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Family care physicians and DSM-5
Mental health a major part of primary care
The chair of the task force responsible for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, David J. Kupfer, MD, and Darrel A. Regier, co-authors of a recent commentary in JAMA, suggested their perspective in the commentary title: "Why All of Medicine Should Care About DMS-5."1
Although the next edition is not scheduled for publication until 2013, the authors maintained that all health care professionals not just psychiatrists and other mental health care professionals should be interested in the development of DSM-5.
"For instance, in primary care settings, approximately 30% to 50% of patients have prominent mental health symptoms or identifiable mental disorders, which have significant consequences if left untreated," the authors write.
The commentary indicates "several major goals of the DSM-5 process, which include facilitating further integration of psychiatry into the mainstream of medical practice, facilitating the clinical feasibility of addressing the diagnostic challenges posed by mental disorders in general medical settings, and emphasizing the importance of attending to patients with mental disorders regardless of the clinician's medical specialty."1
Family docs already on board
Lori Heim, MD, of the American Academy of Family Physicians in Leawood, KS, tells Medical Ethics Advisor that mental health care is already a "major part of our training in family care in particular, but I think primary care in general is much more aware of the impact of mental health than many of the other sub-specialties."
In family medicine, she notes that the goal is to treat the "entire family within their community."
"It's very apparent from primary care research and from what we train our residents that if you're going to affect behaviors, you have to include the mental health component of that," Heim says. "Much of the old sort of non-compliant patient really had to do with mental health issues that were layered on top of their either acute or chronic disease. And so without dealing with the mental health issues, you really weren't successful in trying to help optimize the health of the patient. So, that has permeated our training and our practices."
Heim also notes that in the health care reform legislation passed in March 2010, the Medicare Innovation Center has "demonstration projects dealing more with team care."
"So, the patient-centered medical home, accountable care organizations, whenever you start looking at outcomes-based care, as opposed to volume-based care, then mental health issues have to be part of that if you're going to be successful," she says.
Other factors impact care
Two other factors affect how much access patients have to mental health services and how physician are paid for providing mental health services, Heim maintains.
"One is that, in many states, [primary care physicians are] not paid if we code for a mental health diagnosis," she says.
However, some states, such as North Carolina, have mental health parity laws in place. What that means, she says, is that "if the insurance company paid for [about eight or nine codes] by anyone, then they have to pay for them for everyone."
Mental health parity legislation is "an issue in all states that have not passed this" type of legislation, she says. But part of what such legislation does is skew much of the research, according to Heim.
"So, for example, if you look at North Carolina before the legislation and after the legislation, and you go to the insurance company and you say, 'How many primary care physicians were treating patients with depression?' well, before the law was passed, we didn't code for depression. We coded for fatigue and weight loss, or sleep problems all these symptoms of depression, but not the depression," Heim explains.
"Now, if you looked at it, you might think, 'Gee, there's a whole lot more depression in the state of North Carolina,' but it's simply because we've been able to code for bipolar disease and depression and some other mental health conditions," she says.
Heim emphasizes that primary care patients were getting the treatment before, which one could see by looking at the medication prescribed. "But if you just looked at the code, it can be misleading," she says.
The second challenge Heim sees is that there simply are not enough mental health services available to patients and for physicians to refer to in the United States.
"There's not a physician that I talk to that thinks they have a wide enough network for additional mental health services," she says. "So, we can screen; we can treat; but there are many things where I would really want to have the patient be able to see somebody for a weekly or biweekly counseling session, and that is often just not available. And it's either not available because there aren't the professionals in place, or it's not available because their insurance doesn't cover mental health issues . . ." And it can be limiting to self-paying patients to try to access such services.
"So, I think that's the next step in trying to beef up the integration of mental health with primary care delivery services," Heim says.