Though many people associate a primary care clinic visit with physical health care, a growing percentage of primary care providers are now also caring for their patients’ mental health.
At The Good Clinic, group of primary care clinics with six Twin Cities locations, nurse practitioners provide mental and behavioral health support for clients in the form of screening and treatment for anxiety and depression. Sometimes this treatment includes providing prescriptions for antidepressants and other psychiatric medications.
“We can manage many behavioral health issues,” said Kevin Lee Smith, DNP, Good Clinic chief nurse practitioner officer. “We can prescribe mental health medication based on the individual. We take a collaborative approach where we offer referrals for counseling, psychology or psychiatry when necessary, if this is someone who might be beyond the more common depression and anxiety diagnoses.”
Offering these services is a natural extension of the “person-centered” approach to health care that’s part and parcel of the primary-care approach to medicine, Smith said.
“Addressing mental health issues has been an important component of our approach from the get-go,” he explained. When leadership set out to design The Good Clinic, Smith continued, “we looked at where there are gaps in health care in general, especially in primary care. It was clear there were opportunities for improvement in mental health care for our clients.”
Smith said that a large percentage of Americans now seek mental health support from their primary care providers, rather than from mental health-focused providers like psychologists or psychiatrists. There are many reasons for this trend.
“For some individuals,” he said, “there’s a barrier in accessing mental health services because they think they might have to go to a specialist for treatment or because there is a stigma around seeing a psychologist or a counselor.”
Because people are often more familiar with their primary care provider, and because primary care clinics offer routine screenings for common mental health conditions, a growing number of people turn to those providers for assistance with their mental and behavioral health concerns.
“One of the reasons that a great deal of behavioral health services are being provided in primary care clinics is that trusting relationship that is developed over time with repeated visits,” Smith said. “Having that trust makes it OK for many clients to talk about their mental health issues.”
More treatment options
This spring, in an extension of its mental and behavioral health support offerings, The Good Clinic began offering clients the option of using GeneSight, genetic testing that determines how an individual may respond to specific mental health medications before actually taking them. Because not all mental health medications work the same for every person, this option can help avoid multiple medication trials.
Not so long ago, GeneSight tests were only available at large medical institutions like the Mayo Clinic, but in recent years, they have become available to smaller providers. Smith said that Good Clinic staff were excited to add this option for their clients. The test is taken with a cheek swab, and can be done in a medical provider’s office or at home, though it must be ordered by a health care professional. The swabbed sample is then sent to a lab for analysis, and a color-coded report is issued, listing medications that are safe to use as directed (green), have a potential for moderate gene-drug interaction (yellow) or a significant history of gene-drug interaction (red).
Smith said that he and his colleagues wanted to offer GeneSight to their clients as a way to help make the process of finding the right mental health medication easier and less time-consuming.
“For many antidepressant medications, a typical approach for a provider is to ask a patient to take the medication for 4 or 6 weeks, giving it that much time to see if it has the expected benefit. If the medication doesn’t have a positive impact, the dose could be adjusted or the patient might have to start over again with another medication and take the time to see if that one works.”
That time commitment may be OK for one or two rounds, but often patients have to try several medications to find the right match. Long trial periods that result in less-than-ideal results or discouraging side effects mean higher patient drop-out rates.
“With the GeneSight testing,” Smith said, “you are able to determine from the get-go whether or not this individual will appropriately metabolize that medication. It really saves a lot of time.”
Paul Linson, lead nurse practitioner at The Good Clinic’s St. Louis Park location, has used GeneSight testing for several of his patients. He said the test has helped him help his patients find the right medication in a shorter amount of time.
“I have used GeneSight for various reasons,” Linson said. “The test has guided treatment in cases where the client wanted to start with something accurate from the very beginning. It has also been useful to guide therapy in people who have tried other medications that didn’t work or they had side effects. In each case, the information we have received from the test has been very helpful.”
The Good Clinic was founded and is staffed by nurse practitioners. The philosophy of this field of medicine, Smith explained, tends to be more holistic, with a focus on a range of needs of each individual patient, or client. “Nurse practitioners are focused around the bio-psycho-social person,” Smith said. “We’re not just working with individuals with conditions. You can’t treat a condition without the context of who that human is.”
Taking this kind of approach to patient care means that providers take time to truly understand their clients’ needs, Smith said. This often means that discussions about care will extend beyond physical health concerns: “A component of that is addressing behavioral or mental health. That’s been part of primary care practice for a very long time.”
Treating the whole patient requires more time than a classic “blood pressure-reflexes-weight” checkup. “We build our schedules around being able to give our clients the opportunity to talk about their concerns,” Smith said. “Our appointments are 30 and 60 minutes long. We want to take the time to really understand what the individual’s concerns are.”
The extra time often allows room for a patient to build the relationship and talk more freely about their mental health, Smith said.
“In most health care clinics, every client who comes through gets screenings for depression and anxiety. Those are good tools, but you also need slow down, to make time, to build the relationship. You need to have the conversation.”
In those longer conversations, Smith said that Good Clinic nurse practitioners work to help clients understand possible connections between their physical health and their mental health. All bodily systems work together as one whole, he explained.
It’s not unusual for a client to make an appointment for treatment of a physical issue but leave seeing that there might be a connection to their mental health, Smith said. “Generally I would say that the individuals where we are managing their mental health issues typically are seeing us for other things as well. Their mental health is often not the chief complaint or the reason for their visit. Usually it is an issue that comes out of their coming in for other kinds of care.”
Helping clients make those connections can lead to a greater understanding of how the human body actually works, Smith said. “Oftentimes, clients are not aware of the connection between their physical symptoms and their mental health issues. We try to look at the individual, look at all the components that make up that person’s physical and mental health and treat them all equally. Those connections are very strong.”