Primary Care Expansion Could Improve Minorities' Access to MH Care

The humble neck—whether perceived anatomically or philosophically—may be enjoying a resurgence, said Ruth Shim, M.D., M.P.H., at the national conference of the 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellows Program in March in Rockville, Md.

The conference brought together fellows in psychiatry, nursing, psychology, social work, and family therapy to learn more about how to improve mental health in diverse populations. Eight APA/SAMHSA Minority Fellows attended, as did three APA Diversity Leadership Fellows (partly supported by AstraZeneca).

Shim was referring both to the physiological interactions between the brain and the postcervical body and, metaphorically, to the integration of psychiatric and primary care.

"Half of all mental disorders are treated in general medical settings," she reminded her listeners.

Primary care physicians prescribe the majority of psychotropic medications to children and adults, said Shim, an assistant professor of psychiatry and behavioral health at Morehouse School of Medicine in Atlanta. She also serves as associate director of behavioral health at the National Center for Primary Care at Morehouse.

Primary care settings are also the first place that most patients—especially members of minority groups—are likely to go when they are experiencing mental health problems, she said. That makes those clinics a good place to address deficiencies and disparities in access to care.

"Given some of the lingering stigma around mental illness in racially and ethnically diverse populations, it is essential to expand capacity within primary care settings, or those mental health needs will go unaddressed," said Annelle Primm, M.D., M.P.H., an APA deputy medical director and head of its Office of Minority and National Affairs, who attended the conference.

Racial and ethnic disparities in mental health were documented in the landmark 2001 "Surgeon General's Report on Mental Health: Culture, Race, and Ethnicity." According to the report, minorities had less access to mental health services and were less likely to receive care and more likely to get poor quality care than non-Hispanic whites.

Racism, poverty, discrimination, and violence all affect the incidence and treatment of mental illness, said Shim; thus, it's not surprising that minority groups still underutilize mental health services. In areas where many minority patients are treated, there is often a lack of resources, she said. Also, clinicians serving those populations can easily get burned out.

For these and other reasons, progress in ending disparities in mental health care has been slow, she said. For instance, among African Americans, schizophrenia is overdiagnosed, while typical antipsychotics are overprescribed, compared with whites. Among Latinos, schizophrenia is underdiagnosed, but there are too few studies on prescribing antipsychotics to tell whether there are significant differences in prescribing patterns between Latinos and whites, said Shim in an interview afterward.

Integrating primary and mental health care might help overcome some of those anomalies, she said, echoing recommendations in the surgeon general's supplementary report. The majority of people treated in these settings have good clinical outcomes that are also achieved cost-effectively. Primary care has far to go as a locus of mental health care, however.

"Most mental disorders go undiagnosed there, so patients are poorly treated," she said. Or primary care clinicians may refer patients to mental health specialists but often do not participate in follow-up care.

At the same time, people with mental illnesses often have increased levels of physical illnesses. "Mental illness exacerbates disabilities caused by cardiovascular disease, pulmonary disease, diabetes, arthritis, and others," said Shim. "This leads to higher medical utilization and costs."

Yet specialist mental health care providers either may not be trained to provide general medical care for patients with co-existing conditions or, in the case of psychiatrists, may be so busy at their specialty that it does not seem a good use of resources for them to work as general medical doctors. Many do not practice at locations where patients can also get such care, she said. Many primary care physicians have had only minimal training in psychiatry, as well.

Better integration of mental health care with other types of medical care might ease some of the problems facing patients, clinicians, and health systems. Strong evidence from several randomized trials on anxiety and depression shows that those conditions can be effectively treated in primary care, given careful advance planning.

For instance, in the IMPACT trial, University of Washington researchers demonstrated the value of stepped care for late-life depression. Based in a primary care clinic, the IMPACT plan used a care manager (usually a nurse, social worker, or psychologist) to educate, counsel, and monitor patients and to support antidepressant therapy prescribed by the primary care physician. A psychiatrist consulted to the care manager and the primary care clinician on difficult cases and recommended additional treatment or referral for patients who did not improve as expected.

IMPACT is now available for other health systems to place into regular use.

A second approach, RESPECT-D, is also being implemented. It used phone-based support and consulting psychiatrists to monitor patients and add interventions as needed. About 16 percent of patients were members of "ethnic minorities."

The NIMH-funded Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), published in 2009, reduced depression in older patients as part of a program to prevent suicide in this population. After two years, patients were more likely to achieve remission than were those in usual care. About 68 percent of the patients were listed as "white," while the rest were of "unspecified" race or ethnicity, so the results need to be replicated in minority populations.

"More and better research is needed on minority populations," said Shim. "It is incorrect to assume that the research findings that apply to one specific population (like white males) can uniformly apply to people from all different populations."

Myriad studies show that health differences in racial and ethnic populations exist, but there is not enough research on those populations to characterize those differences, she said.

She urged the fellows in the audience to pursue research on health disparities as part of their careers.

"Research data are the currency for making population-based change," she said.

"There will be more and more opportunities to practice in primary care," said Primm. "So I hope discussions like these will raise the fellows' interest in that setting as a career path."