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Appearing anxious and overwhelmed on a routine visit with her primary-care
provider, Lucy Cressey was prescribed an anti-anxiety medication and
referred for talk therapy with a social worker.
The treatment recommendations came after Ms. Cressey agreed to fill out two questionnaires during the medical visit at the John Andrews
Family Care Center in Boothbay Harbor, Maine, last year. Ms. Cressey
scored high on both questionnaires, designed to help depression and
Following the recent death of her best friend, a tough spinal surgery and some family financial woes, "a lot of stressors just
snowballed for me," says Ms. Cressey, a 52-year-old veterinary
technician. "But in rural Maine it's not so cool to talk about being
depressed or anxious, and those questionnaires really open some doors
for them to help you."
A growing number of primary-care providers are using screening tools to
assess depression and other mental-health conditions during
routine-care visits. They are also coordinating care of depressed
patients with behavioral-health specialists. Such so-called
mental-health-integration programs have been shown to reduce
emergency-room visits and psychiatric-hospital admissions, and to
increase employees' productivity at work.
One in four American adults who visit their primary-care doctors for a routine checkup or physical complaint also suffer from a
mental-health problem, federal data show. But patients often don't
raise the issue and doctors are too busy to ask. As a result, many
never get treatment: Less than 38% of adults in the U.S. with mental
illness received care for it last year, according to the federal
Substance Abuse and Mental Health Services Administration.
A number of health-care groups work in tandem with behavioral-health providers. And some insurers, including Aetna, are promoting integrated care. About 5,000 physicians participate in
Aetna's Depression in Primary Care program, which reimburses them for
administering a Patient Health Questionnaire, or PHQ-9, to patients.
Aetna is also training behavioral-health specialists, and stationing
them in primary-care offices.
Health groups increasingly recognize that physical and emotional health are intertwined. Many patients with mental-health problems have
two or more other issues such as heart disease, obesity or diabetes. As
many as 70% of primary-care visits are triggered by underlying
mental-health issues, according to behavioral-health researchers.
Intermountain Health in Salt Lake City, Utah, uses the PHQ-9 depression-screening tool in about 70 of its 130 medical practices.
"The aim is to see if we stabilize patients and get them well in
primary care, or whether we need to transition them to a
behavioral-health expert," says Brenda Reiss-Brennan, director of the
Intermountain Mental Health Integration program.
Wayne Cannon, an Intermountain physician helping lead the effort, says that patients who are asked to fill out the PHQ-9 form might be
classified as mildly, moderately or severely depressed. Scoring
programs on the questionnaires include guidelines to help doctors
determine whether patients need just watchful waiting, medication or a
course of psychotherapy. Patients can be immediately seen by a
behavioral-health specialist in what's known as a "warm hand-off," Dr.
Cannon says, making them more comfortable and likely to follow through
Amy Young, a 32-year-old patient at Intermountain who has multiple sclerosis and takes antidepressants, says her primary-care doctor last
year referred her to a psychologist who works in the same office and
knew about some struggles faced by MS patients. "Your primary-care
doctor can't talk to you for an hour at a time like a therapist can,"
says Ms. Young. "They can talk to each other if they have questions
about anything going on with me and I feel much more relaxed because
I'm used to going to the same office."
Intermountain says its own studies show that adult patients treated in its mental-health integration clinics have a lower rate of growth in
charges for all services than those treated in clinics without the
service. It also found that depressed patients treated in the clinics
are 54% less likely to have emergency-room visits than are depressed
patients in usual care clinics.
Patients being treated for depression should have the PHQ-9 test regularly administered, says John Bartlett, senior adviser in the
mental-health-care program at the nonprofit Carter Center in Atlanta,
which promotes mental-health treatment in primary care. If doctors
don't offer it or don't repeat it, patients should take the test on
their own and alert their doctor to any worrisome score, he says. The
test is available free online at depressionscreening.org.
MaineHealth, a network of providers in the state that includes the John Andrews Center where Ms. Cressey is
treated, recruited behavioral-health specialists to work in doctors'
offices in different communities. Cynthia Cartwright, program director,
says MaineHealth created an Adult Wellbeing Screener combining
questions from the PHQ-9 for depression, and other tests for anxiety,
bipolar disorder and substance abuse. "It's hard sometimes to reduce
depression symptoms to the questions on a form, but you have to start
somewhere, and I think they help doctors notice, ask about and treat
mood disorders," says Debra Rothenberg, one of the physicians
participating in the program.
Because behavioral-health services are typically covered separately under most insurance plans, doctors often have to advise patients to
seek out additional mental-health care by calling their insurer for a
referral. But many patients don't follow through to make the
appointments, and there are often limits to their mental-health
coverage. That is changing as new federal rules take effect prohibiting
insurers from setting stricter limits on mental-health benefits than
they do for other illnesses. And mental-health-integration programs are
expected to get a boost from the new federal health law, which includes
funding for programs creating "medical homes" that coordinate physical-
and mental-health care for patients.
In the Aetna program, the insurer's case managers help track patients' progress and alert physicians if they are not improving. Case
managers also assist with referrals to additional mental-health
Aetna's studies show that on average, patients completing the case-management
program experienced a 4.7% increase in productivity at work, based on a
questionnaire measuring the impact on productivity of employee health
problems. Hyong Un, Aetna's chief psychiatric officer, says the insurer
uses its own records to identify patients who may be candidates for
depression screenings, including those who have stopped filling their
Richard Wender, chair of the department of family medicine at Thomas Jefferson University in Philadelphia, says participation in the
Aetna program has helped motivate its doctors to administer the screens
and follow up with patients. Having a behavioral-health specialist in
the same office "has helped us assess behavioral-health issues more
frequently and have a plan in place to deal with them," he says.