Leonard J. Haas, PhD, and Frank V. deGruy, MD
The psychological needs of primary care patients can be classified into three general categories, related to (a) psychopathology or true mental disorders, (b) stress-related symptoms and problems related to chronic medical conditions or behavioral health problems, and (c) membership in vulnerable populations, including abuse victims, those who are socially isolated, and those who are economically disadvantaged.
Sara James comes to her primary care physician complaining of deep fatigue. Sara is 36 years old, works part time as a paralegal, is married to a busy contractor, and is the mother of three small children. She wonders if she has mononucleosis or perhaps a thyroid problem like her sister. Her physician does a thorough physical examination and finds no evidence of poor thyroid functioning, infection, or other biomedical explanation for her fatigue.
Scenarios like this occur many times every day in the offices of pediatricians, internists, family physicians, and gynecologists across the United States. What happens next depends on the training and attitudes of the primary care physician and the health care professionals involved in the patient’s care. This scenario could follow at least three different pathways:
The Biomedical Pathway: Suspicious that he hasn’t exhausted all possibilities, the physician suggests additional tests to Ms. James. Eager to discover if she has something serious, Ms. James agrees to a full workup. When results are normal, her worries are not assuaged. She requests a referral to a specialist in fatigue-related medicine. Her doctor reluctantly refers her to a rheumatologist, who also cannot explain her condition with a conventional diagnosis. Ultimately, she finds an alternative medicine practitioner who practices herbology, where she receives a diagnosis of multiple chemical sensitivities and a prescription for aromatherapy and herbal remedies.
This scenario conforms to data on the pathways patients commonly take in primary care when their symptoms have no medical explanation (e.g., Kroenke & Mangelsdorff, 1989). The physician who is unwilling to consider psychosocial or emotional causes of distress and dysfunction often begins to pursue increasingly rare conditions. Convinced that there is something wrong, the patient may turn to complementary and alternative medicine, such as acupuncture, herbology, or aromatherapy. Or, the case could continue along a different path.
The Psychiatric Pathway: Recognizing that women are more likely to experience depression and knowing that her mother suffered from depression, the physician suspects that the fatigue may be related to underlying depression. He probes Ms. James about her mood and her life. She notes that things have been a bit frustrating at work, and she has found herself uncharacteristically out of sorts, even sad, since a coworker with whom she had a long and satisfying work relationship was transferred to another state. On further probing, she reveals that her sleep and appetite have been disturbed, she has lost interest in sexual intimacy, and she becomes tearful every day. Believing that he has successfully diagnosed a case of major depressive disorder, the physician prescribes an antidepressant and suggests that Ms. James follow up with him in one month.
This is probably the second most common scenario in primary care when the physician encounters a likely mental health problem. The majority of psychoactive medication prescriptions are written by primary care physicians and not by psychiatrists. However, it is also clear that prescribing antidepressants does not mean that the depression has been treated. In fact, the evidence suggests that half of antidepressant prescriptions either are not filled or are taken improperly, and a considerable proportion of responses to them are placebo responses (Moncrieff, Wessely, & Hardy, 2001).
Psychiatric Pathway Continued: One month later, Ms. James returns to her primary care physician, noting that she is still tired and admitting that she took the fluoxetine he prescribed for 1 week, but found that it gave her diarrhea, and discontinued taking it. She felt better briefly but now is tired and wonders what is going on. Telling her that she needs to have a thorough evaluation and empathizing with her difficulties, her physician suggests that Ms. James should restart the medication and also see a psychologist who specializes in depression. Although the psychologist’s office is located several miles away and he is on a different insurance panel, Ms. James agrees to make an appointment. Her physician suggests that she should return for a follow-up visit in six weeks.
This aspect of the case illustrates the traditional method of linking mental health and primary care through referrals. However, this is an inefficient and often not helpful method because it puts additional barriers in the path of the patient who wants help. Assume for the sake of this illustration that Ms. James is able to overcome the chief obstacles that account for the dismal rate of successful referrals from primary to specialty mental healthcare, namely: she is able to schedule an appointment within a reasonable time, she is motivated enough to make her way across town to see the psychologist, and she is savvy enough about health care benefits to arrange to have the services reimbursed.
Psychiatric Pathway Continued: At the initial appointment, the psychologist does a thorough history of Ms. James’s symptoms and then begins to explore her self-esteem, her sense of loss, and her relationship with her husband. Ms. James rapidly becomes defensive and wonders why the psychologist needs to know this. Can’t the psychologist simply suggest a better medication or give her some techniques that will make her feel better? The psychologist reflects on whether she is resistant or has some deeper personality pathology that was misdiagnosed by the primary care physician. He returns to evaluating her symptoms and considers that perhaps she would be better diagnosed as having atypical somatoform disorder with depressive personality disorder features, rather than having major depressive disorder. He privately concludes she is not a good candidate for therapy. He suggests that she try to think more optimistically and concludes the session, indicating that he can suggest a psychiatric referral or Ms. James could return for further work with him. She does not make a follow-up appointment.
This scenario describes what we believe is a typical difficulty in traditional mental health practice as it relates to primary care. The primary care patient may not believe that she has a mental health problem, and may not be ready to agree to psychological treatment. In addition, the presentation of common psychological problems in the primary care arena is often different from the presentation in specialty care, and the psychologist must be attuned to the ways in which psychological distress may be expressed. Consider the following as an alternative:
The Primary Care Psychology Pathway: After exploring Ms. James’ reluctance to restart fluoxetine and the fact that her improvement was probably not attributable to the medication, her physician suggests that she see a psychologist. Although privately worried that perhaps her doctor believes she is just a hypochondriac and is trying to get rid of her, Ms. James agrees so that she can at least say that she tried what he recommended. The psychologist, who practices in the physician’s clinic 2 days each week, is able to see her that same afternoon for a brief initial visit. This session primarily involves the psychologist explaining psychological treatment to her and exploring her understanding of her condition. Ms. James expresses her puzzlement at the referral because she does not understand how just talking could help her and wonders if what she really needs is an energizing medication such as modafinil, which she has recently learned about on television.
Agreeing that he will discuss this idea with the primary care physician at a later point, the primary care psychologist explains that it sometimes helps to talk over things that are on one’s mind and briefly explores her symptomatology. She acknowledges that she experienced a significant loss when her colleague was transferred because she is quite isolated and lonely. She agrees to come back in 3 days for a psychotherapy session. After four additional sessions over the following 2 months and some homework exercises aimed at improving her social support, Ms. James indicates that she feels much better and feels no need for further counseling.
Although he recognizes that Ms. James is likely at risk for further depressive reactions, the psychologist agrees that she has made considerable progress and leaves the door open so that if she experiences similar symptoms in the future she will find it easier to come in for a short course of therapy. He then reviews with her the common symptoms of social isolation and depression and notes that, in her case, sadness and fatigue are warning signs that she is becoming isolated. He then dictates a brief note to her physician describing her progress and notes what the physician might see in the future that would suggest the need for further treatment.
Although this case is not meant to imply that all fatigue is masked minor depression, it does illustrate the need for the primary care psychologist to make services accessible and understandable to patients who may not initially understand the connection between the somatic symptoms they present to their primary care physicians and their emotional lives. Practicing psychology in primary care offers the opportunity to address mental health issues where they are most often presented; the opportunity to address the psychosocial aspects of medical complaints; and the prospect of helping the primary care system truly meet the needs of its patients without erecting more barriers to care. However, the practice of primary care psychology demands skills, attitudes, and a knowledge base broader than that typically obtained by the conventionally trained psychologist.
Working in Primary Care Psychology
We begin with episodes from a day in the life of Dr. Emily Versatile, a psychologist in independent practice who spends two days each week in a primary care clinic.
Dr. Versatile’s first patient of the day is Tanya Brown, a 53-year-old woman referred for smoking cessation. As they discuss what has made it difficult for her to quit smoking, Tanya describes an abusive 10-year marriage that ended recently. She has never discussed the abuse with anyone other than her children, who were quite unsupportive of her and did not believe that their father could have been abusive. This 45-minute discussion of her background proves enormously relieving to Tanya (she returns for three more sessions, in which smoking is still the main focus, but she notes that her mood and her self-esteem have increased dramatically).
Dr. Versatile’s next patient is Saliri Mowese, a 32-year-old Somalian woman who is having difficulty parenting her adolescent son. On further exploration, it becomes clear that her emigration from Somalia followed some traumatic experiences, and she is showing symptoms of posttraumatic stress disorder. The son, who is in the waiting room, is invited to join the session, and a productive discussion of the family’s adjustment to life in the United States occurs. (Three more sessions over the following 6 weeks, focused on parenting, culture clash, and efforts to resolve posttraumatic stress disorder symptoms, result in much improved functioning; the patient gets a new job, and the son finds friends who are not delinquent.)
The third patient does not come. Dr. Versatile takes the opportunity to begin a conversation with Dr. Matt Hendricks, a primary care physician with whom she has collaborated for several years, about why he finds himself so tired and sad when working with a patient who has multiple unexplained physical ailments. They have a productive discussion of the similarities between this patient and the physician’s hypochondriac complaining mother.
Dr. Versatile’s next 5 hours are spent in a variety of ways: conventional psychotherapy sessions, brief health and behavior interventions, parenting skills coaching, and evaluating new patients.
Her last patient of the day is Harry Dourman, a depressed 38-year old man who seems unresponsive to the selective serotonin reuptake inhibitor prescribed for him. Because a consultation was requested, Dr. Versatile asks that the medical assistant find his physician, who is able to join them for the visit. She finds that the most appropriate diagnosis appears to be bipolar-II disorder and suggests to the physician that a mood stabilizer might be more appropriate for such a condition than a selective serotonin reuptake inhibitor. She schedules the patient for a session the following week (to which she suggests he bring his wife) to begin to work on strategies to cope with his condition.
This range of activities and rapid shifts in focus typify the challenges faced by psychologists who practice in the primary care setting. Primary care psychology is different from subspecialties of clinical health psychology, such as cardiac risk prevention, chronic pain management, cognitive rehabilitation, or psycho-oncology. Although it defies precise definition, primary care psychology draws heavily from clinical health psychology, behavioral medicine, developmental psychology, family psychology, systems theory, learning theory, and educational psychology as well as from the philosophy of primary care (Garcia-Shelton & Vogel, 2002; Strosahl, 2001).
A Way of Thinking Rather Than a Particular Service
Although many writers (e.g., Bray & Rogers, 1995; Coleman and Patrick, 1976; McDaniel, Haley, et al., 1998) emphasize co-location as an essential element, primary care psychology is as much a point of view as it is a set of procedures or physical proximity to primary care physicians. In addition to endorsing the philosophy of primary care, the primary care psychology approach includes a special regard for generalism; an integrative, biopsychosocial orientation; an awareness that resources are limited and must be managed effectively; a perspective on psychopathology that searches for and builds on existing competencies; attentiveness to opportunities for educational and preventive interventions; and a population-based perspective.
Seven Characteristics of Primary Care Patients’ Needs, Problems, and Expectations
1. Many patients have both medical and psychological conditions. The primary care psychologist must be familiar and comfortable with the reality of patients’ medical conditions. Two-thirds of primary care patients with a psychiatric diagnosis have a significant physical illness (Spitzer, Williams, et al., 1994), and chronic medical illnesses substantially increase the likelihood of depression. Also, the primary care psychologist must be conscious of two additional difficulties: medical complications can masquerade as psychological symptoms (Morrison, 1997), and psychological symptoms are frequently expressed somatically by primary care patients (Kroenke et al., 1994).
2. Patients’ psychological problems are frequently messy: multiaxial, comorbid with other conditions, and mixed with miscellaneous symptoms and subthreshold conditions. Unlike specialty patient populations or patient populations selected for research on treatment effectiveness, problems may be less cleanly defined. For example, the initial research into the effectiveness of screening primary care patients for psychopathology (Spitzer et al.,1994) found that nearly one third of the respondents had three or more mental diagnoses. In the World Health Organization primary care study (Von Korff, Ormel, et al., 1992), patients with all but one of the specific diagnoses had comorbidity rates of about 50%.
The co-occurrence of depression and anxiety in the primary care patient is extensive (Parkerson, Broadhead, et al., 1996), as is the overlap of anxiety and panic disorder (Simon, Gureje, et al., 2001;Walker, Katon, et al., 2000); depression and panic disorder (Ronalds, Kapur, et al., 2002); and Axis I and Axis II problems (Sansone, White-Car, et al., 2001). Relevant to this last point, significant prevalence of Axis II disorders, particularly borderline personality disorder, has been found in primary care populations, again much of it unrecognized and untreated (Gross, Olfson, et al., 2002). One implication drawn from these findings by several researchers is that effective integration of psychological services into primary care medical services might allow intervention when problems are less entrenched (Coyne, Fechner-Bates, et al., 1994; Katon, 1987; Ransom, 1983).
3. Patients frequently have abuse or trauma histories. The prevalence of abuse and trauma histories is significant and is related to both overall levels of health as well as somatic preoccupation (Sansone et al., 2001) and depression (Walker et al., 2000).
4. Patients may not consider themselves to have psychological problems. A considerable number of patients follow through on psychology referrals because “the doctor told me to.” The primary care psychologist cannot take for granted that the patient understands or accepts the premises under which most psychological treatment is conducted. Thus, the effective primary care psychologist will be able to work from a health or competence perspective and not over-pathologize (Schroeder, 1997). The issue of stigma must be addressed early in treatment as well. Perhaps one of the subtlest changes required of the psychologist who practices in primary care is shifting away from the covert blaming of the victim that is embodied in much popular psychology and some psychosomatic theorizing about medical illnesses. Conversely, the behaviorally trained psychologist must recognize the biological realities of organic pathology and not insist that everything can be modified or cognitively restructured. A reasonable understanding of the realities of primary care medicine will be necessary to provide effective care to patients who have both medical and psychological problems or problems that manifest in both the medical and mental health areas (Wickramasekera, 1989).
5. Patients may not expect or need psychotherapy. The effective primary care psychologist must have an extensive awareness of community resources (Kates & Craven, 1998). In addition, primary care settings provide opportunities to develop programs in coordination with community agencies (Schroeder, 1997).
The primary care psychologist must also think beyond individual psychotherapy in considering how to deliver better care. Such interventions as psychoeducational classes and support groups (Caudill, Schnable, et al., 1991; Kennell, Klaus, et al., 1991; Lorig, Mazonson, et al., 1993) and such self-help materials as books (Kemper, Lorig, et al., 1993) and videotapes (Robinson, Schwartz, et al., 1989) should be at the ready for the patients of the primary care psychologist. Meeting the informational needs of primary care patients may well be therapeutic and may prove to be a potent addition to the care provided by the primary care physician.
6. Patients may expect brief, practical, directive, and pharmaceutical-based treatment. The effective primary care psychologist must be able to explain psychotherapy and counseling to patients unfamiliar with it and be able to raise patients’ motivation without promising unrealistic outcomes. Ideally, the primary care psychologist should have the ability to focus on interventions that have immediate payoff (e.g., within a matter of days); this may involve helping the patient to appreciate the importance of small behavior changes.
In addition, the primary care psychologist should be an effective educator because he or she may need to explain the process of psychological change and help the patient maintain motivation in the face of discouragement; still, it is important to note that a significant proportion of primary care patients will experience enormous relief simply from the caring, empathic, attentive moments they experience in the primary care psychologist’s office (Adler, 1997). In these cases, the psychologists’ job is to help the patient develop some appreciation of the changes that may be necessary to maintain this relief.
7. Care is often sought episodically. It is quite common for primary care psychologists to see a patient for three sessions, resolve a focal problem, and then see the patient a year or more later for a new crisis. This is in keeping with the continuity-of-care model and common practice in primary care, but it is quite different from the more thorough approach that treats everything in one course of therapy prominent in many mental health training programs. The primary care psychologist must become comfortable with episodic care and enable the patient to return for additional treatment if necessary.
Primary care psychology, although it defies easy definition, is a different approach from specialty mental health care, clinical health psychology, or behavioral medicine. The opportunity to provide psychological services in the primary care setting offers the possibility that the primary care psychologist can improve patients’ health as well as the health care system itself. Primary care psychology requires preventive, educational, and consultative skills in addition to the full array of clinical skills possessed by the well-trained clinical psychologist. Primary care is integrated, continuous, generalist care, and this definition applies as much to psychologists as it does to physicians.
Primary care needs psychology to address the enormous amount of untreated psychopathology, the significant lifestyle and behavioral health problems, the psychological impact of chronic illness, and the combined psychological impact of being ill and being a member of a vulnerable population. Neither the pressured and overburdened primary medical care system nor the often-inaccessible specialty mental health system can easily meet these needs.
The practice of psychology in primary care settings must be adapted to the unique expectations and needs of the primary care patient, the existence of an ongoing relationship between the patient and the primary care physician, and the fact that psychological services are delivered in a medical environment. The primary care psychologist must be a consummate generalist; have a competence-oriented practical perspective; and be able to provide services that go beyond conventional psychotherapy in working with the primary care patient and the primary healthcare team. Effective work in primary care may result in some reduction of professional autonomy, but in return it offers the chance to affect a much larger system and to offer psychological service where it is desperately needed.
Leonard J. Haas, PhD, is a clinical psychologist and professor of Family & Preventive Medicine at the University of Utah; he is the Director of Behavioral Science for the Family Practice Residency. Dr. Haas maintains a clinical psychology and behavioral medicine practice in the Department of Family & Preventive Medicine, and conducts practice-building and professional development workshops in primary care psychology, behavioral medicine, healthcare communications, and professional ethics.
Frank Verloin deGruy III, MD, MSFM, is the Woodward-Chisholm Professor and Chair of the Department of Family Medicine at the University of Colorado School of Medicine, a position he has held since 1999. He served as the chair of the National Advisory Committee for the Robert Wood Johnson Foundation’s Depression in Primary Care program, and currently serves on the editorial boards of Families, Systems and Health, the Annals of Family Medicine, and the Primary Care Companion to the Journal of Clinical Psychiatry. He has authored over 150 papers, chapters, books, editorials, and reviews.
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