Aug. 7, 2018 -- At a busy family medical clinic in Denver, a middle-aged man who is going through a divorce complains of stomach pain and fatigue. Corey Lyon, MD, suspects the patient’s symptoms are due to anxiety, a treatable mental illness.
After doing a physical exam to rule out medical issues, Lyon explains to his patient that sometimes our brains can make us feel a certain way. Then he asks: “Would you be willing to talk with one of my psychologists?”
Lyon is medical director at the AF Williams Family Medicine Center, which is among a small but growing number of primary care practices in the United States that have a licensed health psychologist on staff.
When it comes to managing our physical health, we tend to seek out trained specialists. But with mental health issues -- which affect nearly 1 in 5 adults in the United States each year -- half of adults seek help from primary care doctors for common disorders like anxiety, attention deficit hyperactivity disorder, depression, and substance abuse, according to the National Institute of Mental Health (NIMH).
Having a primary care doctor address physical and mental health needs isn’t really new. Generations ago, the family doctor handled everything from birth to death. But over the years, the field split into doctors who care for the body and those who care for the mind, even though illnesses have a clear mind-body connection.
But most primary care doctors don’t have the training or time to manage disorders like depression, posttraumatic stress disorder, anxiety, and substance abuse. Yet many end up writing prescriptions for antidepressants and anxiety medications. Others give patients referrals to mental health professionals, even though only half of them follow through with making an appointment, according to the NIMH, for reasons that range from perceived shame or embarrassment over the stigma of having a mental health problem to difficulty finding a therapist who takes new patients or is part of their insurance network.
The reality is that many people will go without mental health care if it doesn’t come from their primary care doctor, so integrating mental and behavioral health care into doctor practices makes sense, according to the American Psychological Association.
“You’re dealing with a population that may have some sort of motivational problems (depression) or anxiety issues,” Lyon says, and asking them to find a mental health provider on their own is often overwhelming.
By having a psychologist in his office, he says he provides a “warm handoff” to a mental health professional immediately.
Treating the Whole Patient
Fully integrated clinics with embedded psychologists tend to be in large academic medical centers, like Lyon’s clinic, which is associated with the University of Colorado’s medical school.
This is changing as a growing body of research shows that integrated behavioral health care at the right time improves patient health and saves money in the long run, according to the federal Agency for Healthcare Research and Quality.
The American Psychological Association doesn’t have data on the number of psychologists working in primary care settings, says Doug Tynan, director of integrated health care at the association. But he says large health care systems in Utah, Delaware, Pennsylvania, Nebraska, Tennessee, Massachusetts, and Oregon are using integrated health care. Also, the Veterans Health Administration allows an estimated 75% of its patients with a mental health condition to have their needs met in primary care.
Amy Wachholtz, PhD, an assistant professor of psychology at the University of Colorado Denver, says training programs for health care psychologists are growing.
“We’re training people up as fast as we can, but the need is outstripping the levels of training,” she says. “The people who do this are very passionate about the need for this.”
The University of Colorado Denver has one of the oldest programs in the nation for training psychologists to work in medical settings. Similar programs are also offered at the University of Massachusetts, Harvard Medical School, and Duke University Medical Center, and there are also online programs that train licensed psychologists to work in primary care settings.
Wachholtz describes a typical patient: a 60-year-old recent widower with worsening diabetes. “His PCP [primary care physician] may talk to him about diet, exercise, and the need to check his blood sugar more often, but he doesn’t have the time to talk about the role the loss of his wife may be playing in his illness,” she says.
Another patient, a woman in her 30s with a successful career and a young family, is having trouble sleeping. “The doctor may provide sleeping pills, but a psychologist may see an anxiety-related sleep disorder that can be helped with cognitive behavior therapy instead of medication,” she says.
Lyon says his staff psychologists provide therapy for everything from depression and anxiety to weight loss and smoking cessation. Most patients need six to eight sessions “to get over the hump or down the path of what they need to become healthy,” he says.
Medications are prescribed if necessary. Patients with more serious issues are connected with outside therapists covered by insurance.
Some patients are wary of talking to a psychologist, he says, but often agree when Lyon tells them he’ll be part of the discussion.
“We do it together,” he says, noting that staff psychologist Shandra M. Brown Levey, PhD, meets patients in the exam room. This setup erases the stigma of seeking out a mental health professional for patients who have never spoken to a therapist and may be uneasy.
Levey and Lyon work closely together, something vital to the success of integrating mental health care into primary care, he says. They both enter notes into the patient’s electronic record, so they can work as a team.
“The psychologist really kind of leads the discussion, but I’m involved because I have a relationship with the patient,” Lyon says. “It just feels like you’re at the doctor and getting better.”