Primary Care2018-02-11T19:56:13+00:00

Most adults who receive mental health services are treated in primary care, such that “primary care and general medical practices have long been considered the de facto or hidden mental health and addiction service system in the United States” (Speer & Schneider, 2003, p.86). Older adults prefer to receive mental health services in primary care, (Areán & Gum, 2013), yet evidence has shown that primary care providers fail to detect approximately 50% mental health problems of their older patients. Further, primary care provides suboptimal treatment and referral for those with known problems, possibly due to myriad barriers including stigma, ageism, medical comorbidity, misattribution of symptoms to physical illness, limited time and reimbursement incentives to address psychosocial issues, and lack of access to qualified providers (Sirey, Bruce, & Kales, 2010; Speer & Schneider, 2003; Wang et al 2005). The confluence of patient, provider, and systemic barriers to services likely disproportionately impacts minority older adults who may be least likely to venture out of a primary care setting to seek mental health treatment (Areán, et al., 2005).

Increased recognition of the critical role of primary care in mental health service delivery has led to the development and testing of models for collaborative treatment, in which mental health providers are integrated into the primary care setting. Models of integrated care share a core structure in which multiple disciplines actively collaborate in activities of evaluating, planning, and delivering coordinated mental health care to the patient and family (APA, 2008). Elements of such models typically include “provider education, patient activation, systematic treatment monitoring, mobilization of community resources and ready access to mental health services within the target system of care” (Areán, et al., 2005, p. 382).

Several randomized multisite studies (e.g. PROSPECT, PRISM-E, RESPECT-D, IMPACT) which aimed to improve detection and treatment of depressed older adults in primary care have conclusively demonstrated that collaborative care models are more effective than treatment-as-usual in improving treatment engagement, improving the course of depression, and reducing symptoms, suicidal ideation and overall functional impairment (Areán & Gum, 2013; Bruce et al 2004; Unutzer et al, 2002; Bartels et al, 2004; Oxman, Dietrich, & Schulberg, 2003). Psychotherapeutic treatments developed for older adults in primary care (e.g. IPT-PC; PST-PC) have demonstrated effectiveness when delivered as part of an interdisciplinary collaborative care model (Areán et al, 2005; Areán et al, 2008; Skultety & Zeiss, 2006).

Integrated care models have drawn on existing and newly developed assessment methods to detect and monitor psychological problems in primary care patients. Many standardized psychological measures developed for adults (Center for Epidemiological Studies-Depression Scale, CES-D; Beck Depression Inventory-II, BDI-II) and for older adults (Geriatric Depression Scale, GDS), as well as newer measures developed for primary care (Patient Health Questionnaire-9 item, PHQ-9; and the PHQ-4, which detects both depression and anxiety) have been employed to improve detection of depressed older adults (Areán & Ayalon, 2005). More recently, measures such as the Geriatric Anxiety Inventory (Pachana et al, 2007) and the Geriatric Anxiety Scale (Edelstein & Segal, 2011) have been developed to detect manifestations of anxiety disorders in older adults. A set of brief measures (The Alcohol Use Disorders Identification Test, AUDIT-C and CAGE test) including one developed for geriatric populations (Michigan Alcohol Screening Test – Geriatric, MAST-G) have been proposed to screen for alcohol use problems in primary care settings. As part of its “Foundations of Integrated Care” website, the Veteran’s Administration has developed a training program which includes instruction on screening for mental disorders including depression, anxiety, and alcohol misuse in primary care settings. The SAMHSA Center for Integrated Health Solutions also provides a toolkit of measures useful for primary care screening for depression, bipolar disorder, anxiety, substance abuse, suicide risk and trauma. However, there are sparse data regarding the psychometric properties of many of these screening tools for older adults, or their utility across varied demographic and clinical populations.

Instructional modules and measures that are in the public domain and available online:

Psychologists may have direct roles on integrated healthcare teams providing services to older adults in primary care, including evaluation, psychotherapeutic treatment, and mobilizing of community resources, as well as indirect roles including supervising care, promoting interdisciplinary collaboration, and research and program evaluation (APA, 2008). Practice in primary care requires competencies which draw on and extend psychologists’ foundational knowledge and skills (APA, 2013). Competencies for Psychology Practice in Primary Care were developed by the Interorganizational Work Group on Competencies for Primary Care Psychology Practice. The APA Committee on Aging (CONA) is also currently working to examine linkages between primary care and geropsychology competencies to enhance care for older adults in primary care. The full implementation of the collaborative care model, in which psychologists and interdisciplinary team members all play vital roles, holds great promise for improving the detection and treatment of mental health problems in primary care, and thereby improving the quality of life of older adults (Areán & Gum, 2013; Zeiss & Karlin, 2008).

Written by Richard A. Zweig, PhD, Ferkauf Graduate School of Yeshiva University

GENERAL

American Psychological Association Interorganizational Work Group on Competencies for Primary Care Psychology Practice (2013). Competencies for Psychology Practice in Primary Care

American Psychological Association Interorganizational Work Group on Competencies for Primary Care Psychology Practice (2013).  Competencies for Psychology Practice in Primary Care

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American Psychological Association Presidential Task Force on Integrated Health Care for an Aging Population. (2008). Blueprint for change: Achieving integrated health care for an aging population. Washington DC: American Psychological Association. http://www.apa.org/pi/aging/programs/integrated/integrated-healthcare-report.pdf

American Psychological Association Presidential Task Force on Integrated Health Care for an Aging Population. (2008). Blueprint for change: Achieving integrated health care for an aging population. Washington DC: American Psychological Association. http://www.apa.org/pi/aging/programs/integrated/integrated-healthcare-report.pdf

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American Psychological Association. (1998). Interprofessional health care services in primary care settings: Implications for the education and training of psychologists. Available online.

American Psychological Association. (1998). Interprofessional health care services in primary care settings: Implications for the education and training of psychologists.  Available here.

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Areán, P. A., & Gum, A. M. (2013). Psychologists at the table in health care reform: The case of geropsychology and integrated care. Professional Psychology: Research & Practice, 44(3), 142-149. doi: 10.1037/a0031083

Areán, P. A., & Gum, A. M. (2013). Psychologists at the table in health care reform: The case of geropsychology and integrated care. Professional Psychology: Research & Practice, 44(3), 142-149. doi: 10.1037/a0031083

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Callahan, C.M., Hui, S.L., Nienaber, N.A., Musick, B.S., & Tierney, W.M. (1994). Longitudinal study of depression and health services use among elderly primary care patients. Journal of the American Geriatrics Society, 42(8), 833-8.

Callahan, C.M., Hui, S.L., Nienaber, N.A., Musick, B.S., & Tierney, W.M. (1994).  Longitudinal study of depression and health services use among elderly primary care patients. Journal of the American Geriatrics Society, 42(8), 833-8.

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Haley, W. E. (2005). Clinical Geropsychology and Primary Care: Progress and Prospects. Clinical Psychology: Science and Practice, 12: 336–338. doi: 10.1093/clipsy.bpi040

Haley, W. E. (2005). Clinical Geropsychology and Primary Care: Progress and Prospects. Clinical Psychology: Science and Practice, 12: 336–338. doi: 10.1093/clipsy.bpi040

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Liu, C. F., Cedrick, S. C., Chaney, E. F., Heagerty, P., Felker, B., Hasenberg, N., et al. (2003). Cost effectiveness of collaborative care for depression in a primary care veteran population. Psychiatric Services, 54, 698–704.

Liu, C. F., Cedrick, S. C., Chaney, E. F., Heagerty, P., Felker, B., Hasenberg, N., et al. (2003). Cost effectiveness of collaborative care for depression in a primary care veteran population. Psychiatric Services, 54, 698–704.

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Sherrod, T.P., Quinlan-Colwell, A., Lattimore, T., Shattell, M., & Kennedy-Malone, L. (2010). Older adults with bipolar disorder: Guidelines for primary care providers. Journal of Gerontological Nursing , 36(5), 20-29.

Sherrod, T.P., Quinlan-Colwell, A., Lattimore, T., Shattell, M., & Kennedy-Malone, L. (2010). Older adults with bipolar disorder: Guidelines for primary care providers. Journal of Gerontological Nursing , 36(5), 20-29.  Article online.

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Ziess, A., & Karlin, B. (2008). Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System. Journal of Clinical Psychology in Mental Health Settings, 15, 73-78.

Ziess, A., & Karlin, B. (2008). Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System.  Journal of Clinical Psychology in Mental Health Settings, 15, 73-78.

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ASSESSMENT

Areán, P.A. & Ayalon, L. (2005). Assessment and treatment of depressed older adults in primary care. Clinical Psychology: Science and Practice, 12 (3), 321-335.

Areán, P.A. & Ayalon, L. (2005). Assessment and treatment of depressed older adults in primary care.  Clinical Psychology: Science and Practice, 12 (3), 321-335.

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Edelstein, B. A., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. Warner Schaie & S. L. Willis (Eds.), Handbook of the psychology of aging (7th ed, pp. 325-337). London: Academic Press. doi: 10.1016/B978-0-12-380882-0.00021-8

Edelstein, B. A., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. Warner Schaie & S. L. Willis (Eds.), Handbook of the psychology of aging (7th ed, pp. 325-337). London: Academic Press. doi: 10.1016/B978-0-12-380882-0.00021-8

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TREATMENT

Areán, P. A., Ayalon, L., Hunkeler, E., Lin, E. H., Tang, L., Harpole, L.,. . . Unützer, J. (2005). Improving depression care for older, minority patients in primary care. Medical Care, 43, 381–390. doi:10.1097/01.mlr.0000156852.09920.b1

Areán, P. A., Ayalon, L., Hunkeler, E., Lin, E. H., Tang, L., Harpole, L.,. . . Unützer, J. (2005). Improving depression care for older, minority patients in primary care. Medical Care, 43, 381–390. doi:10.1097/01.mlr.0000156852.09920.b1

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Arean, P., Hegel, M., Vannoy, S., Fan, M., & Unuzter, J. (2008). Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48, 311-323. doi:10.1093/geront/48.3.311

Arean, P., Hegel, M., Vannoy, S., Fan, M., & Unuzter, J. (2008). Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48, 311-323. doi:10.1093/geront/48.3.311

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Areán, P.A. & Ayalon, L. (2005). Assessment and treatment of depressed older adults in primary care. Clinical Psychology: Science and Practice, 12 (3), 321-335.

Areán, P.A. & Ayalon, L. (2005). Assessment and treatment of depressed older adults in primary care.  Clinical Psychology: Science and Practice, 12 (3), 321-335.

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Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Area´n, P. A., et al. (2004). Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. American Journal of Psychiatry, 161, 1455–1462.

Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Area´n, P. A., et al. (2004). Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. American Journal of Psychiatry, 161, 1455–1462.

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Bogner, H.R., Morales, K.H., Post, E.P., Bruce, M.L. (2007). Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care, 30(12), 3005-10.

Bogner, H.R., Morales, K.H., Post, E.P., Bruce, M.L. (2007). Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care, 30(12), 3005-10.

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Bruce, M. L., Ten Have, T. R., Reynolds, C. F., III, Katz, I. I., Schulberg, H. C., Mulsant, B. H., . . . Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA: Journal of the American Medical Association, 291, 1081–1091. doi:10.1001/jama.291.9.1081

Bruce, M. L., Ten Have, T. R., Reynolds, C. F., III, Katz, I. I., Schulberg, H. C., Mulsant, B. H., . . . Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA: Journal of the American Medical Association, 291, 1081–1091. doi:10.1001/jama.291.9.1081

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Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice, 16 , 394-407.

Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice, 16 , 394-407.

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Emery, E.E., Lapidos, S., Eisenstein, A., Ivan, I., & Golden, R. (2012). The BRIGHTEN Program: Implementation and evaluation of a program to Bridge Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking. The Gerontologist, 52 (6): 857-865. DOI: 10.1093/geront/gns034.

Emery, E.E., Lapidos, S., Eisenstein, A., Ivan, I., & Golden, R. (2012). The BRIGHTEN Program: Implementation and evaluation of a program to Bridge Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking.  The Gerontologist, 52 (6): 857-865.  DOI: 10.1093/geront/gns034.

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Oxman, TE, Deitrich, AJ & Schulberg HC (2003). The depression care manager and mental health specialist as collaborators within primary care. American Journal of Geriatric Psychiatry, 11, 507–516.

Oxman, TE, Deitrich, AJ  & Schulberg HC (2003). The depression care manager and mental health specialist as collaborators within primary care. American Journal of Geriatric Psychiatry, 11, 507–516.

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Roy-Byrne, P. B., Katon, W., Cowley, D. S., & Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry, 58, 869–876.

Roy-Byrne, P. B., Katon, W., Cowley, D. S., & Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry, 58, 869–876.

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