August 25, 2020

Mental Health and Physical Health – We Need to Advocate for Integrative Care Models

By Susan Parmelee, LCSW

As a Licensed Clinical Social Worker specializing in mental health services for youth ages 12-25 years old, I spend a lot of time talking to youth and colleagues about mental health and how we can prevent suicide. Suicide remains one of the most difficult challenges in our work due to the complicated interaction of many factors. As a nation, we continue to lose young people at increasingly staggering rates to death by suicide, and rates of hospitalization for self-harm and attempted suicide are also of concern. 

Suicide is Complex and Multi-factorial

The perfect storm that leads to a death by suicide usually includes environmental, societal, biological, and emotional components. However, at the trainings and meetings I sit in to “lower the stigma,” get to “zero suicide,” and increase access to mental health services, very few physical healthcare providers are in the room. If they are present, those medical doctors often look to the mental health providers for the answers and approaches. 

I received my degree in Clinical Social Work in the early 2000s. In my program we learned the importance of referring youth and adults with symptoms of mental health diseases to their primary care provider to rule out certain medical conditions that could be evaluated through a comprehensive lab work order and physical exam. As the rule out article describes, ‘common examples are sleep and thyroid dis­orders; deficiencies of vitamin D, folate, and B12; Parkinson’s disease; and anti-N-methyl-d-aspartate receptor autoimmune encephalitis.’

Additionally, a careful evaluation of substance use is critical to a correct diagnosis and then appropriate treatment, as many substances (both prescribed and illegal) and withdrawal scenarios can trigger psychosis, agitation, and other mental health symptoms. In youth, conditions such as Attention Deficit Disorder and Autism Spectrum Disorder can be diagnosed by pediatricians and referred for evaluation, and some of these neurological symptoms can mimic, co-occur, and/or trigger the diseases of mental health. 

I supervise graduate student social work interns, so I have asked them what they are now taught as medical rule outs. Their list is more comprehensive, as research has allowed for an increase in knowledge about human physiology and how this affects neurological and social-emotional functioning. Of note, these students now learn about how the gut biome may be a culprit in the diseases of anxiety and depression. 

Beyond the bloodwork that I suggest to have primary care docs check in every new referral – thyroid function, vitamin D, and iron levels – there is now extensive research on lipid levels in blood and associated symptoms of anxiety and depression and suicide risk. While we do not yet have clinical guidelines and there are questions about causality, this appears to be an important link and a reminder to consider diet and nutrition. 

In fact, I was taught, as were my graduate students, to carefully evaluate sleep, exercise, and diet as part of each psycho-social evaluation.  Addressing these areas and providing referrals to nutritionists, helping people become more active, and coaching people on sleep hygiene can effectively reduce mental health symptoms. Exploring these modifiable behaviors and working to encourage healthier habits is a preferred approach and should be tried prior to a referral to a psychiatrist for a medication.  The exception is when the client is in the midst of a psychosocial crisis, then referrals for more intensive services may be required, particularly if the client is at risk of harming themselves or others. 

What is the role of Primary Care Medicine?

Returning to my original comment, I do not truly know how primary care doctors are trained to address their patients’ mental health. However, in the important work that I participate in to lower rates of suicide and self-harm, medical doctors are not sitting at the table. I spent some time looking into how their professional societies suggest addressing suicide and the diseases of mental health. 

The American Academy of Pediatrics (AAP) developed a periodicity screening that guides pediatricians in behavioral health development from an early age and stresses the importance of prevention of and recovery from adverse childhood experiences. In 2018, the AAP added guidelines for screening depression in teens that should start when a child turns 12 years old, using a standardized form that the AAP adopted. This policy was in response to findings by the AAP prevention committee which stated, “The report reveals that half of teenagers with depression are not diagnosed in the pediatric primary care setting before reaching adulthood, resulting in two-thirds going without needed treatment. Even in cases in which adolescent depression is diagnosed, about half of teenagers still go without appropriate intervention.”

The guidelines stress the need for pediatricians to develop a treatment plan that includes educating the teen and their parents about treatment options, referrals to outside services, safety planning with emergency measures clearly taught, and ongoing management. The guidelines note the difficulty in finding enough time in a patient visit to screen and provide the appropriate management of the results. The AAP guideline’s authors note that they are optimistic about the prevalence of pediatricians who incorporate these screenings, yet note that many pediatricians have not adopted these measures. 

In my practice, I do not typically talk with the outside pediatricians who care for my clients. Managed care requirements make it very difficult for pediatricians to have time to consult with other health care providers. Healthcare in the United States is fragmented and managed care leaves little time for professional consults outside of a healthcare network. Additionally, there is a shortage of mental health care professionals who treat youth across the globe. In the US, many suggest increasing the responsibility of the pediatrician and the primary care doctor in caring for our mental health. They note, in particular, that nearly three-quarters of mental health disorders have childhood onset and there is evidence that challenges such as anxiety and depression can be prevented or ameliorated through early intervention. 

Fostering Collaborative Approaches

I would lobby for public funding for the education of mental health social workers and mental health nurse practitioners to fill this gap in practitioners. Additionally, insurance companies should allow psychiatrists to bill for longer intensive visits. Prescribing psychotropic medications is an art form, much different from prescribing an antibiotic and watching an infection clear up. There are no clear markers that a medication is working, and many can do harm. Furthermore, most pediatricians who prescribe antidepressants and anti-anxiety medications report no formal training in use of these medications. 

For depression and anxiety, as well as many other psychiatric diseases, the optimum treatment includes a medical exam to rule out physiological symptoms, sleep disorders, nutritional concerns, and possible side effects from other medications.  The medical evaluation may be concurrent to the therapist assessment and formulation of a treatment plan.  If the therapist and the primary care doctor see the need, a referral to a psychiatrist for medication may be the next step. 

The most successful outcomes with medications also employ continued counseling or behavioral therapy using evidenced-based treatments targeted to the diagnosis and symptoms. In my experience, clients often drop out of therapy when medications are working, sometimes leading to adverse outcomes when the medications are no longer effective or sufficient. Fully understanding the individual’s challenges and circumstances before prescribing psychotropic medication is essential.  The optimum combination is a team approach where the psychiatrist and therapist consult regularly and establish mutual goals with the client.

A promising model is embedding mental health professionals in the pediatric setting for ease of referral and consultation between professionals and a focus on treating the whole person. A hurdle to this model is the lack of parity in insurance reimbursement for mental health care and resistance by insurance companies to provide ongoing mental health care to keep these conditions from escalating. However, this model has been adopted in Health Resource & Service Centers and Health Center Programs (which predominantly serve adults with public health insurance or no insurance) using integrated behavioral health programs. These centers report a reduction in costs for chronic illness management, lowered stigma about the diseases of mental health and addiction, as well as the benefit of data sets for research and knowledge-sharing across federally funded healthcare programs and to the general public. Enhancing resources, costs savings, and better treatment for each individual seems like something we should all support.

Susan Parmelee, LCSW is a board member of the James Kirk Bernard Foundation and the founder and Executive Director of the Wellness & Prevention Center (WPC), a nonprofit mental health clinic in South Orange County, California. WPC’s mission is to help youth and families lead healthy lives. The WPC provides easy to access clinical services on secondary school campuses and educates the community about the diseases of addiction and mental health.