Brief measures for screening and measuring mental Health outcomes

Lynn F. Bufka and Nicholas Camp

As the United States continues to struggle to find solutions to providing affordable health care to all residents, the role of primary care providers has been increasingly emphasized. The use of the primary care physician (PCP) and associated medical staff, such as nurse practitioners and physician assistants, as “gatekeepers” to the health care system has grown.

Increasingly greater numbers of individuals see their PCPs for the majority of their health care needs or, at the very least at the beginning of their search for appropriate treatment. A 1993 study found that more PCPs see patients for psychiatric problems than do mental health professionals (Narrow, Regier, Rae, Manderscheid, & Locke, 1993). Since then, analyses of National Comorbidity Survey data from 1990 and 2001 found a 153% increase in utilization of only general medical services by those with mental health concerns (Wang et al., 2006).

In theory, the use of primary care settings as the entry point to health care appears to make good sense as an opportunity to coordinate care and reduce costs. In practice, however, while the gatekeeper model has given responsibility for identifying mental health problems in many patients to primary care staff, the data indicate that PCPs are doing an inadequate job of recognizing mental health problems, and that existing mental illness remains undetected in many patients (Simon & Von Korff, 1996).

One difficulty is that behavioral and mental health experts, such as psychologists, are infrequently integrated into primary care treatment settings and are therefore not readily available to screen, assess, or provide consultation. Another complication is that many symptoms of mental illness can present as physical symptoms, further obscuring recognition.

It has also become increasingly important to assess the outcomes of the services provided. When information is gathered at the systems level, it generally consists of relatively simple information regarding discrete types of care, but more specific information is increasingly being collected that not only details system outcomes but also, at times, can be used to describe the outcomes of individual clinicians.

Additionally, individual clinicians frequently find it desirable to record and to demonstrate their own outcomes. This can be useful to demonstrate the quality of the services to payers, the effectiveness of services to potential consumers, and the progress made in treatment to current patients. Some payers are beginning to require documentation of outcomes, and programs such as the Physician Quality Reporting Initiative (PQRI), initiated by the United States’ Centers for Medicare and Medicaid Services (CMS), is but one example. While externally imposed outcomes measurement systems may be unavoidable at times, it is preferable to select and implement measurement strategies consistent with the type of care provided by the individual practitioners.

Programs such as the PQRI do not always include measures appropriate to behavioral care, and individual clinician control of data is lost when larger systems implement the strategies. When faced with possible participation in an externally developed outcomes measurement system, clinicians may wish to review the American Psychological Association’s Criteria for the Evaluation of Quality Improvement Programs and the Use of Quality Improvement Data (2008).

In addition to discussion on screening for mental health problems, this article  focuses on the need for outcomes measurement as determined and controlled by the clinician, rather than on systems created or imposed by external groups, such as institutional management or government payers.

The value of Screening for mental health Problems

Underdiagnosis of emotional disorders is a major problem from several vantage points, including increased medical costs, work loss, and increased human suffering. In addition, undiagnosed and untreated mental health problems are known to complicate medical treatment.

Studies have shown that patients who do not receive mental health services visit a medical doctor twice as often for unnecessary care as patients who received appropriate mental health care (Lechnyr, 1992). Kraft, Puschner, Lambert, and Kordy (2006) found that individuals receiving psychotherapy had reduced medical costs, even when there was no improvement in psychological well-being.

In addition to the financial cost of underdiagnosis in the primary care setting, there is a clear social cost as well. The consequences of untreated mental disorders can be serious on multiple levels. It is well documented that untreated depression leads to significant loss of work time and productivity, and it follows that other untreated mental illnesses may lead to similar losses.

Numerous studies of the relationship between depression and work have found that depressed workers have more short-term work disability days and less productive time in the office than non-depressed workers, resulting in salary productivity equivalent losses per person of $182 to $395 and estimated cost to employers of $31 billion per year (Kessler et al., 1999; Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). Also, anxiety (like depression) is associated with increased morbidity and mortality in adult populations (Wetherell & Areán, 1997).

Recent research suggests that a fully integrated approach to medical and behavioral health care may be beneficial for clinicians and patients. Screening patients with brief tools for assessing depression, anxiety, somatization, substance abuse, and social difficulties, and providing the opportunity for counseling resulted in patients who were more positive and satisfied with their health care than previously, and who felt less need to talk to their physician about personal or emotional needs (Miller & Farber, 1996).

Yet given that most settings are not well integrated and primary care medical staff are often not able to assess mental illness accurately due to lack of training or time, what can be done to increase appropriate recognition of mental health issues in the primary care setting?

The prudent use of screening tools and brief assessments for mental illness can serve to maximize the appropriate identification of mental health problems. Data that have been collected to date indicate that the use of brief screening tools does lead to more accurate diagnosis of mental illness in primary care settings (Carmin & Klocek, 1998; Noltorp, Gottfries, & Norgaard, 1998; Williams, Pignone, Ramirez, & Stellato, 2002).

The value of assessing outcomes

it is clearly essential that payers, who are already assessing cost and utilization in the primary care setting, begin to look at outcomes of care, including reduction in symptoms, improved functioning, and quality of life, as related to mental health problems and appropriate treatment.

Fortunately, a wealth of data demonstrate that the treatment of depression and other emotional disorders leads to decreased medical utilization and increased work functioning, as well as improved life functioning and remission of psychiatric symptoms.

In an analysis of 91 studies of the effect of mental health treatment on medical utilization, 90% of studies reported a reduction in medical utilization with 20–30% savings when compared to those who did not receive psychological intervention (Chiles, Lambert, & Hatch, 1999).

Mental health treatment also contributes to positive changes in work functioning. In a study by the RAND Corporation, patients who utilized a large quantity of medical services evidenced a reduction in days of disability and unemployment following successful treatment of depression (Broadhead, Blazer, George, & Tse, 1990).

Assessment of traditional outcomes for mental health services also is increasing. Tools for the screening of mental health conditions can also be used to track outcomes, but these typically provide only rough determinations of changes in level of distress and may not provide more detailed information about changes in symptoms, functioning, or quality of life. Measuring these factors provides a better understanding of the impact of psychological interventions and also can serve as a gauge of effectiveness of treatment and determination of when treatment can end.

Additionally, tracking these factors throughout treatment may provide opportunities for identifying when patients are not doing well in treatment and altering interventions such that patients do indeed achieve favorable outcomes (Lambert, 2006).

References

Martin m. Antony & David H. Barlow, 2010, Handbook of assessment and treatment planning for Psychological disorders, Second edition, structured and semi-structured diagnostic interviews, The Guilford Press

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