Mental Health Services for Seniors in Primary Care

1. Mental Health Services for Seniors in Primary Care Scott J.Kloberdanz, DPM, LMSWSenior Outreach Counseling

2. Psychosocial Needs of Seniors • Primary Care Providers (PCPs)-most seniors with mental health complaints/needs present to their PCP when seeking help. • Usually have long term relationship - can note any changes in their physical and mental functioning • Less stigma w/PCP – more likely to discuss distress • Addressing psychosocial needs/concerns - may lower distress and help maintain independence. e.g. isolation, home safety, ADLs and IADLs, meals, home nurse and/or homemaker • Psychotherapy works in conjunction with meds to help work through personal issues, negative thoughts, poor coping skills, provides psychoeducation, improve relationships, increase resiliency

3. Rationale for Change In Delivery of Mental Health Services • Depression Under Diagnosed - up to 50% patients that have signs of depression, and present to primary care providers, are not diagnosed or treated. (Recognition, management, and outcomes of depression in primary care. Archives of Family Medicine, 1995, 4, 99-105) • Depression and heart disease – Depression may be independent risk factor for death in seniors with history of an MI and in patients with coronary heart disease.(Schulz R, et al: Association between depression and mortality in older adults. Arch Intern Med 2000; 160: 1761-1768) • Suicide Risk – 20% of seniors that commit suicide saw their PCP that day, 40% were seen within a week of their suicide, and 70% had been seen within one month of committing suicide. (Older adults: Depression and suicide facts. NIH Publication no. 99-4593)

4. Treatment Barriers For Seniors For Mental Health Services • Stigma of mental illness • Lack of awareness of mental health problems • Denial or underreporting of symptoms • Attribute problems to medical illness • Under diagnosis of problems and underutilization of mental health services • Challenges in accessing free standing mental health clinics – e.g. transportation • Financial-larger co-payment mental health

5. President’s New Freedom Commission On Mental Health - Recommendations • Increase screening for mental disorders in primary health care and connect to treatment and supports. • Early assessment and treatment critical to prevent progression mental health problems. • Integrated and collaborative treatment strategies pairing mental health professionals with primary care providers is a more effective treatment approach .

6. Mental Health Services • Traditional Care • Medical and mental health providers provide services independently • minimal to no communication and/or coordination of care - e.g. PCP providers often may not know that MH providers are treating their patients • Psychosocial needs/concerns often not be addressed by PCPs • Collaborative/Integrated Care • Medical and mental health providers provide MH services collaboratively • regular communication and coordination of care • direct PCP provider - MH provider discussions in person or by phone • MH provider - PCP staff communication • PCP receives regular progress reports on their patients progress • Medical and psychosocial needs/concerns addressed

7. Research Supporting Collaborative/Integrated Care Model • More Effective Clinical Results - A nationwide clinical trial for tx. late-life depression (IMPACT model) concluded that the collaborative care model is significantly more effective for depression, functioning, and quality of life than usual care in primary care practices. (Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 2002, Dec 11; 288(22):2836-2845) • Seniors Preferred Counseling to Medication – A trial of 1602 seniors tx for depression in primary care practices revealed that a collaborative care model greatly improved access to patient’s preferred tx., esp. counseling, which was preferred 57% to 43% over medication. (Depression treatment preferences in older primary care patients. Gerontologist, 2006 Feb., 46 (1): 14-22) • PCPs Prefer Integrated Mental Health Services - Trial involving 127 PCPs preferred integrated (provider co-located in office) over referral for mental health care for many aspects of mental health treatment with elderly patients. (Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E). Annals of Family Medicine, 2004, 2, (4), 305-309)

8. Benefits to Collaborative/Integrated Model Primary Care Providers • Reduce staff and provider time-detailed assessment and/or referral other community resources done by MH provider • Patients more closely monitored for progress and medication response/side effects • External referral not necessary-maintain gatekeeper role • Enhanced communication between PCP and MH provider • More comprehensive services for patients-combine medical and psychosocial tx. • Home environment can be assessed for self neglect and/or safety issues Patients • Research - combined medical and psychotherapy approaches often most effective treatment esp. for depression and/or anxiety • Obtain information about community services and resources • Increase opportunity to communicate concerns and questions • Less stigma regarding mental health care

9. Signs/Symptoms (Suggesting) Mental Health Problems • Primary care providers may detect the following problems • Noncompliance with medications • Memory problems • Vague complaints with frequent visits • Multiple somatic c/o disproportionate to examination • Multiple grief/loss issues associated with aging • Chronic pain • Depression/anxiety • Relationship problems • Suicidal thoughts • Isolation/loneliness

10. Mental Health Screening • Depression with seniors difficult to detect(e.g.-somatization, pseudodementia) – “Danger of inappropriate txs”. (Predictors of Bereavement Depression & Its Health Consequences. Medical Care, 1988, 26, 882-893.) • Depression undetected in up to11% of all seniors - screening tests should be considered in routine assessments of seniors (Screening Recommendations for Elderly Americans. American Journal Public Health, Sept. 1991, 81, 1131-1140.) • Screening tests led to increased detection of major depression in seniors - at a rate of five times that usually detected in primary care practices (Screening for depression among a well elderly population. Social Work, May 1995, 40(3), 295-304.)

11. Senior Mental Health (Integrated Care) Project • Pilot project funded through a federal block grant administered through DHS - renewed 10/1/05 • Senior Outreach Counseling – Des Moines • outreach program of Eyerly-Ball Community Mental Health Services • one of two Iowa agencies currently contracted • Serves persons who are 60 years and older – no charge • 2 - master degree level clinical social workers • Collaborate with 5 primary care practices in community – family practice, internal medicine – providers include MDs, DOs, PAs, ARNPs • Services provided include: • mental health assessments and screenings • ongoing psychotherapy • referral to other community resources and services as needed • Spanish interpreters available

12. Senior Mental Health Integrated Care Project • Patients/clients can be seen in provider’s office or in their own homes • PCPs identify referrals through clinical hx. & exam and/or mental health screens • MH provider calls patient/client & arranges appointments in their home or at PCP office • PCP and MH provider both tx concurrently • Mental health educational presentations • Primary care providers (family practice/internal medicine) and staff • Other medical and mental health providers • Community groups of seniors or serve seniors • Outcome evaluations and data collection will: • affect future funding sources • help develop evidence-based practices • shape future models of mental health delivery for seniors.

13. Case Example CC: elder female presents to PCP for F/U appointment for DM and c/o “arthritis” pain in several joints X 2 mo.. • Labs, X-rays and physical exam neg. except early DJD changes in knees and muscle tension in back and neck • Before leaving office starts to cry - reports recent “stress” – has been having “problems with my kids” • PCP put on Lexapro and referred for mental health assessment/therapy.

14. Case Example-Assessment Stressors: • poor interpersonal and psychological boundaries - has significantly dysfunctional family problems • Financial problems – housing, utilities • Isolation - except family Significant hx: • “Ashamed” to tell PCP depressed for mo. & that has dysfunctional family • Personal and family history of childhood sexual abuse • Multiple family members abuse substances (intergenerational) • Multiple interpersonal family conflicts • Low self-esteem, isolated (except family) • “Worrier”- chronic untreated generalized anxiety disorder

15. Case Example- Interventions • SSRI meds-reduces symptoms to help make desired changes • called PCP to consider increasing Lexapro – little improvement symptoms • CBT-evaluate & challenge negative thoughts/distortions, action (behavioral) steps - reconnect w/church and friends - increase social interaction to reduce isolation • Connect resources to decrease financial stressors - energy assistance, MOW, housing options • Boundaries – appropriate psychological and interpersonal w/family • Self-esteem – develop sense self – efficacy • manage moods- self-awareness/monitoring, coping skills-relaxation, distraction, etc. • boundaries-empathy/love w/o “taking on” others distress