OPUS Spring 2017
Letter from the Editor
Staff Articles
- Managing Mental Health in the Primary Care Sector
- An Interview with Dr. Joshua Aronson
- An Interview with Dr. Elise Cappella
- Childhood Emotional Abuse and Borderline Personality Disorder
- Split: A Review and Its Unexpected Merit
- The Influence of Leadership Style on Individuals’ Satisfaction on Small Teams
- The Impact of Postpartum Depression on the Mother-Child Relationship
- Don’t Worry, But Don’t Just Be Happy
- Teachers’ Use of Positive and Negative Feedback: Implications for Student Behavior
Peter Goldie
Each year, 42.5 million people in America struggle with debilitating mental health issues (Bekiempis, 2014). Individuals with mental health issues (e.g., depression, anxiety) experience high rates of unemployment, feel less pleasure, and are at a higher risk of experiencing chronic physical illnesses (Leahy, Holland, & Lata, 2012; National Alliance, 2014; Schaub, 2012). Although many psychiatric treatments exist, less than half of patients in need are treated with the most effective methods (Davey, 2014; Pull & Damsa, 2008). Mental health issues are treated predominantly in the primary care sector, which frequently leads patients on ineffective treatment trajectories (Agency for Healthcare Research and Quality, 2012). Although integrating mental health services into primary care may reduce mental health care costs and can allow for more comprehensive, patient-centered treatment (World Health Organization, 2008a), primary care providers (PCPs) currently lack the education, knowledge (Agency for Healthcare Research and Quality, 2012), and time to treat mental health issues effectively (World Health Organization, 2008b).
The training that PCPs receive in psychiatry during medical school is shallow and brief, leading them to misdiagnose patients and overprescribe psychotropic medications that pose significant health risks (Agency for Healthcare Research and Quality, 2012). Furthermore, PCPs rarely follow up with patients because they are overbooked (World Health Organization, 2008b). Thus, the primary care sector leaves many mental health patients with lingering issues that could be treated more effectively by qualified mental health professionals (Pull & Damsa, 2008). Mental health professionals are the only doctors qualified to treat mental health patients, with training that generally extends for multiple years (Agency for Healthcare Research and Quality, 2012; American Psychiatric Association, 2017).
Psychotherapy, a treatment often recommended by mental health professionals, is key in treating mental health patients—especially those who are treated with medication. Psychotherapy has been demonstrated to improve interpersonal skills and mood (Dakin & Areán, 2013) and allows patients to be closely monitored and process their experiences with treatment. Specifically, cognitive and relaxation therapy, as well as combination treatment (i.e., the use of medication in conjunction with psychotherapy), have been efficacious in mitigating debilitating symptoms of anxiety and depression, two of the most common mental health issues afflicting individuals in America (Bowers, 1990; El Alaoui et al., 2016; Pull & Damsa, 2008). Mental health professionals frequently utilize psychotherapy, whereas PCPs tend to recommend medication-only treatment (Davey, 2014). Furthermore, mental health professionals are able to treat mental health patients more effectively because they receive years of intensive training and supervision developing skills to accurately evaluate patients, create effective treatment plans, and closely monitor patient progress (American Psychiatric Association, 2017). For instance, to become licensed, psychiatrists must attend medical school, pass an exam demonstrating their skills, and complete four years of hands-on work in residency (American Psychiatric Association, 2017). Mental health professionals are able, capable, and trained to work with patients to adjust treatments and find one that works; they simply need referrals from PCPs.
Many individuals with mental health concerns reach out to PCPs as a first step, likely because it is convenient. Additionally, there is a stigma associated with mental health issues in America, which may incentivise patients to seek services solely through a PCP rather than seeing a mental health specialist (Jean, 2010). Moreover, treatment in primary care may allow patients to avoid additional costs associated with mental health care, such as psychotherapy (Jean, 2010); for less financially stable individuals, this may be a deciding factor. Conversely, PCPs may also be inclined to treat individuals the cheapest way possible, which is often solely with medication (Nydegger, 2008).
Referrals to mental health specialists would counter the prevalence of medication-only treatment and help reduce chronic mental health issues. However, data suggests that PCPs refer patients less than 40% of the time (Kravitz et al., 2006). PCPs may be reluctant to refer mental health patients for a few reasons. First, there is a clear lack of mental health professionals in America (Nydegger, 2008); PCPs may be wary of this and refrain from referring patients in hopes of avoiding long waitlists that would lengthen the time that an individual is untreated. But by doing so, they inappropriately take patients’ treatment into their own hands and treat patients in less efficacious ways than mental health professionals would. Additionally, prescribing medication provides doctors with financial benefits (Smith, 2012); although this is a clear conflict of interest, this likely skews many PCPs’ referral rates downward.
When treating mental health patients, PCPs often utilize medication-only treatment, prescribing 85% of psychotropic medications nationwide (Goodwin, Gould, Blanco, & Olfson, 2001). This is an alternative to referring patients to mental health specialists and most likely occurs because they want to reap the available financial benefits (Smith, 2012). However, medication-only treatment poses many risks. For example, certain medications can lead to adverse health outcomes or serious side effects such as seizures, cardiovascular problems, and suicidality (National Alliance, 2016; Teixeira, 2009). Additionally, medication-only treatment has shown less efficacy in treating prevalent disorders such as anxiety (Pull & Damsa, 2008) and may lead to negative effects experienced when medication intake is terminated if it is not supplemented with psychotherapy (Pull & Damsa, 2008); but PCPs rarely utilize psychotherapy (Nydegger, 2008). PCPs are also often unfamiliar with the medications they prescribe; their full training in psychiatry typically spans just four to eight weeks (Agency for Healthcare Research and Quality, 2012; Smith, 2011), which does not compare to the appropriate amount of time (i.e. four or more years) that psychiatrists study mental health treatment (American Psychiatric Association, 2017). Thus, PCPs cannot monitor patient progress appropriately or understand when to change a patient’s dosage or instruct them to stop using the medication (Nydegger, 2008). This is a failure of the primary care system to make patients aware of how they can best be treated.
Clearly, there is a disconnect between facets of the current medical system regarding the treatment of mental health issues. To combat this, many individuals have recently identified themselves as proponents for the integration of mental health treatment into the primary care sector, posing that this would allow for mental health issues to be identified more accurately (Agency for Healthcare Research and Quality, 2012). However, this integration is not feasible at this point given the drastic changes in training models for PCPs that would need to be implemented (World Health Organization, 2008b). Additionally, time constraints concern PCPs as they are overburdened with patients already; increasing numbers of PCPs in America are necessary to account for the extra time that effective mental health care would take if implemented (World Health Organization, 2008b). Lastly, licensing is another problem, as mental health clinics and primary care clinics have different staffing requirements for employees. These requirements are incompatible with most proposed integration models (Houy & Bailit, 2015), indicating that new models must be created or that changes must be made to the medical care system before integration is feasible.
In contemporary America, PCPs remain unqualified to treat mental health patients (Agency for Healthcare Research and Quality, 2012); allowing them to continue to do so will cause further stagnation in patients’ treatment progress or problematic side effects. To counter this, we must work to combat the stigma surrounding mental health. By doing so, patients may increasingly seek mental health services from mental health specialists who will be able to recommend and monitor proper treatment instead of PCPs (American Psychiatric Association, 2017). Additionally, it is key that policymakers fight the financial incentives to prescribe medication, as this creates a conflict of interest that is evidently detrimental to mental health across the country. Because the integration of mental health care into primary care is not currently feasible at this point, mental health patients must be treated solely in the mental health sector. This will ensure that diagnoses are accurate, treatment is effective, and patients are closely monitored by experienced, specialized professionals (Agency for Healthcare Research and Quality, 2012).