Primary Care Psychiatry Integration

Health Systems Context

Mental Health Workforce Shortage

Insurance Parity (MHPAEA 2008)

The Mental Health Parity and Addiction Equity Act of 2008 requires that:

• Mental health/substance use disorder benefits cannot be more restrictive than medical/surgical benefits
• Quantitative treatment limitations (visit limits, day limits) must be parity
• Non-quantitative treatment limitations (prior auth, step therapy) must be comparable
• Out-of-network benefits must be parity for mental health vs. medical

Insurance Barriers to Referral

Social Determinants of Mental Health

Social determinants significantly impact mental health outcomes in primary care:

• Housing Instability: Homelessness increases depression/anxiety risk 3-fold
• Food Insecurity: Linked to depression, stress, poor medication adherence
• Employment Status: Unemployment doubles depression risk
• Adverse Childhood Experiences (ACEs): 4+ ACEs increase depression risk 4-fold
• Social Isolation: Loneliness equivalent to smoking 15 cigarettes/day for mortality

Case Studies

Implementation Toolkit

Practice-Level Implementation Checklist

EHR Template Language

MENTAL HEALTH FOLLOW-UP TEMPLATE

Patient: {{Name}} | DOB: {{DOB}} | Date: {{Date}}

SCREENING SCORES:
□ PHQ-9: {{Score}}/27 ({{Severity}}) | Prior: {{PriorScore}} | Change: {{Change}}
□ GAD-7: {{Score}}/21 ({{Severity}}) | Prior: {{PriorScore}} | Change: {{Change}}

SUICIDE RISK ASSESSMENT:
□ C-SSRS completed: {{Date}}
□ Ideation: Denied / Present (describe): _____________
□ Intent: None / Ambivalent / Definite
□ Plan: None / Vague / Specific
□ Access to means: Assessed and addressed
□ Risk level: Low / Moderate / High / Imminent

CURRENT MEDICATIONS:
{{MedicationList}}

□ Adherence: Good / Partial / Poor
□ Side effects: None / [describe]
□ Efficacy: Full response / Partial / None

TREATMENT PLAN:
□ Continue current regimen
□ Optimize dose: [dose] → [new dose]
□ Switch to: [medication]
□ Augment with: [medication]
□ Referral: Psychiatry / Therapy / Crisis

FOLLOW-UP:
□ Return in: 2 weeks / 4 weeks / 8 weeks
□ Care manager contact scheduled: {{Date}}

TIME SPENT: {{Minutes}} minutes total
  - Counseling/coordination: {{CounselingMinutes}} minutes

Registry Template Fields

Weekly Team Meeting Agenda

COLLABORATIVE CARE TEAM HUDDLE
Date: {{Date}} | Time: 30 minutes
Attendees: PCP(s), BHCM, Psychiatric Consultant (phone/video)

1. REGISTRY REVIEW (15 min)
   • New enrollments since last meeting
   • Patients not improving (PHQ-9/GAD-7 unchanged or worsening)
   • Overdue contacts

2. CASE CONSULTATIONS (10 min)
   • Complex cases requiring psychiatric input
   • Medication questions
   • Diagnostic uncertainty

3. OPERATIONAL REVIEW (5 min)
   • Billing/coding issues
   • Workflow barriers
   • Success stories

ACTION ITEMS:
_____________________________________________
_____________________________________________
_____________________________________________

Patient Navigation Guide

Screening Tool Comparison

Clinical Pearls

12 Clinical Pearls

• Always screen for bipolar disorder (MDQ) before starting antidepressants—antidepressant-induced mania is preventable.
• Paroxetine has the worst discontinuation syndrome—taper slowly or avoid if discontinuation likely.
• Bupropion is weight-neutral and sex-friendly—consider in patients concerned about these side effects.
• Mirtazapine's paradox: more sedating at lower doses (15mg) than higher doses (30-45mg).
• First-generation antipsychotics (haloperidol) are not first-line for agitation—start with behavioral interventions.
• SSRI-induced hyponatremia—check sodium in elderly patients starting SSRIs, especially with diuretics.
• "Activation" in early SSRI treatment is common—warn patients, usually transient (1-2 weeks).
• Sexual dysfunction on SSRIs—sildenafil/tadalafil often effective for both genders.
• Serotonin syndrome—look for triad: altered mental status, autonomic instability, neuromuscular abnormalities.
• Treatment adherence improves when patients understand timeline—"You won't feel better tomorrow, but you will in 4-6 weeks."
• Sleep disturbance predicts antidepressant non-response—address sleep hygiene aggressively.
• The PHQ-2 (first 2 items) is a valid rapid screen—if positive, administer full PHQ-9.

10 Common Errors to Avoid

Knowledge Check