Study combines mental health, primary care

As connections between mental illness and chronic medical illnesses are better understood, researchers and clinicians are looking for ways to integrate mental health care with primary care.

Because of a shortage of psychiatrists, the key to this integration might well be found in technology — the kind that allows a psychiatrist to “beam in” via tablet or computer screen to “meet” with a patient online, coupled with technology that keeps a patient’s health care record on one network that doctors can access with the touch of a button.

At the University of South Carolina School of Medicine, a team of researchers, clinicians and family doctors are identifying primary care patients who have symptoms of depression or anxiety. Using telemedicine, those patients are able to visit with a psychiatrist during their regular doctor’s visit and get an evaluation and course of treatment.

The goals are to make it easier for patients to get mental health care, which, in turn, can improve the way a patient handles co-occurring chronic illnesses, such as diabetes, high blood pressure or heart disease.

For patients, this means no long waits for an appointment and obtaining a specialty care in the environment with which they are familiar.

For doctors, it means that the specialist does not have to wait days to see patients or their lab work, and primary care providers are not waiting months to follow up with patients after a psychiatric consult.

Researchers also are hoping to show payers’ insurance companies and government health care programs like Medicaid and Medicare — how this collaborative treatment can save money in the long run while improving patient outcomes.

“The changing health care landscape has put a tremendous demand on providers and payers to improve health outcomes while reducing costs,” said Meera Narasimhan, M.D., professor and chair of the Department of Neuropsychiatry and Behavioral Science at the School of Medicine. “This can only be achieved by breaking down the silos between behavioral health and physical health.”

Narasimhan and Suzanne Hardeman, MSN, MRC, assistant professor of clinical psychiatry at the School of Medicine, are principal investigators on a three-year grant from the Fullerton Foundation to explore ways to use innovative technology to deliver affordable, collaborative health care.

The team includes doctors at the Family Medicine Center, the university’s Palmetto Health-affiliated primary care clinic in Columbia. Family medicine clinicians identify those patients with depression or anxiety who would benefit from mental health consultations.

Without having to leave the doctors’ office, patients get a one-on-one session with a psychiatrist via a touchscreen tablet. Sometimes the interaction is so real, doctors say, patients will extend a hand to say goodbye before realizing the doctor isn’t in the room with them.

“Once I start the interview with the patient, it is just like the person is with me in the room,” said Asifa Choudhry, M.D., assistant professor of clinical neuropsychiatry and behavioral science and a clinician at University Specialty Clinics. “We are talking one-to-one, the patient is getting undivided attention, and the process is the same as seeing the patient in person.

“Patients seen via telepsychiatry get a complete assessment with the discussion of diagnosis and available treatment plan just as if they were seen in our clinic.”

Technology also plays a role in having the psychiatrist up to speed on patients’ lab work, medications and vital signs with access to the family medicine chart, Choudhry said. “It is so easy for me to go in and look up the vitals, all the previous labs, the medicine lists. When I write the medications, it is easy to check the drug-to-drug interactions and other medications they are on before prescribing.”

The medical goal is to help address both mental health concerns — primarily depression and anxiety — and accompanying chronic diseases like diabetes and hypertension. Managing the mental health issues can improve the way patients manage their physical illnesses.

“Some of these folks have been dealing with depression for quite a while,” Hardeman said. “Their physician introduces the idea of talking with a psychiatrist, so they are not totally apprehensive about seeing the specialist.”

Ashley Rippy, M.S., the study’s coordinator and health coach, works from the Family Medicine Clinic and takes the referrals. She coordinates the referrals with neuropsychiatry and prepares the patient for the telepsychiatry visit.

“Many of the patients have never used a tablet computer or heard of telemedicine,” she said. “Initially, they are skeptical but they quickly catch on to using the tablet and quickly get comfortable with talking to the doctor on the screen.”

Based on the clinician’s recommendations, Rippy provides health-coaching for the patients.

Patient response has been positive, researchers say. “I liked it,” one patient said when asked for feedback. “I felt like I was able to talk more since the doctor was not actually in the room with me.”

The coordination also helps the primary care physician.

“Sometimes, it can be a struggle to get good feedback,” said Mark Humphrey, M.D., an assistant professor of clinical family and preventive medicine. “If I have to send them out to a specialist, it can be months until their next visit and I find out what the specialist said.”

That immediate feedback for the patient and doctor can lead to better management of diseases that are controlled as much by changes in diet and other behaviors as by medication.

“Definitely when someone’s mood is better, they treat themselves better,” Humphrey said.

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