depression to get involved in their care. 

One way is to explain to patients how depression affects their physical health, including conditions they may see specialists for like heart disease. I recommend specialists follow a script, such as: 

“You did screen positive for depression. Is this something you'd like to talk about a little bit more? People who suffer from mood problems sometimes have difficulty with more medical problems as well. I think this would be important for you to address in addition to the issue that you're coming to see me for.” 

Strategies to support integration 

With both specialists and primary care physicians working to screen and treat patients for depression, we can help more patients experience improvement. Through Major Depressive Disorder Value Stream, we hope to achieve clinically significant improvement in depression among 50% of screened patients. We can use strategies such as a patient care coordinator to reach out to patients, no matter what office they are screened in, and offer resources.  

We can also use digital health programs to help patients improve without having to wait weeks or months to see a therapist. Digital health programs are typically apps that a patient can use on their phone to improve mental health or manage their care. These apps can be a great resource as patients wait to see a therapist.  

The faster patients can begin receiving some sort of intervention or follow-up, the fewer patients who will have really chronic depression that can be challenging to treat. Patients are also less likely to experience crises when they are able to get help or follow-up, even in the form of an app.  

The demand for mental health services continues to grow at all levels, from outpatient care to inpatient psychiatric beds. But we can only reduce this demand by meeting the goals of mental health integration and catching depression early, before it reaches a crisis. With increased screenings, improved follow-up and immediate access to cost-effective programs, we can improve patient health outcomes and treat depression before more intensive care is needed.  

Contributor

Rachel Weir

Psychiatrist, Associate Professor, University of Utah Health

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