Veterans who receive mental health screening during primary care visits are generally getting adequate follow-up treatment, but the process for acquiring care could be improved, finds a new study in General Hospital Psychiatry. The study examined primary care screening for depression, post-traumatic stress disorder (PTSD) and alcohol misuse at a large Veterans Affairs (VA) medical center.
"For all three screens [depression, PTSD, and alcohol misuse], we looked at the provision of treatments that receive A-level recommendations in the VA-Department of Defense clinical practice guidelines for the related disorder. This means that in patients who actually have the disorder, there is good evidence that the intervention improves important health outcomes and benefits substantially outweigh harm," said lead author Brian Shiner, M.D., M.P.H., staff psychiatrist at the White River Junction VA Medical Center and assistant professor at the Geisel School of Medicine at Dartmouth. "Therefore, we assume that we can help to improve veterans' health by following up screens with clinical exams and delivering these treatments when they are indicated."
Shiner and his colleagues analyzed three mental health screening tests given in 2011 to primary care patients at the White River Junction VA Medical Center. These patients did not have prior mental health problems.
Of the 20,682 patients seen for primary care, 3,272 screened positive for one or more mental health disorders. Of patients with positive screens, 16 percent screened positive for depression, 12 percent for PTSD, and 84 percent for alcohol misuse. These percentages include 10 percent that were positive for two or more disorders.
The study found that, post-screening, those who went on to mental health clinics received recommended care. Patients identified with alcohol misuse issues often didn't receive recommended medications, however, "we should use caution in interpreting the findings on alcohol misuse," noted Shiner.
"A positive screen on the [screening tool] identifies both alcohol misuse and alcohol dependence. Different treatments are appropriate for these two problems," he explained. "In alcohol misuse, brief counseling in primary care receives an A-level recommendation from the VA and Department of Defense. With alcohol dependence, medications like naltrexone receive an A-level recommendation, but this report does not disentangle these populations."
Rick Hafer, Ph.D., clinical professor of psychiatry and vice chairman of clinical services in the department of psychiatry at the University of Wisconsin School of Medicine and Public Health, said pre-screening in primary care clinics is important since it might identify patients who may not seek services or they will wait until their symptoms become more severe.
"Early detection and treatment for mental health is similar to other medical conditions. Early intervention leads to more effective, efficient care," he said. "Since more than 60 percent of mental health conditions are treated in primary care, it is important to develop pre-screening tools to better evaluate mental health conditions and early intervention."
"Keep in mind some patients see their 'mental health problems' as private, only to be shared with a mental health specialist," said Hafer. "The main limitation to primary care rests with whether clinicians are available in addition to medication intervention. But many patients do not want medications but prefer some form of therapy."
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