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WQA survey conducted for the Robert Wood Johnson Foundation has found that most primary care physicians have difficulty finding high-quality mental health services when they seek to refer patients.
Approximately 70 percent of the respondents report they "cannot always or almost always" obtain either high-quality inpatient or outpatient mental health services for their patients, according to the survey.
The survey was conducted by the Center for Studying Health System Change, a project of the Robert Wood Johnson Foundation. The results were released October 15 at a press conference in Washington, D.C. John McIntyre, M.D., a former APA president and chair of APA’s Steering Committee on Practice Guidelines, and Miles Shores, M.D., the Bullard Professor of Psychiatry at Harvard Medical School and a member of APA’s Committee on Universal Access to Health Care, joined a panel discussing the findings.
Among primary care physicians there is "a veil of ignorance" surrounding mental health care, observed panelist Gail Povar, M.D., M.P.H., a primary care physician and clinical professor of medicine and health care sciences at George Washington University in Washington, D.C. A variety of issues contributes to this ignorance, she said.
There is a lack of cross-training, said Povar. Primary care physicians "have very little understanding of [psychiatrists’] training," she noted. Primary care doctors "talk a different language" from psychiatrists and other mental health care providers, which complicates communication.
Psychiatric and psychological interventions are discussed only rarely in the general medical literature; thus, unless nonpsychiatric physicians go out of their way to read psychiatric journals, they will remain ignorant of developments in the field.
Access is a problem even for the insured, Povar noted. For the underinsured or uninsured, high-quality mental health care is not even an option. There are "real access problems in terms of cost," she commented. Cost barriers are "tremendous even for the insured population and for the uninsured are insurmountable," she said.
The health care system in the United States "doesn’t work very well as a system," said Shore. "What we’re seeing in these data shows that one part of the system is even less well coordinated and works even less well than the whole system. But we shouldn’t overlook the fact that the system itself needs lots of fix-up."
It is good news for those in the mental health field that primary care doctors are concerned about the mental health of their patients, Shore noted. And it is encouraging that they believe that high-quality mental health services "can improve the care of their patients."
But lack of access has serious social consequences, said Shore. This is borne out by a growing body of epidemiological data showing the social burden of mental disorders, including substance abuse.
The estimated economic burden of mental disorders is $147 billion a year, with about $67 billion of that in direct costs. The balance includes lost productivity, crime, incarceration, and welfare.
For example, the average prevalence of lost work days for those without any mental illness in the last 30 days is two days a month per 100 workers. For those who have had a behavioral disorder in the last 30 days, however, the rate is six days a month per 100 workers. And of those with more than one disorder, including substance abuse, the figure is 49 days a month per 100 workers.
Early-onset disorders take a particularly devastating toll. An estimated 14 percent of high-school dropouts and 4.7 percent of college dropouts suffer from early-onset psychiatric disorders—a total of 7.2 million people.
Early-onset disorders are also associated with teenage parenthood and out of wedlock births among millions of young men and women. Marital instability is heavily impacted, resulting in an estimated 50 million lost marriage years among men and 100 million lost marriage years for women. Clearly these statistics add up to a huge social and economic burden, said Shore.
The problem of access reflects that often there are two separate systems of care, observed McIntyre: general medical care and psychiatric care.
This has been institutionalized through state offices of health that segregate mental health services, and in the private sector through carveouts and other systems that isolate mental health services. Carveouts make up "a large portion of mental health services in the managed care market today," he noted.
Many, if not most, health plans in the U.S. simply lack mental health services or have a highly limited benefit, said McIntyre. This is "experienced by primary care physicians as difficulty in getting the needed services for their patients." This exclusion is clearly discriminatory, he noted.
The data presented at the press conference are "clearly most unfortunate, not only in terms of the personal burden" that patients and families endure as a result, "but also because of the reality" that mental illnesses can be reliably diagnosed and treated, said McIntyre.
Psychiatry’s "criteria-based nomenclature" is "in some ways leading the way for the rest of medicine" by setting a standard for criteria-based diagnosis, McIntyre added.
There are "specific treatments available for specific disorders," he noted, with APA and others having developed practice guidelines to inform caregivers.
The efficacy rate for treating psychiatric disorders compares favorably with that for nonpsychiatric disorders, he noted. Depression treatment is successful about 80 percent of the time, and schizophrenia treatment about 60 percent of the time. Angioplasty, by contrast, is successful about 45 percent of the time.
Another issue is that "mental health treatment is clearly affordable," said McIntyre. Not only do treatments work, but there are cost offsets in increased productivity and better general health when people suffering from mental illness are treated adequately.
There are good models for collaboration between primary care physicians and mental health care providers, said McIntyre. In the Rochester Model in which McIntyre works, for example, there are 20 primary care sites throughout the community where mental health consultations are provided. Patients do not have to be referred elsewhere.
The mental health consultations occur "shoulder to shoulder with the rest of medical treatment," McIntyre stressed. The communication between the mental health specialist and the primary care physician is "much improved," he noted. "The notes by the mental health specialist are in the same chart as the primary care notes."
If primary care physicians are to improve collaboration with mental health specialists, they must demand reports about referred patients from those specialists when information is not freely provided, said McIntyre. Lack of communication is "not acceptable."