The document discusses the integration of behavioral health services into primary care. It notes the current mental health system is inadequate to meet the high need, as mental illnesses are prevalent while psychiatric resources are limited. Integrating behavioral health into primary care can improve coordination of care for the many patients with mental and physical health comorbidities. Conditions like depression commonly co-occur with chronic diseases like diabetes and heart disease. The document advocates screening and treating behavioral health issues in primary care settings to better address patients' full range of needs.

1. BEHAVIORAL HEALTH IN
PRIMARY CARE
Dr. Rebecca Cowan
Eastern Virginia Medical School
4/1/2021
1

2. CURRENT STATUS OF MENTAL HEALTH
DELIVERY SYSTEM IN THE USA
 The number of individuals with Severe Persistent
Mental Illness has reached epidemic proportion.
 Shortage of psychiatric hospital beds.
 Severe shortage of general and child psychiatrists
in all locations.
4/1/2021
2

3. CURRENT STATUS OF MENTAL HEALTH IN
VIRGINIA
 262,000 adults & 82,000 children in Virginia live
with serious mental illness (2010).
 An estimated 395,000 adults (7.1%) had a MDE in
the past year.
 In 2006, 876 Virginians died by suicide.
4/1/2021
3

4. UNTREATED MENTAL ILLNESS HAS DEADLY
AND COSTLY CONSEQUENCES
 Nationally, we lose one life to suicide every 16
minutes.
 Suicide is the 11th leading cause of death overall
and is the 3rd leading cause of death among youth
and young adults aged 15-24.
 During the 2006-07 school year, approximately 30%
of Virginia students aged 14 and older living with
serious mental health conditions dropped out of
high school.
4/1/2021
4

5. PUBLIC MENTAL HEALTH SERVICES ARE
INADEQUATE TO MEET NEEDS
 Virginia’s public mental health system provides
services to only 19% of adults who live with serious
mental illnesses in the state.
 Virginia spent just $82 per capita on mental health
agency services in 2006, or $613.4 million. This
was just 1.9% of total state spending that year.
4/1/2021
5

6. WHY INTEGRATE?
 Treat mental health disorders where the patient feels
most comfortable receiving care (less stigma)
 Better coordination of care
 Mind and body connection
 More likely to keep appointments where multiple
issues are being addressed
 Many completed suicides were seen by PCP
 20% on the same day
 40% within 1 week
 70% within 1 month
 92% of elderly patients receive BH solely from PCP
4/1/2021
6

7. COMMUNITY MENTAL HEALTH/PRIMARY CARE
SPLIT
• PCP’s often feel unprepared to deal with behavioral
health disorders
• PCP’s frustrated when they refer into CMHC’s
• long waiting lists, drop outs before first
appointment/soon after
• CMHC’s busy, refer people back to PCP’s for
depression, ADD, etc
• Difficult for real communication given busy
schedules
4/1/2021
7

9. PHYSICAL HEALTH IS OFTEN COMORBID WITH
MENTAL HEALTH
4/1/2021
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10. CHRONIC DISEASE AND MENTAL HEALTH
 According to the CDC, about half of all Americans
had at least one chronic disease in 2005.
 Chronic diseases accounted for 1.7 million (70%)
deaths in the United States in 2005.
 Based on estimates from the Milken Institute
(2003), Virginia had four million cases of the seven
most common chronic diseases—cancer, diabetes,
heart disease, hypertension, stroke, pulmonary
conditions, and mental disorders.
4/1/2021
10

11. ARTHRITIS AND MENTAL HEALTH IN VIRGINIA
 1.5 million adults in Virginia with doctor-diagnosed arthritis
(2005).
 Adults with arthritis who experience activity limitation are 2.4
times more likely to report frequent mental distress than
adults with arthritis, but no activity limitation
4/1/2021
11

12. ASTHMA AND MENTAL HEALTH IN VIRGINIA
 8.4% of Virginians have asthma.
 Individuals with an anxiety disorder have double
the risk of having asthma.
 Those with an anxiety disorder are 78% more likely than
those without anxiety to report having an asthma attack
in the past 12 months (75.2% versus 42.2%).
 Individuals with depression are 2.5 times more
likely to have asthma.
 Adults with asthma who also have a depression are
45% more likely than adults without depression to have
had an asthma attack in the past 12 months (62%
versus 42.7%).
4/1/2021
12

13. CANCER AND MENTAL HEALTH
 Patients with at least one insurance claim for a mental health
disorder were at increased risk for brain and central nervous
system tumors and respiratory cancers, particularly at younger
ages (Carney et al., 2004).
 A similar study found an association between depression
and risk for pancreatic cancer (Carney et al., 2003).
 People with mental health disorders may die from
cancer at a higher rate.
 Men with mood disorders were more likely to have
advanced cancer diagnosis.
 Women with a long history of chronic clinical depression
were found to have a higher risk of dying from breast
cancer (Carney et al., 2004).
4/1/2021
13

14. CANCER AND MENTAL HEALTH IN VIRGINIA
 Women ages 40 and older with either anxiety or
depression were more likely to not participate in
mammography screening.
4/1/2021
14

15. CARDIOVASCULAR DISEASE AND MENTAL
HEALTH IN VIRGINIA
 Adults diagnosed with anxiety were 33% more likely
to report having high blood pressure.
 A similar pattern was found for adults diagnosed
with depression.
4/1/2021
15

16. DIABETES AND MENTAL HEALTH IN VIRGINIA
 7.4% of Virginians have diabetes.
 When applying National Health and Nutritional
Examination Survey data to Virginia’s population, it
is estimated that another 1.1 million adults have
pre-diabetes.
 Adults with a depression were 57% more likely to
report having diabetes.
4/1/2021
16

17. CHRONIC DISEASE RISK FACTORS IN
VIRGINIA: SMOKING
 Adults with an anxiety disorder were 94% more
likely to smoke, and adults with depression were
81% more likely to smoke than people without a
mental health problem.
4/1/2021
17

18. CHRONIC DISEASE RISK FACTORS IN
VIRGINIA: PHYSICAL INACTIVITY
 Physical inactivity is related to depression, but not
anxiety. Adults with depression were 51% more
likely to not participate in any exercise or physical
activity in the past month.
4/1/2021
18

19. OBESITY AND MENTAL HEALTH IN VIRGINIA
 Adults diagnosed with depression were 54% more
likely to be obese. There was no relationship
between anxiety and obesity.
4/1/2021
19

20. HOW TO SCREEN, ASSESS, & TREAT
COMMON MENTAL HEALTH
DISORDERS
4/1/2021
20

21. BIPOLAR DISORDER-
MAJOR PUBLIC HEALTH ISSUE
 Overall economic burden is estimated at $45 billion
dollars annually
 Costs of treatment for an individual exceed $17,000
per year
 1 in 3 people with bipolar disorder fail to comply
with medications
 Non-adherence to treatment often results in
hospitalization and suicide
4/1/2021
21

22. BIPOLAR DISORDER
• Bipolar I
– 1+ manic or mixed
episodes
– May have other
mood episodes
• Bipolar II
– 1 + major
depressive
episodes AND
– 1 + hypomanic
episodes
– Never manic or
mixed episode
4/1/2021
22

23. BIPOLAR I
 = in men and women
 Men>manic episodes
 Women>dep episodes
 Women>rapid cycling
 Ave. age onset = 20
4/1/2021
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24. BIPOLAR II
 May be more common in women than men
 Men>hypomanic than depressive episodes
 Women>depressive than hypomanic
episodes
 Women>rapid cycling
4/1/2021
24

25. SUBSTANCE ABUSE AND BIPOLAR DISORDER
 B. D. is the highest Axis I disorder
comorbid/concurrent with substance abuse
 21-61% of people with B.D. abuse or are addicted
to substances as compared to 3-13% in the general
population
 Substance use adversely effects medication,
produces earlier onset of symptoms and often leads
to hospitalization
4/1/2021
25

26. MAJOR ISSUES THAT IMPEDE DIAGNOSIS AND
RECOGNITION OF B.D.
 Misdiagnosed as unipolar depression
 Children, adolescents and young adults are often
diagnosed with ADHD
 People often do not have clear cut, discrete mood
episodes
 Unwillingness of the client to seek treatment
 Lack of insight from client in mood episodes
 Clinicians are not looking for manic/hypomanic
episodes
 Denial/Stigma may cause clinicians to under
diagnose and clients may not accept the diagnosis
4/1/2021
26

27. 4/1/2021
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28. SUICIDE RISK
MUST BE CONTINUALLY MONITORED
 Suicide completion rates in patients with B.D. 10-
15%
 Presence of suicidal or homicidal ideation, intent, plans
 Access to means
 Psychotic features, severe anxiety
 Substance abuse
 History of previous attempts
 Family history
4/1/2021
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29. TREATMENT OVERVIEW
 Perform a careful diagnostic evaluation
 Ensure the safety of client
 Establish & maintain a strong alliance
 Continually monitor psychiatric status
 Referral to psychiatrist
 Refer for CBT
4/1/2021
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30. SCHIZOPHRENIA
4/1/2021
30

31. PSYCHOTIC DISORDERS
Schizophrenia Usually
insidious
Many Chronic >6 months
Delusional
disorder
Varies
(usually
insidious)
Delusions
only
Chronic >1 mo.
Brief psychotic
disorder
Sudden Varies Limited <1 mo.
Onset Symptoms Course Duration
4/1/2021 31

32. DIFFERENTIAL DIAGNOSIS
 Medical/surgical/
substance-induced
Psychotic d/o due to GMC
Dementias
Delirium
Medications
Substance induced
Amphetamines
Cocaine
Withdrawal states
Hallucinogens
Alcohol
 Mood disorders
Bipolar disorder
Major depression with psychotic
features
 Miscellaneous
PTSD
Dissociative disorders
Malingering
Culturally specific phenomena:
Religious experiences
Meditative states
Belief in UFO’s, etc
4/1/2021
32

33. DIAGNOSTIC PROCESS FOR SCHIZOPHRENIA
 Physical and lab exams rule out psychotic disorder
due to a medical condition and substance-induced
psychosis
 Imaging (CT, MRI, PET) are seldom helpful in
diagnosis
 The diagnosis is commonly made from history and
the mental status exam
 Consider urine drug screen
4/1/2021
33

34. EPIDEMIOLOGY OF SCHIZOPHRENIA
 Lifetime prevalence of about 1%
 No differences related to culture or race
 Onset in men is usually earlier (15-24) than in
women (25-34)
4/1/2021
34

35. LONG-TERM TREATMENT OF SCHIZOPHRENIA
 Antipsychotic medications are effective for preventing
relapse in stabilized patients
 Effective nonpharmacological treatments include patient
and family education, skills training, cognitive behavior
therapy
 For most individuals, antipsychotic medications control the
symptoms while non-pharmacological treatments address the
impairments in social, vocational, and educational functioning
4/1/2021
35

36. CLINICAL CHALLENGES
 Substance use disorders are common in people
with schizophrenia
 Insight can be impaired leading people with
schizophrenia to refuse treatment
 Adherence to treatments can be irregular
4/1/2021
36

37. DEPRESSION
4/1/2021
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38. DEPRESSION
 Vary from person to person
 2 key signs are loss of interest in things you like to
do and sadness or irritability
 Additional signs include:
4/1/2021
38

39. CHANGES IN FEELINGS
 Feeling empty
 Inability to enjoy anything
 Hopelessness
 Loss of sexual desire
 Loss of warm feelings for family or friends
 Feelings of self blame or guilt
 Loss of self esteem
 Inexplicable crying spells, sadness or irritability
4/1/2021
39

40. CHANGES IN BEHAVIOR AND ATTITUDE
 General slowing down
 Neglect of responsibilities and appearance
 Poor memory
 Inability to concentrate
 Suicidal thoughts, feelings or behaviors
 Difficulty making decisions
4/1/2021
40

41. PHYSICAL COMPLAINTS
 Sleep disturbances such as early morning
waking, sleeping too much or insomnia
 Lack of energy
 Loss of appetite
 Weight loss or gain
 Unexplained headaches or backaches
 Stomachaches, indigestion or changes in
bowl habits
4/1/2021
41

42. TREATMENT FOR DEPRESSION
 Medication
 Antidepressants can help ease the symptoms of
depression and return a person to normal functioning.
 Psychotherapy
 This can help many depressed people understand
themselves and cope with their problems. For example:
 Interpersonal therapy works to change relationships that affect
depression
 Cognitive-behavioral therapy helps people change negative
thinking and behavior patterns
4/1/2021
42

43. DEPRESSION SCREENING SCALES
 Patient Health Questionnaire for Adolescents
(PHQ-A)
 5 minutes to complete, easy to score based on DSM-IV criteria
for Major Depressive Disorder and Dysthymia
 Patient Health Questionnaire (PHQ-9)
 Children’s Depression Rating Scale
 Measures distress; clinical cut-off 20
 Edinburgh Postnatal Depression Scale
4/1/2021
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44. 4/1/2021
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45. 4/1/2021
45

46. TREATMENT
 Laboratory studies may be useful
 TSH
 Vitamin Levels
 For patients treated with medication, f/u in 1-2
weeks to check on adherence to treatment and
side-effects.
 Achieve a 5-points decrease in PHQ-9 which
indicates clinically significant improvements until a
score of <5 is attained.
 Evaluate w/ PHQ-9 1x per month until remission
and then treat for an additional 6-12 months.
4/1/2021
46

47. ANXIETY
4/1/2021
47

48. ANXIETY
 Often have an early onset- teens or early twenties
 Show 2:1 female predominance
 Have a waxing and waning course over lifetime
 Similar to major depression and chronic diseases
such as diabetes in functional impairment and
decreased quality of life
4/1/2021
48

49. ANXIETY DISORDERS
 Specific phobia
 Social anxiety disorder
(SAD)
 Panic disorder (PD)
 Agoraphobia
 Generalized anxiety
disorder (GAD)
 Anxiety Disorder due to a
General Medical
Condition
 Substance-Induced
Anxiety Disorder
 Anxiety Disorder NOS
4/1/2021
49

50. COMORBID DIAGNOSES
 Once an anxiety disorder is diagnosed it is critical
to screen for other psychiatric diagnoses since it is
very common for other diagnoses to be present and
this can impact both treatment and prognosis.
4/1/2021
50

51. GAD-7
 Generalized Anxiety Disorder 7 Tool
 simplified questionnaire developed to help in the
diagnosis of Generalized Anxiety Disorder
 7 item questionnaire
 a score of 10 or more on the GAD-7 represented a
reasonable cut point for identifying cases of GAD
 Cut points of 5, 10, and 15 may be interpreted as
representing mild, moderate, and severe levels of
anxiety on the GAD-7.
4/1/2021
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52. 4/1/2021
52

53. CRANK UP THE SEROTONIN
 Cornerstone of treatment for anxiety disorders is
increasing serotonin
 Any of the SSRIs or SNRIs can be used
 WARN THEM THEIR ANXIETY MAY GET WORSE
BEFORE IT GETS BETTER!!
4/1/2021
53

54. BENZODIAZEPINES
 Benzodiazepines are very effective in
reducing anxiety sx however due to the risk
of dependence must use with caution
 Depending on the patient may either use on
a prn basis or scheduled
 For patients with a history of addiction or
active drug/ETOH abuse or dependence
benzodiazepines are not an option
4/1/2021
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55. ADHD
 How long have symptoms been present?
 Must be present continuously since early childhood.
 Do symptoms impair daily functioning?
 Use rating scales-
 Vanderbilt Scale for children
 Adult ADHD Self-Report Scale & Wender Utah Rating
Scale (Consider depression/anxiety)
4/1/2021
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56. 4/1/2021
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57. ADHD
 Check lead levels if patient lives in area with high
levels of lead exposure.
 Sleep study-if patient snores loudly or has brief
breathing cessation during sleep.
 Check PMP
4/1/2021
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58. DEMENTIA
 AD is the most common form 60-70% of cases.
 Symptoms commonly arise after age 70.
 Slow but progressive course.
 Consider using the MOCA
4/1/2021
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59. 4/1/2021
59

60. CONSIDER:
 Check Vitamin B12 level
 Neurosyphilis
 Assessing caregiver at each visit
 Address advanced directives early
 Educate patient and caregiver
 Referral to Alzheimer’s Association
 Treat secondary disorders (anxiety/depression)
 Consider Aricept (or similar medications)
 Avoid benzodiazepines
4/1/2021
60

61. QUESTIONS?
4/1/2021
61