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Mental Health Disparities in Primary Care Practices

Lindsey Hunt, BSN, RN ~ Jesika Moore, BSN, RNJennifer Peifer, BSN, RN ~ Jennifer Raines, BSN, RN ~ Ann Sparks, BSN, RN

Faculty Mentor: Elizabeth Carlson, PhD, MPH, GNP-BC, PHCNS-BC

In 2001, the Surgeon General issued a report on the cultural, racial, and ethical issues that contribute to mental health disparities in the U.S. In that report, the recommendations identified the necessity of integrating mental health care into primary health care; this process would call for research and demonstration programs that would strengthen the capacity of primary care providers in the delivery of integrated services. The purpose of this research project is to find the best strategies and evidence for shifting the cultural norms of primary care practice.

Researching mental health issues in primary care has demonstrated there is still not cohesive integration of services. Nursing cannot tackle the PICO question without collaborative efforts and it will be difficult to change cultural norms for patient screening and treatment by nurse-driven commitment alone. Multidisciplinary perspective for a collaborative approach is required in order to yield a cohesive integration of mental health into primary care. Individualized case-by-case nursing treatment plans that include multidisciplinary resources are required. Ultimately, further nursing research integrating other disciplines is still needed to clearly identify best practices.

(P) In primary care practices, (I) What strategies are effective at shifting cultural norms of service delivery, (C) Versus the current compartmentalization of mental health and primary care, (O) So that mental health care is cohesively integrated with primary care services?

In primary care practices, what strategies are effective at shifting cultural norms of service delivery,

versus the current compartmentalization of mental health and primary care, so that mental health care is cohesively integrated with primary care services?

Consistent findings from two systematic reviews of primary literature, three quasi-experimental studies and one observational study identify that screening for mental health problems is an inadequate response for cohesive integration of mental health with primary care practice.  Varied screening techniques were utilized in the studies and screening did not change the rate of antidepressants prescribed, referrals to mental health providers or patient outcomes. Therefore, the answer of what strategies are most effective in shifting cultural norms and causing integration between providers remains unknown.

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Two librarians specializing in nursing research were consulted and a search was conducted of CINAHL, PubMed, Cochrane, Medline, PsychInfo and TRIP databases; using the MeSh terminology as database appropriate. We limited our search to English written articles published between the years 1999-2009 and used the keywords: Health Care Delivery, Mental Health, Integrated, Primary Care, strategies, Medical Home Model. Exclusion criteria were of articles focusing on dementia and Alzheimer’s disease. Of the articles meeting the known criteria for the PICO question, five were selected successfully.

Background

Methods and Search Strategy

Nursing Implications & Recommendations

ConclusionObjectives/PICO Statement

Article 1 Article 2 Article 3 Article 4 Article 5

Article Citation Gilbody, S., Sheldon, T., & House, A. (2008). Screening and case-finding instruments for depression: a meta-analysis. Canadian Medical Association Journal, 178(8), 997-1003.

Bower, P., Gilbody, S., Richards, D., Fletcher, J., & Sutton, A. (2006). Collaborative care for depression in primary care: Making sense of a complex intervention: systematic review and meta-regression. British Journal of Psychiatry, 189, 484-493.

Sousa, K. H., & Zunkel, G. M. (2003). Optimizing mental health in an academic nurse-managed clinic. Journal of the American Academy of Nurse Practitioners, 15(7), 313-318.

Horwitz, S. M., Hoagwood, K. E., Garner, A., Macknin, M., Phelps, T., Wexberg, S., Foley, C., Lock, J. C., Hazen, J. E., Sturner, R., Howard, B., & Kelleher, K. J. (2008). No technological innovation is a panacea: A case series in quality improvement for primary care mental health services. Clinical Pediatrics, 47(7), 685-692.

Rost, K., Nutting, P., Smith, J., Werner, J., & Duan, N. (2001). Improving depression outcomes in community primary care practice: A randomized trial of the QuEST intervention. Journal of General Internal Medicine, 16, 143-149.

Type of Article Systematic Meta-Analysis Systematic review Experimental Case Study Experimental Randomized Trial

Level of Evidence Level I Level I Level IV Level III Level III

Background In many health care systems, the use of screening questionnaires in primary care without additional enhancement of care has become the most commonly used quality-improvement strategy for care of depression. Nonetheless, the potential of these screening instruments to improve the ability of nonspecialists to recognize and manage depression is substantial but cannot be assumed under mandates of evidence-based practice implementation.

Current management of depression is suboptimal. Collaborative care interventions are effective, but little is known about which aspects of these complex interventions are essential.

When a patient presents at a primary care practice, evaluation and treatment of mental health disorders is not being tracked. It is unclear weather increased awareness and adequate recognition would improve health outcomes if more closely tracked.

The available data for primary pediatric practices does not demonstrate a consistent ability to recognize, treat and follow through on patient mental health care. There remains a gray area between preparation of physicians, identification of mental health issues, and application of the tools that are most appropriate for improving the problem.

Patients with major depression are likely to receive substandard care and management leading to poor outcomes.Would an intervention program in a primary care setting improve outcomes for patients beginning a new treatment episode for major depression?

Purpose The purpose of this review was to determine the specific clinical effectiveness of screening and case-finding instruments without additional enhancement of care in improving the recognition, management and outcome of depression.

The purpose of this article is to examine the relationship between the content of collaborative care interventions and outcomes to assist in the design of collaborative care needed for the care of depression.

The purpose of the article is to evaluate the initial results of tracking and health outcomes, specifically in mental health, for clients at an academic nursing clinic and to describe an approach to mental health treatment in this setting.

The purpose of this article was to evaluate the findings of three different methods of identification of pediatric mental health issues, in hopes to improve healthcare outcomes as reported by clinicians.

The purpose of this article was to provide suggestions for primary care clinics who did not employ onsite mental health specialists.

Methodology Research Design: Cochrane Systematic Review

Setting: Not applicable Population:N=11,389 research studies Sample: N=16 randomized controlled studies 

Variables: •In-patient and out-patient settings•Unselected versus high-risk patients•U.S. studies versus other 

Tools:•Data extraction•Two Independent Data Reviewers•Mediation for bias

Outcomes:•Rates of detection•Rates of intervention/referral•Outcomes

• < 6 months• 6-12 months• > 6 months

Research Design: Systematic review Setting: Not applicable Population: N=12,398 research studies Sample: N=62 collaborative care studies 

Variables:•Collaborative care •Primary care provider•Mental health specialist•Case management

Tools: •Data extraction•Two Independent Data Reviewers•Discussion for bias

Outcomes: •Antidepressant usage•Reduction in depressive symptoms 

Research Design: Descriptive-survey

Setting: Nurse-managed clinic

Population: Audited charts at a Primary Care Clinic

Sample: N=151 patient charts

Variables: •Monitoring of health perceptions and quality of life

Tools: •Mental Component Scale (MCS- comprised of: Vitality Scale; SF-36 Social Functioning Scale; Role-Emotional Scale; Mental Health Scale)

Outcomes: •Rates of detection•Adequacy of treatment•Availability of detection facility

Research Design:Quasi-experimental

Setting: Ohio

Population: Physicians and clients of pediatric clinics

Sample: N=3 pediatric practicesN= 11 pediatriciansN= 376 parents

Variables:•MD knowledge •Parent participation

Tools: •Pretest/Posttest•Child Health And Development Interactive System (CHADIS)•Edinburgh Postnatal Depression Scale

Outcomes:•Change in practice•Physician perceptions•Parent perceptions

Research Design:Randomized effectiveness trial

Setting: Community primary care practices

Population: Primary care patients with major depression

Sample:N=12 primary care clinicsN=479 patients

Variables:•Antidepressants•Prescription therapy•Psychotherapy •Satisfaction of care

Tools:•Modified 23 Item Center for Epidemiologic Studies-Depression Scale (mCES-D)•SF-36•Patient recall•Satisfaction

Outcomes:•Depressive symptoms

Statistics •Random effects pooling •Random effects meta-regression •Multi-variant analysis•Linear T-score transformation

•Descriptive statistics •SAS 8.0 •Multivariate analysis•T tests w/p values

Key Findings •Use of screening, questionnaires, or case-finding instruments had a modest increase in recognition/management of depression by clinicians.

•Once identified with depression through a screening tool, there was no documented increase of antidepressant initiation.

•Positive effect of collaborative care on decreased depressive symptoms

•Case managers with specific mental health backgrounds and regular supervision has a positive effect decreased symptoms

•Mental health scores for these clinic patients were lower than the national norms, likely reflecting unmet needs. •This confirmed the problem but did not address the solution.

•Comprehensive electronic systems appear to have the potential to overcome several obstacles to primary mental health care.

•A reasoned, organized approach to screening and clear clinical guidelines for management of problems need to be developed.

•Redefining staff roles significantly improved outcomes in patients with newly identified depressive symptoms.

•Redefined roles were beneficial but impractical due to financial constraints, more research on sustaining these roles would improve longevity of patient outcomes.

Clinical Meaningfulness

The findings of this study suggest that, in patients presenting to their primary care practice, the utilization of a screening tool/questionnaire/case-finding instrument was not beneficial in the cohesive integration and management of those with depression.

The findings of this study suggest that, in shifting cultural norms in primary care practice collaborative care (which includes primary care, case manager with a mental health background, and regular supervision by a mental health care professional) shows efficacy in terms of decreases in depressive symptoms.

The findings of this study suggest that, in patients presenting to their primary care practice, the utilization of a screening tool was not beneficial in cohesively integrating mental health care.

The findings of this study suggest that strategies to effectively shift the cultural norms of current primary care will require a great deal of education and technical support to integrate mental health and primary care service-delivery-systems.

The findings of this study suggest that redefining staff roles to effectively shift cultural norms of current primary care will require further evaluation of financial re-distribution for maintenance of these roles and improved health outcomes for mental health patients.

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Level I

40%

Level III

40%

Level IV

20%

Levels of Article Evidence

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