Original Research

Behavioral Health Problems in Medical Patients

Journal of Clinical Outcomes Management. 2014 November;21(11)

Author(s):

Francesca C. Dwamena, MD, MS

Heather Laird-Fick, MD, MPH

Laura Freilich, MD

Dale D’Mello, MD

Jeffrey Frey, DO,

Katelyn Grayson-Sneed, MS

David Solomon, PhD

Robert C. Smith, MD

References

1. Norquist GS, Regier DA. The epidemiology of psychiatric disorders and the de facto mental health care system. Annu Rev Med 1996;47:473–9.

2. Collins C, Hewson D, Munger R, Wade T. Evolving models of behavioral health integration in primary care. In: Fund MM, editor. New York: Milbank Memorial Fund; 2010.

3. Kroenke K. The interface between physical and psychological symptoms. Prim Care Companion J Clin Psychiatry 2003;5(Suppl 7):11–8.

4. Kroenke K, Price RK. Symptoms in the community--prevalence, classification, and psychiatric comorbidity. Arch Intern Med 1993;153:2474–80.

5. Melek S, Norris D. Chronic conditions and comorbid psychological disorders. Millman Research Report. Seattle, WA: Millman 2008:19.

6. Smith R, Laird-Fick H, D’Mello D, et al. Addressing mental health issues in primary care: an initial curriculum for medical residents. Patient Educ Couns 2013;94:33–42.

7. Cutler RB, Fishbain DA, Rosomoff HL, et al. Does nonsurgical pain center treatment of chronic pain return patients to work? -- a review and meta-analysis of the literature. Spine 1994;19:643–52.

8. Katon W, von Korff M, Lin E, et al. Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355–62.

9. Sharpe M, Hawton K, Simkin S, et al. Cognitive behaviour therapy for the chronic fatigue syndrome:a randomised controlled trial. BMJ 1996;312:22–6.

10. World Organization of Family Doctors. Accessed 26 Aug 2013 at www.who.int/workforcealliance/members_partners/member_list/wonca/en/index.html.

11. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36.

12. Vidyo. www.vidyo.com/products/use/.

13. Allison JJ, Wall TC, Spettell CM, et al. The art and science of chart review. Jt Comm J Qual Improve 2000;26:115–36.

14. Vieweg WV, Lipps WF, Fernandez A. Opioids and methadone equivalents for clinicians. Prim Care Companion J Clin Psychiatry 2005;7:86–8.

15. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85–92.

16. Kessler R, Stafford D. Primary care is the de facto mental health system. In: Kessler R, Stafford D, editors. Collaborative medicine case studies—evidence in practice. New York: Springer; 2008:9–21.

17. Schneider RK, Levenson JL. Psychiatry essentials for primary care. Philadelphia: American College of Physicians; 2008.

18. Von Korff M, Ormel J, Katon W, Lin EHB. Disability and depression among high utilizers of health care—a longitudinal analysis. Arch Gen Psychiatry 1992;49:91–100.

19. Von Korff M, Ustun TB, Ormel J, et al. Self-report disability in an international primary care study of psychological illness. J Clin Epidemiol 1996;49:297–303.

20. Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66:271–3.

21. Kroenke K, Spitzer RL, Williams JB, Lowe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010;32:345–59.

22. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

23. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA 2000;284:2606–10.

24. NIDDK. Overweight and obesity statistics. Accessed 30 May 2014 at win.niddk.nih.gov/statistics/

25. Allison DB, Newcomer JW, Dunn AL, et al. Obesity among those with mental disorders: a National Institute of Mental Health meeting report. Am J Prev Med 2009;36:341–50.

26. Salmon P, Humphris GM, Ring A, et al. Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention. Psychosom Med 2007;69:571–7.

27. Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013;154 Suppl 1:S94–100.

28. Rush AJ. STAR*D: what have we learned? Am J Psychiatry 2007;164:201–4.

29. Cunningham PJ. Beyond parity: primary care physicians’ perspectives on access to mental health care. Health Aff (Millwood) 2009;28:w490–501.

30. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States—results from the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:629–40.

31. Morrisey J, Thomas K, Ellis A, Konrad T. Development of a new method for designation of mental health professional shortage areas. Chapel Hill, NC: University of North Carolina at Chapel Hill; 2007.

32. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, editors. Primary care—America’s health in a new era. Washington, DC: National Academy Press; 1996:285–311.

33. World Organization of Family Doctors. Companion to primary care mental health. New York: WONCA and Radcliffe Publishing; 2012.

34. Craig TJ, Huffine CL, Brooks M. Completion of referral to psychiatric services by inner city residents. Arch Gen Psychiatry 1974;31:353–7.

35. Chen Y, Li H, Li Y, et al. Resemblance of symptoms for major depression assessed at interview versus from hospital record review. PLoS ONE 2012;7:e28734.

36. World Health Organization. Composite International Diagnostic Interview (CIDI) – core version 2.1. Geneva: WHO; 1997.

37. Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med 2003;18:478–89.

38. Lin EH, Simon GE, Katzelnick DJ, Pearson SD. Does physician education on depression management improve treatment in primary care? J Gen Intern Med 2001;16:614–9.

39. Huffman JC, Niazi SK, Rundell JR, et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the Academy of Psychosomatic Medicine Research and Evidence-Based Practice Committee. Psychosomatics 2014;55:109–22.

40. Summergrad P, Kathol R. A vision of integrated psychiatric and medical care for 2023. In: Summergrad P, Kathol R, editors. Integrated care in psychiatry: redefining the role of mental health professionals in the medical setting. New York: Springer; 2014.

From Michigan State University, East Lansing, MI.

Abstract

Objective: To describe the clinical presentations of medical patients attending a behavioral health clinic staffed by medical residents and faculty in the patients’ usual medical setting.
Methods: We extracted the following clinical data from the patients’ electronic medical records: duration of problem; symptom presentation; symptom types; use of narcotics, antidepressants, benzodiazepines, antipsychotics, and mood stabilizers; impairment/disability; PHQ-9 scores and DSM-V diagnoses; and prior care from behavioral health professionals.
Results: There were 64 patients, with an average age of 48.6 years. 68.8% were female, and 81.3% had had the presenting problem > 5 years. Presentation was psychological in 21/64 (32.8%), physical in 16/64 (25%), and both in 27/64 (42.2%). Patients averaged 3.3 common comorbid medical disease diagnoses. DSM-V diagnoses averaged 2.3 per patient; 30/64 (46.9%) had somatic symptom disorder, 27/64 (42.2%) had major depressive disorder, and 24/64 (37.5%) had generalized anxiety disorder. Social and economic impairment was present in > 70%. Some narcotic use occurred in 35/64 (54.7%) but only 7/35 (20.0%) were on unsafe doses; 46/64 (71.9%) took antidepressants but only 6/46 (13.0%) were on subtherapeutic doses. Averaging 71.9 months in the same clinic, only 18/64 (28.1%) had received behavioral health care for the presenting problem, and only 10.9% from psychiatrists.
Conclusion: We described the chronic behavioral health problems of medical patients receiving behavioral care in their own medical setting from medical residents and faculty. These data can guide educators interested in training residents to manage common but now unattended behavioral health problems.

Patients with “any DSM behavioral health disorder” (mental health and substance use problems) account for 25% of patients seen in medical clinics [1]. These patients frequently present with poorly explained and sometimes confusing physical symptoms, and less often with psychological symptoms [2,3]. Common complaints in this population include chronic pain in almost any location, bowel complaints, insomnia, and fatigue [4]. Multiple somatic symptoms and increasing severity of symptoms correlate with the likelihood of an underlying depressive or anxiety disorder [3]. Unfortunately, medical physicians often do not recognize behavioral health problems and provide inadequate treatment for those they do [5].

As part of a Health Resources and Services Administration (HRSA) grant to develop behavioral health training guidelines for medical residents [6], we developed a special clinic for these patients. The clinic was located in their regular clinic area, and care was provided by medical residents and faculty. The objective of this paper is to describe the clinical presentation of patients attending the behavioral health care clinic, thus highlighting the common problems for which medical physicians are increasingly called upon to diagnose and treat.

Methods

We are in the third year of a 5-year HRSA grant to develop a method for teaching residents a primary care behavioral health care treatment model based on patient-centered, cognitive-behavioral, pharmacologic, and teamwork principles [6]. It is derived from consultation-liaison psychiatry, multidisciplinary pain management, and primary care research [7–10] and adapted for medical physicians. Described in detail elsewhere [6], we intensively train PGY-2 and PGY-3 residents in the Complex Patient Clinic (CPC), the name we applied to a behavioral health care clinic and the focus of this report.