When it comes to the treatment of military veterans, often one provider just isn’t enough. This particular population, which faces disproportionately higher rates of mental illness than others, can benefit greatly from integrative and collaborative treatment by a mental health clinician, in addition to a primary care provider. With stigma still attached to receiving mental health services, the ability to identify and engage more veterans into treatment may hinge on the development of integrated settings. By embedding mental health services that are specialized in the needs of veterans within a primary care practice, more connections to treatment can be made. Federally Qualified Health Centers, with missions to serve the underserved, often serve veterans who are disconnected from traditional veteran services. These health centers have workflows that integrate disciplines; helping veterans daily by not only addressing their medical needs, but also making sure that a veteran’s psychosocial and mental-health needs are also being addressed. This includes case management, care management, mental health treatment, and psychiatric care.
The ability for a veteran’s primary care provider to successfully collaborate with a mental health clinician is highly important. Mental health clinicians, who are specially trained, are able to diagnose post-traumatic stress disorder, bipolar disorder, and major depressive disorder—all common conditions in veterans—during a medical visit. The primary care provider, when they recognize a need, can provide a “warm hand-off” to the mental health clinician, or have the mental health clinician join in together during the visit. The mental health clinician has the ability to perform a crisis intervention, assess the veteran’s safety and risk, perform a psychosocial evaluation, or assist with any case management issues the veteran needs help with. The ability to meet a mental health provider during a primary care visit significantly decreases stigma and improves the likelihood of ongoing services.
It is crucial for these mental health clinicians in a primary care setting, to know how to work with this specific population, because veterans qualify for specific benefits that could affect their treatment. There is a need to ensure mental health providers in integrated settings have the specialized training to inform their care and support the needs of this population.
One case example of the effectiveness of a collaborative approach, involves a veteran who saw his primary care physician to address his chronic hiccups. At the time, the doctor had seen this patient multiple times already to address his hiccups, but nothing seemed to be helping him. The physician then contacted a mental health clinician newly embedded in the practice as a consult to assess the veteran during the visit. It was discovered that the patient’s hiccups were actually a symptom of his undiagnosed anxiety disorder, and it was found that the veteran was also experiencing depressive symptoms. By the end of the visit, the veteran was scheduled for weekly therapy sessions with the mental health clinician, a follow-up with his primary care provider, and a psychiatric evaluation with a psychiatrist. Through consistent team treatment, the patient began having less frequent hiccups and his Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores have decreased steadily over time. An on-site case manager was added to the team assisting the patient with housing and other concrete services.
Integrated settings, like community health centers, are ideal for meeting the comprehensive needs of veterans in a setting that many veterans already consider their “clinical home”. The primary care provider, who often has a long-standing relationship with the patient and/or patient’s family, can play a critical role in engaging a veteran into mental health treatment.
Research suggests that the collaborative management by the primary care providers has resulted in a decrease in major depressive symptoms, and has improved patients’ satisfaction with their care (1). Patients feel more cared for when they see both professionals are working together to follow up with them regularly. Mental health services in the primary care setting are greatly beneficial to veterans because they can receive a multifaceted intervention that specifically caters to their needs.
(1) Katon, W., Korff, M., Lin, E., Walker, E., Simon, G., Bush, T., Robinson, P., Russo, J. (1995). Collaborative management to achieve treatment guidelines: Impact on depression in primary care. JAMA: The Journal of the American Medical Association, 273(13), 1026-1031.