A survey of 500 patients aged 18 to 64 in a Colorado primary-care clinic that serves only uninsured, low-income adults indicated that many were troubled by emotional distress and physical pain. Their most common medical problems were headache, back problems and arthritis. The most common concerns the patients wanted to discuss with their doctor were mood difficulties, such as feeling depressed.
Many previous studies have shown that people living in poverty have higher death rates, more physical and mental illness, and a greater impairment of physical, psychological, and social function than do people in middle- and high-income brackets.
The latest report from the Colorado clinic for low-income, uninsured people builds on two previous, published analyses of this population. Compared to patients in general medical clinics, the patients had an extremely high prevalence of mental disorders. Patients experiencing a mental illness also had a significantly higher incidence of pain, chronic illness, stresses in their lives, and physical symptoms. They were more likely to come from a home in which they were battered, neglected, or sexually abused.
The researchers studying the mental health-care needs of low-income, uninsured patients were Larry Mauksch, a behavioral scientist and clinical associate professor of family medicine at the University of Washington (UW); Dr. Wayne Katon, UW professor of psychiatry; Dr. Joan Russo, UW research associate professor of psychiatry; Dr. Suzanne Tucker of the Marillac Clinic in Grand Junction, Colorado; Dr. Edward Walker, UW professor of psychiatry and medical director of UW Medical Center; social worker Janet Cameron, executive director of the Marillac Clinic; and Dr. Robert Spitzer of the Department of Psychiatry at Columbia University.
The researchers suggested that the United States health-care system could change in several ways to address both the physical and mental health concerns of poor, uninsured populations. At present, most mental health services for poor, uninsured adults usually operate in settings separate from primary-care clinics and are supported by different funding streams than indigent primary care.
“Communication and coordination between the mental health and primary-care service sectors is often incomplete,” Mauksch said. The Colorado clinic survey showed that most patients would prefer that their primary-care physicians communicate with their mental-health providers about their health care.
“We wanted to explore patient preferences for more collaborative mental health/primary care service structures, because attending to patient wishes might enhance the effectiveness of future interventions,” Mauksch explained. The UW has many national leaders in developing such collaborative models, including Walker, Katon, Russo, and UW graduate Dr. Jurgen Unutzer. In randomized clinical trials, UW researchers have shown that collaborative treatment of depression in primary care settings has higher recovery rate of 70 percent, compared to 40 percent with usual care.
Mauksch and Cameron have put together provider training programs; ways to align clinical, operational, and financial components to support integration of mental and physical health services; and methods for strengthening community connections.
The researchers do not expect immediate success in promoting integrated care. There are barriers to overcome in changing the minds of patients and providers, in funding, in removing the stigma that keeps people from seeking mental health care, and even in the architectural design of clinics.
However, surmounting these obstacles could be worthwhile. “Integration of mental health and primary care services,” Mauksch said, “might improve the well-being of those with the greatest need.”
Funding for the Marillac Clinic survey and for implementing integrated mental/physical health delivery came from the Robert Wood Johnson 2000 Local Initiative Funding Partners, which matched funding from local contributors led by the Colorado Trust.