Time for a New Patient-Centered Home: One for Mental Healthcare

Now let’s try building a patient-centered mental healthcare home.

As I’ve written before, and as we’ve all seen happening day-to-day, week-to-week, and month-to-month, this pandemic has revealed a dramatic increase in the need for mental healthcare for so many of our patients, across all of our communities. So much of this was there, and we just didn’t know about it; so much more has been unearthed, revealed by the stress and challenges everybody has faced. It feels like over and over again, in almost every interaction we have with our patients, there is a component of mental healthcare that needs attending to. It might be something seemingly as simple as stress management, recommending techniques to help deal with stress such as exercise, good nutrition, and sleep hygiene, or something more serious, all the way up to the spectrum of unearthing a serious underlying or exacerbated mental illness.

Limited Resources a Challenge

I’ve written before about the challenges we face in our practice, with limited resources and overwhelmed systems that are available to take care of our patients suffering from mental health issues. It remains unacceptable to have a several-months wait for patients to get into the counseling they need, or the medical management of a complex mental health disorder.

Our team is overwhelmed and stressed by the effects of this themselves, and it’s taking a toll. I’m hopeful that we can work together to pump up the resources, find more people willing to work on this problem, and help take care of these unmet needs. Perhaps the patient-centered model that adds more members to the team can help deliver some improved mental health in the primary care setting.

One of my oldest friends is a psychiatrist who deals with incredibly sick and complicated mental health patients, and she once said to me, “God bless the internist who starts an antidepressant, and damn the internist who starts an antidepressant.” By this she meant that we in primary care are necessary to help manage an enormous amount of mental health, and should take it on ourselves (which we willingly do) to recommend counseling and start first-line medications for uncomplicated depression and anxiety. But the second part of her message was that often we do an inadequate job of correctly diagnosing patients, and she has seen the effects of outpatient doctors tipping patients over into mania, or otherwise mischaracterizing and misdiagnosing serious underlying mental health disorders.

But this is what we all do, when our patients come to us with depression and anxiety, obsessive-compulsive disorder and PTSD — we do our best, and often this means referring to social workers and therapists for talk therapy, or the initiation of medications. Part of the problem of this model is that we don’t really have a mechanism in place for longitudinal management of mental health disorders in our practice.

Not Enough Followup

Far too often I see patients being given a prescription for a psychiatric medicine to try, which then continues in perpetuity, without much follow-up or ongoing evaluation, either for up-titration or tapering off. Medications just get refilled when patients send in a portal message requesting a refill. Most psychiatrists will not do this; they insist on seeing patients or at least having a talk session or video session. But in the primary care setting, when we are overwhelmed with thousands of messages requesting refills and durable medical equipment and forms that need to be completed, and a world of other chronic medical conditions our patients have, it’s understandable that these things slip through the cracks, and while it may not be the best medicine, it may be better than nothing.

I think a better model would be to form a structure for mental healthcare into which almost every one of our patients would be entered when a diagnosis of depression or anxiety or something else that we’re going to manage is placed on their problem list, or when a psychiatric medication is added to their medication list. At a first visit with their primary care provider, when an evaluation is done and is felt to be sufficient to come to a diagnosis which can then lead to treatment recommendations, we could then enroll patients in this structured program with pre-scheduled follow-up appointments.

The first visit would be in-person, or even a video visit, but subsequent ones could probably all be done over video or telephone. A nursing visit would come next, to accomplish a discussion about medication side effects and compliance. A pharmacist visit would be done to discuss medication up-titration.

A video visit with a mental health provider, either a psychiatric nurse practitioner or social worker, would be done to assess the improvement or lack of improvement in symptoms, and help move the patients towards ongoing care with mental health resources in their community. Connection to community-based organizations and therapists in their own neighborhood would be built into the system, automatically linking them to ongoing care that could augment what we are doing in our practice. And along the way we would have access to electronic consultations with psychiatry, who could provide opinions about our management, and recommendations when a higher level of care might be needed, and even assume care if the primary care provider does not feel comfortable with a complex medication regimen or a more serious underlying psychiatric disorder.

Putting a Framework in Place

Clearly this is going to take a lot of resources, and a lot of building, but it’s got to be better than what we have now. We are just starting to chisel out the rough framework for how this will work, and I fervently hope that we can get the support for the personnel we need and the infrastructure to help make this happen.

The unmet mental health needs of our patients live along a spectrum, from the mild to the overwhelmingly severe and potentially disastrous, and we need to address them all, each and every one, right where they are now. We need to be able to reach everyone in every community, and help them get to the best place they can be, as we continue to fight the good fight getting through these challenging times.

Once we have more the details in place, I’ll be sure to update progress and barriers in a future column, and let you all know how it’s going. For now, be safe, stay strong, and never hesitate to reach out for help if you need it.

If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.