When talking with nurse practitioners (NPs) in casual conversation, they often share their objections to "dealing" with mental health concerns in primary care practices, believing that this is not their responsibility. I found this to be true of many NPs when I conducted a study in 2016 about NP practices, skills, attitudes, and perceived barriers to screening for previous child abuse in adult patients. Most of the primary care NPs surveyed did not regularly screen for childhood abuse and did not believe screening was their responsibility. The NPs reported they did not have enough time to screen, worried about retraumatizing patients, and lacked confidence in their ability to respond appropriately when patients revealed previous abuse (Kalmakis et al., 2017). This raises the question, if primary care NPs do not ask patients about experiences of child abuse, interpersonal violence, substance use, or symptoms of depression, who does? Furthermore, how can we provide effective treatment for chronic stress, depression, and substance misuse problems that stem from behavioral health challenges if we do not ask?
It is time to shift paradigms in advanced nursing practice. After a cursory review, I noted only 12 papers on the integration of behavioral health and primary care published in JAANP over the past 10 years. Nursing researchers, and clinicians, need to shift current paradigms, and our scholarly publications should reflect this shift.
Behavioral health (psychiatric mental health and unhealthy substance use) and physical health (biological/body) have been treated as distinct from each other in the United States with our current acute care-focused health delivery system. A system that NPs have embraced rather than challenged. Traditionally, individuals see one health care provider for behavioral health and another for physical health, and both dedicate a high degree of effort to acute care problems, whereas chronic conditions remain poorly managed. This acute care-focused medical model falls far short of the needs of individual patients whose mental health and physical health are inseparable and influence each other over time. To provide for the needs of the diverse, unique individuals who come to us for their care, NPs must challenge the current health care paradigm by developing integrated skills and approaches that consider the complex, chronic physical and mental health needs of patients. Such skills, and approaches, include the ability to assess for trauma histories, substance misuse, and mental health conditions in primary care settings. This integrated approach to health care will more effectively influence health outcomes.
Practicing NPs are not to blame for this siloed approach to health care; this is how many were educated based on a medical model. Courses for primary care NPs focus on physical health, with a few modules on depression, insomnia, and substance use disorder. But these modules often fail to connect a patient's life experiences, such as child abuse, neglect, or family dysfunction with common health problems. For example, when was the last time you asked an adult with diagnosed obesity, diabetes, and depression about their childhood or current family life? To effectively care for patients with chronic physical health conditions in primary care, we need to understand their mental health. Yes, this will take some time, but if the knowledge leads to treatment of their mental health issues, and improvement in their physical health condition, is not it worth the extra time?
More than 47.6 million American adults have a mental illness, and 20.3 million report unhealthy substance use (Substance Abuse and Mental Health Services Administration (SAMSHA), 2019). Many of these people have histories of adverse childhood experiences (ACEs) or interpersonal violence (IPV). Most patients with depression rely on treatment from their primary care provider, in part due to lack of psychiatric mental health (PMH) services and issues of stigma that prevent patients from seeking PMH care, especially among racial and ethnic minorities (Alson et al., 2016). However, primary care providers only identify half of their patients with depression (Felix et al., 2014). Similar to screening for ACEs and IPV, lack of screening for depression in primary care settings has been attributed to limited time during primary care visits, stigma associated with mental health, and lack of education in behavioral health.
As with adult care, screening for behavioral health problems in primary care is needed to identify children who would benefit from appropriate treatment. Twenty-three percent of U.S. children have, or have had, a psychiatric disorder, with half occurring before the age of 14 years (Child Mind Institute Children's Mental Health Report, 2020). Yet, despite recommendations, most primary care providers do not screen for childhood adversity or other behavioral health problems in their pediatric practices. Although screening measures are readily available, pediatric primary care providers do not do better in integrating behavioral health into primary care. Like their adult primary care counterparts, pediatric primary care providers report lack of time, knowledge, limited behavioral health services, and stigma of mental illness, as reasons for not regularly screening children for behavioral health conditions (Wissow et al., 2016). Sadly, this failure to diagnose and treat children for psychiatric illness may result in academic failure, substance abuse, and criminal behavior, at great cost to families and communities. This is unacceptable; we can and must do better.
The need for behavioral health services has increased since the pandemic began due to the prolonged impact of COVID-19 on education, recreation, and community. I would contend that it is the children who have suffered most from COVID-19 over the last year and a half; few physically, many mentally, emotionally, and socially. It is imperative that now, at this unprecedented time of pandemic, primary care NP providers, be skillfully educated to deliver compassionate care that addresses the behavioral health of our pediatric patients.
We are adding high-quality NP primary care providers to our health workforce every year. Currently, more than 325,000 NPs are licensed in the United States, and approximately 35,000 additional NPs are licensed every year (American Association of Nurse Practitioners, AANP, 2020). NPs are educated to evaluate and diagnose disease, order and interpret diagnostic tests, and prescribe medications, and most NPs are primary care providers (70%) (American Association of Nurse Practitioners, 2021). We are in a position as health care providers to affect significant change in practice through clinical research and scholarly writing that will disseminate novel ideas and stimulate change. Our scholarship and professional writing should reflect our understanding of a changing health care paradigm moving us toward integrated models of health care. We must reject archaic notions of health care delivery that compartmentalize physical and mental health and recognize emerging shifts in health care paradigms in our research and scholarly writing.
Of course, to reach a high level of screening for behavioral health problems, primary care practitioners must feel confident in screening techniques and treatment approaches. Education to give NP primary care providers the knowledge, skills, and attitudes needed to screen for behavioral health conditions is attainable through formal education programs. Educators must consider how they can weave behavioral health throughout NP programs.
Additionally, NPs need to conduct and disseminate research through scholarly writing that focuses on the integration of behavioral health and primary care. There are too few studies that have focused on behavioral health integration. More research and implementation projects are needed to disseminate best practices for integrating behavioral health into primary care settings.
Behavioral health awareness and increased behavioral health screening and treatment in primary care are needed. It is more important than ever that primary care NPs offer whole health care. Embracing a trauma-informed primary care, in which providers are sensitive to the unique mental and physical health needs of diverse patients, can improve the care of patients and revolutionize health care experiences and outcomes of those with trauma histories. To make this happen, we will need to reject the current medical model of siloed health care. How can patients receive quality, patient-centered care if we pursue the archaic notion that physical health and behavioral health exist separate from each other?
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