Summary and conclusions
Lynn
F. Bufka
and Nicholas Camp
It is clear that in current general health care settings, mental health problems often are not routinely assessed. This is problematic for several reasons.
First,
individuals with psychopathology often
first present in primary care settings. In addition, psychopathology is often
misinterpreted in this setting as reflective of a physical condition,
and even when physical
problems are the primary concern, existing psychopathology, especially when undocumented,
can complicate treatment and recovery. Therefore, instituting routine assessment
for mental health problems is an appropriate and necessary step.
The assessment
approach must be brief, flexible, and informative, and this can be accomplished in a variety of ways.
In some settings, it
might be most appropriate to screen for overall level of psychological
distress. Once those individuals meeting some predetermined, clinically
significant level of
distress are identified, they can then undergo a more thorough assessment in another setting.
The goal of
simply identifying high levels of psychological distress might prove easier and
more efficient for clinicians not specializing in mental health, such as general physicians and nurses.
Individuals with high levels of psychological distress will likely be the most
difficult to treat in the immediate setting, and might therefore require a team
of clinicians rather than only the primary care medical staff. Identifying
and properly treating these individuals will prove helpful to the patients, as
well as the PCP.
Finally, noting
high distress in some individuals
might prove a more
straightforward task than requiring staff to identify particular symptom patterns and render a
diagnosis, particularly when staff members are not well trained in the area.
An alternative approach
might be to identify particular disorders or symptom patterns. Although
establishing a psychiatric diagnosis is a learned skill, identifying
provisional or tentative clinical diagnoses with a
screening assessment should be possible.
Also, because
more specialized assessments are often more costly, it might be preferable to identify patients with likely disorders
through screening to streamline the use of assessment resources. This would then
enable the next level of assessment to be more focused. An added benefit of
more precise screening is that, often, only treatment for diagnosable mental disorders is
covered under insurance plans.
Although many
people could benefit from mental or behavioral health interventions, such as stress management or smoking cessation, in
times of limited resources, only those with diagnosable problems might be eligible for
such treatments, and more focused screening would identify these individuals
sooner and direct them to the appropriate resources.
Another approach
might be to screen for specific symptoms. Routine screening for psychotic symptoms, depression, and suicidality
might serve to identify those who are most at risk to themselves and most costly to
the system, especially if left untreated. The screening approach could be relatively
straightforward and potentially identify some very serious problems.
Additional
specific risks for which to screen
include the presence of
violence or abuse in the home, as well as personal or familial substance abuse or dependence.
A final area for which to screen includes the quality of interpersonal relationships
and general psychosocial adjustment. Functional problems at home or work might
suggest that a more detailed mental health assessment is appropriate. Each of these areas, if
problematic, could have substantial impact on a patient’s functioning. This could cause
an individual to not follow through with appropriate medical care when additional
treatment (e.g., by a team of physicians, psychologists, or other therapists) might
better help and enable the individual to comply with medical treatment.
Integration of
behavioral treatments into overall care may be preferred by some patients and may be more cost-effective than
medical interventions or pharmacotherapy alone. Behavioral treatments, in many
instances, are certainly as effective as medications, do not have unwanted
physical side effects, and may therefore be safer for some patients with
complicating somatic concerns (Barlow, 2004; Hollon et al., 2005; Kazdin & Weisz,
2003; Lambert & Ogles, 2004).
Current screening
practices for mental and behavioral health concerns are cursory and unlikely to
yield satisfactory or adequate information. If a formal assessment protocol is not implemented, standard, detailed
questions regarding the previously discussed domains should be a part of all assessments.
For instance, simply asking whether a person uses substances is not going to
provide the quality of information necessary to recommend additional assessment
or to discuss treatment options. Therefore, the implementation of a standardized screen
would eliminate guessing a patient’s status and ensure that relevant domains
impacting treatment and overall health would be assessed.
Systematic
outcomes measurement also provides very valuable information. Clinicians who
collect regular information about their ongoing provision of care can document their successes and use that information to
support the importance of behavioral health care.
Additionally, the
information can be immediately useful at the
level of the individual case by alerting the clinician when a patient is not
responding as expected, so that the clinician can then alter treatment.
Finally, many clinicians find it useful to review with the patient the results
of ongoing assessment in order to stimulate discussion, enhance motivation, and
otherwise facilitate treatment.
Instituting brief self-report screening assessments or standardized brief interviews that are psychometrically sound and patient-friendly may be the most direct and efficient route to the identification of mental health problems. We hope that improved screening in primary care settings and the documentation of the need for accessible and integrated mental health services will lead to increases in availability of and access to services.
Instituting brief self-report screening assessments or standardized brief interviews that are psychometrically sound and patient-friendly may be the most direct and efficient route to the identification of mental health problems. We hope that improved screening in primary care settings and the documentation of the need for accessible and integrated mental health services will lead to increases in availability of and access to services.
Coupled with
integrated outcomes data, the potential for increasing and advancing high-quality mental health
care can be realized. Once individuals are identified as needing mental health
services, systematic collection of outcomes data can help demonstrate to them,
as well as to the larger health care system, the value of specialized
behavioral care in ameliorating problems. The present limitations of the health
care system should not be a deterrent to instituting appropriate procedures that can benefit
patients across the behavioral health spectrum.
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
Read Also
Potential considerations in Selection of a diagnostic interviewStructured and Semi-Structured Diagnostic Interviews
Psychometrics and tool development considerations
Barriers to the implementation of Standardized Screening and outcomes measurement
Factors Influencing Assessment
The Current Status of Health Measurement
Evaluating a Health Measurement: The User’s Perspective
Types of Health Measurements
A Combination Approach: The Diagnostic Assessment
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