Revisiting the De Facto Mental Health System: One Becomes Two

Le résumé fourni par la source

In a classic 1978 study, Regier et al. [1] reported that three times as many individuals with a mental health (MH) condition received treatment in primary care as in the specialty mental health sector. Denoted by the authors as the “de facto mental health system,”, this disproportionate responsibility of primary care to detect and treat MH conditions was reaffirmed in a 2014 study by Olfson et al. [2] The emergency department has increasingly become a second de facto setting for MH care [3-6]. Attention has often focused on psychiatric emergencies (suicidality, overdose, psychosis), whereas mood, anxiety, and substance use are, in fact, more prevalent in the ED setting [4] and often are the underlying or at least comorbid reason for seeking ED care, or they complicate the non-MH condition. The inordinate roles of primary care and the ED in MH care share some root causes: a shortage of mental health specialists, reimbursement policies that place MH care at a disadvantage to coverage of medical and surgical services, and public stigma about seeing an MH specialist. Also, somatic symptoms and medical disorders prompting persons to seek medical or emergency care can mask underlying psychological factors. However, several factors may be contributing to a shift of some de facto MH care from primary care to the ED. Shortages in the primary care workforce parallel those in the MH specialty workforce: lower clinician reimbursement and lower prestige have made selection of either career less popular among medical students than other medical or surgical specialties. Thus, a number of persons in the United States may not have a primary care clinician or, even if they do, have difficulty getting an expedited appointment for new problems or concerns because of large panel sizes and appointments booked months in advance for the care and follow-up of chronic medical problems. In this case, the default option for new problems is all too often going to the ED or urgent care. Unfortunately, the latter settings are best suited for the care of acute problems and not longitudinal follow-up of MH problems, for which treatment often needs to be monitored and adjusted over months. Thus, the ED/urgent care setting is designed for episode-based acute care, whereas the primary care setting can provide longitudinal chronic care. The irony of the pat solutions is that while often insufficient as individual components, their collective use may be more effective. Indeed, several systematic reviews have found effectiveness for multi-component interventions [8, 9]. ED-based care plans and case management have proven an effective strategy for transition to outpatient MH care [10]. Whereas the ED will continue to have a pivotal role in psychiatric crises, its preferred role regarding patients presenting with nonurgent MH conditions is to triage and coordinate with mental health and/or primary care. In patients or settings where follow-up with mental health or primary care may be considerably delayed, virtual interventions using remote monitoring of symptoms, self-management programs, linkage to community resources, and/or telephone follow-up with ancillary personnel (peers, health coaches) may be helpful in bridging the gap in transition [11-13]. Additionally, communication strategies to mitigate the common experience of patients with MH conditions feeling stigmatized and invalidated [14-16] might not only improve the experience in the ED but also facilitate subsequent acceptance of MH treatments. Providing some low level of resources for the pat solutions, plus combining and coordinating their use, can convert the first meaning of pat (overly simplistic) to its second meaning (suitable and well-timed). The authors have nothing to report.

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