Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.
Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.
Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?
Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.
Three issues are important with respect to universal screening and better training of primary care providers. First, while several studies have coupled screening with systematic feedback of depression diagnoses to primary care providers, none of them have demonstrated a significant effect on clinical outcomes of mental disorders, such as depression, even though the rate of mental disorder diagnosis had increased.
Second, findings from multiple studies suggest that primary care clinician education programs, including continuing medical education programs and academic detailing, have only produced modest and temporary improvements in clinical practice with little improvement in patients’ depression level. The nation’s graduate medical education program still only pays lip service to providing training in mental health to meet the needs of patients. Dr. Lisa Rubenstein at the UCLA School of Medicine lamented that the education program for mental health in the nation’s medical schools died a silent death in the last ten years. It is not surprising that a significant number of primary care clinicians feel uncomfortable about diagnosing and treating mental illnesses.
Third, about fifty randomized controlled trials have shown that depression treatment outcomes were improved with collaborative care, i.e., structured care involving a greater role of nonmedical specialists to augment primary care. These results hold for both short (6 months) and longer terms (up to 5 years). Related to what you have noted, collaboration with behavioral health professionals via staff performing care management functions has enabled primary care physicians to achieve better mental health outcomes for their patients.
Several years ago, the Subcommittee on Mental Health Interface With General Medicine of the President’s New Freedom Commission on Mental Health declared that these requirements must be met in order to improve the quality of care: educated consumers and providers; effective detection, diagnosis, and monitoring; valid performance criteria for care; care management protocol that treat to targeted clinical outcomes; effective specialty mental health support for primary care providers; and financing mechanisms for evidence-based models of care.
Primary care services in the ambulatory care setting are mainly provided via conversations between patients and providers. We have observed a couple of primary care physicians in our study who exemplified the future state of what effective detection and management of patients with depression could be. May their communication approaches become the norm rather than the exception for all patients with mental health needs.