Considerations for Improvement

Considerations for Improvement

            With the potential usefulness of primary care physicians in treatment of psychiatric illnesses and the understanding of their barriers of care, a number of considerations for improvement can be made. Among these improvements include education and training, collaboration with mental health care professionals, better insurance reimbursements, and universal use of treatment paradigms among primary care physicians treating psychiatric illnesses.

Education and Training

            The lack of education and training of psychopharmacologic treatment in the primary care setting poses to be one of the greatest barriers of quality care. There are many possible ways to insure training and education are provided to primary care physicians. Integrating psychopharmacological education in medical school and training in residency could help future physicians gain the knowledge desperately needed for better treatment. For current physicians, providing incentives for training and education could be useful. For example, paying physicians to obtain the training and education and then increasing their reimbursement rates for treating psychiatric patients may be considered. Another consideration would be for insurance panels to require education and training in credentialing for physicians who provide psychiatric care.

Integrative Care

Another consideration is utilizing integrative care models that collaborative with other mental health professionals. This would help ensure diagnoses are correct, assessments are utilized, and care is managed. It may also help increase the use of psychotherapy, where the primary care physician would have clinicians on staff or in contact to provide collaborative care.

Insurance Reimbursement

Increasing the insurance reimbursement rates for primary care physicians to treat psychiatric care may allow for more time and more proper treatment. For example, more structured assessment methods would likely be used if there were financial incentives, such as if there were billable assessment codes. Furthermore, higher reimbursement rates for extra time and effort and level of care provided might be useful.

Research Suggestions

Future research regarding the issues discussed in this paper may be useful. Research on the impact of education and training may help provide more awareness of this need. Studies on providing incentives for primary care physicians treating psychiatric patients more appropriately through training and use of assessments may be useful. Finally, qualitative studies regarding how primary care physicians experience treating depression could help our understanding of the phenomenon. 

Barriers of Quality Care

            There are many barriers of quality care in psychiatric treatment in the primary care setting. Among the barriers include lack of training and education, time constraints, meeting levels of expected productivity, lack of proper treatment paradigm, lack of assessments utilized, and lack of patient compliance.

Lack of Psychiatric Training & Education

One of the biggest problems is the lack of training and education of mental illness in medical school for primary care physicians. There are a limited number of primary care physicians who have been trained to treat mental illnesses. The lack of training and education can result in inappropriate diagnosis, such as underdiagnoses of those with true major depressive disorders and over diagnosis of those who are not. The improper diagnosis inevitably leads to improper treatment of mental health patients.

In a research conducted by Tamburrino, Nagel, & Lynch (2011) results found that 70% of primary care patients do not receive a change of medication or dose within the first 3 months, regardless of their continued or worsening symptoms and complaints of depression. This may indicate that primary care physicians lack adjusting antidepressant medications, which the researchers suggested may attribute to poor rates of recovery and remission of depressive episodes.

Time Constraints

            Time constraints of primary care physicians are indicated as problematic. The time in which a physician has to spend is limited, therefore, it is difficult for proper screening and assessment to be utilized (Clark, 2011). Due to decreasing insurance reimbursement rates, primary care physicians are expected to see more patients in a day. Demands of increasing responsibilities requiring more time outside face-to-face treatment, such as clerical duties and use of electronic medical records also add to time constraints.

Attitudes

            Although the stigma of depression and mental health illnesses have steadily decreased, primary care physicians tend to discredit useful interventions outside their practice (Finley, Rens, & Pont, 2003). Due to the attitudes, they also often poorly distinguish between depression “the disease”, “the symptoms” and “the experience.”

Assessment Utilization

            Studies have found that primary care physicians do not utilize assessments often enough. In the study conducted by Baik, Gonzales, Bowers, Anthony, Tidjani, & Sudman (2010) researchers discovered that primary care clinicians do not routinely use depression instruments for diagnosis and maintenance.  Rather, the study found that the clinicians reported most often using the instruments for aiding the patients in acceptance of their diagnosis of depression (Baik et al, 2010). Furthermore, the study found that the use of depression instruments were reduced for the following reasons: the clinicians’ time was limited, they believed depression lacked objective evidence, and the clinicians where familiar with their patients (Baik et al, 2010).

            Another study by Abed Faghri, Boisvert & Faghri (2010) found 77.5% of their participants reported that they relied on clinical interviewing for diagnoses of psychiatric problems rather than using assessment tools.

Other Barriers

            There are several other barriers of psychiatric care in the primary care setting. The Affordable Care Act (ACA) will provide more opportunities for care of individuals who were not able to access the care previously, however, without changes in education, training, and treatment by primary care physicians, the outcome of treating depressive disorders may remain the same. It is possible that decreasing insurance reimbursement rates will affect the quality of care in that primary care physicians may continue to have less and less time with patients.

Other barriers include lack of treatment paradigm among primary care physicians in treatment of psychiatric illnesses. Although there are treatment paradigms for depressive disorders, primary care physicians are not required to use them, unless the setting requires them to do so. In addition, patient resistance and compliance are also barriers. Many patients who may benefit from psychotherapy resist treatment, therefore family physicians rely on psychotropic treatment alone. In addition, there are compliance issues among some patients, such as taking medications consistently or self-medicating with other substances, such as cocaine or opioids, which may interfere with treatment. 

Addressing Issues in Social Change

Addressing Issues

Although the primary care setting has many potential advantages in providing psychiatric care, treatment outcomes have been, and continue to be, unimpressive. Despite the prevalence of psychiatric illness in primary care settings, depression is often underdiagnosed, therefore undertreated, and misdiagnosed, therefore mistreated (Finley, Rens & Pont, 2003). The problems in primary care treatment of psychiatric illnesses must be understood in order to be adequately corrected.

Many research studies have found that about half of those who could benefit from treatment don’t seek care (Olfson & Marcus, 2009). Furthermore, many people who may benefit from treatment don’t receive it and people who cannot benefit from treatment do receive it (Olfson & Marcus, 2009). This indicates several problems: physicians are not properly screening, diagnosing, and treating patients with mental illnesses.

Incorrect Diagnosing

In a study conducted by the World Health Organization (WHO), researchers found 32.5% of patients met the diagnosis of psychiatric illness but primary care physicians only found diagnosis in 24.2%. Of those diagnoses, 87.3% of the diagnoses were not congruent between the researcher’s diagnosis and the PCP diagnosis (World Health Organization, 2008). This suggests there are a under recognized percentage of patients presenting with depressive symptoms are in fact incorrectly diagnosed at presentation and therefore provide insufficient or misguided treatment regimen (Clark, 2011). This may also indicate that the outcome of the lack of education, training and understanding in which primary care physicians have regarding mental health care illness is that there are improperly screening, diagnosing, and treating psychiatric illnesses.

Major Depressive Disorder vs Bipolar Depression

Studies find that primary care physicians are increasing their use of anti-depressants, however, the majority of primary care physicians are using inappropriate pharmacologic treatment (Clarke, 2011). Traditional antidepressants are being over utilized in terms of monotherapy for a great many patients for whom this approach is not only inadequate, but also potentially harmful (Geddes, Gijsman, Goodwin, Nolen, & Rendell, 2004). For example, bipolar depression can be mistaken for major depressive disorder. The psychopharmacologic treatment for major depressive disorder can be much different than with bipolar depression, in that prescribing an antidepressant alone can result in worsening depression and additional harmful side effects (Geddes et al., 2004). An issue with primary care clinicians is that they are often not well enough equipped to differentiate the two and rather than treating the illness, they tend to treat the symptoms (Coyne, Thompson, Klinkman & Nease, 2002).

Psychotherapy

Although the American Psychiatric Association (2000) recommends both psychotropic medication and psychotherapy for the treatment of depressive disorders, there has been a significant increase of antidepressant use and significant decrease of psychotherapy use (Olfson & Marcus, 2009). Studies have found that psychotropic treatment is more favorable than psychotherapeutic treatment among certain populations, such as ethnic minorities and those with anxiety disorders, although research has found psychotherapy to be more effective than psychotropic treatment long term (Wagner, Bystritsky, Russo, Craske, Sherbourne, Stein, & Roy-Byrne, 2005). 

Advantages of this Expanding Role

Over the last few decades, primary care physicians have been treating more and more patients with psychiatric illness. Many factors have contributed to this change of role. Some of the factors may include: stigma, physical symptoms of depression, increase in physician comfort, insurance coverage, shortage of mental health providers, and increase use of antidepressants while decreasing referral for psychotherapy.

Stigma

The increase in treatment of psychiatric illness in the primary care setting may be due to several factors. Social stigma may have also had an impact. Studies have found that patients are more comfortable seeking care for depression from their primary care physicians rather than psychiatrists because it reduces the stigma associated (Olfson, Marcus & Druss, 2002). In addition, primary care physicians are more likely to add diagnostic symptoms, such as chronic fatigue, which patients feel reduces stigma (Chizobam, Bazargan, Hindman, 2009).

Physical Symptoms of Depression

The physical symptoms of depression are often first addressed by family care physicians. This is another reason why so many patients with depression are seen in the primary care setting. Some of the physical symptoms include: lack of energy, fatigue, weakness, slow movements, agitation, insomnia, loss of concentration, and pain. While it is possible that these symptoms are in fact solely caused by depression, they may also be comorbid; medically, psychiatrically, or both. Interconnections between depression and medical comorbidities should, and have the potential to be considered with treatment in the primary care setting, however, is not always done. Among many of the medical illnesses that can be associated with these physical symptoms include: hypothyroidism, hypogonadism, diabetes, and dementia. In addition, studies have found people with mood disorders are at an increased risk of physical illness comorbidity (Zimmerman, 2008).

Physician Comfort

Another factor of the expanding role is that primary care physicians feel more comfortable prescribing antidepressants since seemingly safer treatment options have been available (Olfson, Marcus & Druss, 2002). Toxicity and addictive properties of medications treating mental illness symptoms have improved, however, although psychotropic medications are often thought to be safer than they actually are (Olfson, Marcus & Druss, 2002). This may be contributed by lack of education, lack of awareness, and manipulation by pharmaceutical companies.

In addition, physicians may be more comfortable with prescribing psychotropic medications because patients are more knowledgeable and accepting of using psychotropic medications (Kravits, Epstein, & Feldman, 2005). Furthermore, physicians are more likely to prescribe patients with antidepressants when they either ask for a certain brand or for antidepressants in general (Kravits, Epstein, & Feldman, 2005).

Insurance Coverage Limitations

            Prior to the Affordable Care Act (ACA), many individuals did not have mental health care, or their coverage was limited. Treatment under a primary care physician are more affordable than a psychiatrist, and even with insurance coverage, often require higher copayments and out-of-pocket costs (Olfson, Marcus & Druss, 2002). In addition, insurance premiums could increase once mental health care treatment was documented, therefore going through a primary care doctor, psychiatric diagnoses could be hidden by medical diagnoses (Olfson, Marcus & Druss, 2002.

Other Factors

            Other factors may have contribute to the dramatic increase of treatment of depressive disorders in the primary care setting. The shortage of mental health providers, including psychiatrists could contribute to increase of psychiatric care in the primary care setting. Another possible factor is that primary care physicians have turned to treating depression with psychotropic medications rather than referring to mental health specialists, which may appeal to certain populations.

Advantages of the Expanding Role

The expanding role of primary care physicians with psychiatric care has many advantages. They have the ability and potential to deliver quality care for treatment of mental health illnesses. Individuals are more likely to reach out to their primary care physician than with any other type of professional, which means these physicians have the ability to treat or coordinate care and can be helpful if done so appropriately. Their ability to facilitate care for patients to see other professionals, such as for psychotherapy, nutrition management, or holistic therapies, may provide the patient with the best possible outcome.

Rule out Medical Illness

Primary care physicians have ability to rule out medical illness that may be the explanation behind the symptoms of depression. Physicians that order lab work, such as screening for thyroid dysfunctions or vitamin deficiencies prior to prescribing psychotropic medications can provide a safer treatment for their patients.

Integrate Medical History

In addition, primary care physicians can integrate their patients’ medical history which may help to choose the most appropriate psychotropic treatment, depending on the patients’ other diagnoses, such as heart disease or diabetes which can result in larger or worsening problems when inadequately monitored or poorly considered. They are also able to keep their patients’ conditions under control by monitoring lab work and make changes to psychotropic medications when needed based on the results, rather than waiting for the problem to arise. Furthermore, since primary care physicians often see several members of a family, physicians are able to consider predisposition and environmental influences and if applicable, what treatments have been successful for their relatives in the past.

Other Advantages

Primary care physicians also have ability to recognize depression through screenings performed during physical exams that may have been otherwise ignored without preventative care. When used correctly, psychopharmacologic treatment can reduce symptoms of depression and prevent relapse. These advantages of providing mental health treatment in primary care settings can significantly increase the patients overall quality of care, in turn, greatly improving their quality of life. 

Background Information

Background

The World Health Organization (WHO) estimates that 350 million people in the world suffer from mental health illnesses and 121 million people in the world suffer from depressive disorders (2004). It is estimated that 1 in 4 people will suffer from mental illness at some point in their lives (WHO, 2004). Furthermore, it is estimated that about 15% of those with depressive disorders commit suicide and 60% of those who die by suicide had a primary diagnosis of a depressive disorder (WHO, 2004).

Drug treatments have been utilized for the treatment of psychiatric illness for over 100 years. In the 1940’s, mental illness was viewed as irreversible and individuals suffering from psychiatric illness feared potential for institutionalized (Callahan & Berrios, 2004). The social stigma of mental illness has since decreased overtime, however, many physicians still hold bias towards those with mental illness, particularly depression, understanding it as a character flaw rather than an illness (Olfson, Marcus & Druss, 2002). Due to various factors, including the social stigma, an increasing number of individuals with mental illness have been seeking care from their primary care physicians. Today, in the United States, around 75% of individuals being treated with psychotropic medications are being treated by primary care physicians (Clarke, 2011).

Primary Care Setting

Primary care settings may include the following health care physicians: allopathic and osteopathic physicians, general internists, pediatricians, obstetrician/gynecologists. In addition, nurse practitioners and physician assistants may also serve as primary care clinicians. In primary care, clinicians are expected to comprehensively address the health needs of patients. In the setting, practitioners often maintain a patient-clinician relationship, provide preventative care, and address their patients’ health care needs as they arrive during any point of their lives by either treating the issues themselves, or coordinating care with specialists. 

Social Change Theory

The conflict theory is a possible theory that can be used for my social change topic. With the conflict theory, the framework can help better analyze the issues so that the movement can possibly be readdressed towards a better direction. The conflict theory views society as changing due to scarce resources. My topic discusses the lack of resources of psychiatrists, thus forcing mental health patients onto their primary care doctors, thus causing change in where society receives their psychiatric medication. The overwhelming percentage of primary care doctors, who are not adequately qualified to understand psychiatric illnesses, medications, and treatment. One limitation of this theory is that it explains social instability better than it can explain social instability. 

Significance of Social Change Blog

The significance of this social change blog is that it will identify the need for recognition of the condition and its scope, promote education of patients and providers and therefore influence earlier detection and correct treatment, and to advocate for more specific research, eventually, into the biochemical, cellular, and genetic aspects. In addition, throughout understanding of how PCPs experience treating MDD and other mood disorders, a more efficient treatment paradigm can be suggested. This topic can explore whether or not there is probability that an improved paradigm for treating mood dysfunction exists and can be readily implemented within the primary care setting (Thota et al., 2012). Furthermore, exploration of a model of management based on physiology and genetic predisposition that could hopefully further destigmatize the diagnosis of depression and mood instability, lead to broader access to treatment, and improve outcomes. Lastly, the impact of our healthcare changes can also be examined.