The Provision of Mental Health Services in Managed Care Organizations

Screening and Treatment in Primary Care

This study is one of the first to explore MCOs' policies on the screening and treatment of mental health disorders in primary care settings, including the requirements for screening, conditions that trigger screening for mental health disorders, and support for primary care practitioners (PCPs) through the distribution of relevant practice guidelines (Garnick et al., 2002). MCO medical directors were asked whether PCPs are required to use standard screening questionnaires, such as the Zung Depression Index, or questionnaires on mental health developed by their MCO.

Primary care offers the opportunity to identify mental health problems at early stages and to treat or refer patients for care. Estimates suggest that 20% to 40% of all patients seen in primary care settings have a diagnosable mental disorder or distress that could interfere with daily functioning (Higgins, 1994; Barrett, Oxman, & Gerber, 1998). In 1996, the U. S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for depression with standardized questionnaires (U. S. Preventive Services Task Force, 1996). In May 2002, however, the updated recommendation by the task force is for "screening adults for depression in clinical practices that have systems in place to assure diagnosis, effective treatment and follow-up" (Pignone et al., 2002; U. S. Preventive Services Task Force, 2002). Moreover, formal screening tools increasingly are available to assess mental health problems (e. g., Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire, or Center for Epidemiological Study Depression Scale [Williams et al., 2002]), and a recent review article recommends screening of select patients whose profiles suggest increased risk (Whooley & Simon, 2000). These instruments are not widely used, however, and PCPs generally have a difficult time detecting mental disorders such as anxiety and depression (Von Korff et al., 1987; Wells et al., 1989; Heneghan et al., 2000).

Requirements for Mental Health Screening in Primary Care

Overall, 21% of products require PCPs to conduct screening for mental health disorders, including 2% that require specific mental health screening only, 13% that require general screening instruments that include mental health, and 6% that require both approaches. It is also important to note that for 12% of products, respondents did not know if specific mental health screening was required (Figure V.1). Of the small number of products that require screening for mental health disorders, 93% report allowing PCPs' clinical judgment to determine what types of patients to screen. Around 63% report requiring screening of all new patients and 67% report relying on specific conditions to trigger screening. Only 28% of those products that require any screening for mental health problems in primary care settings also report that they require such screening for all patients on a periodic basis. For the 5% of products that report screening requirements as a result of trigger conditions, the most commonly cited conditions are chronic pain, the presence of a substance abuse problem, and sleep problems.

Practice Guidelines for Mental Health Treatment in Primary Care

Practice guidelines, defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical services" have been published in recent years for the primary care treatment of mental disorders in both children and adults (Birmaher, Brend, & Benson, 1998; ICSI, 1999). Practice guidelines can offer direction and support to PCPs in providing appropriate mental health care or referring patients to mental health specialists. While MCOs were not asked what organization wrote the practice guidelines for primary care, the study did find that most MCOs with specialty behavioral health guidelines used self-developed ones. (See Chapter VIII.) It also examined the distribution of behavioral health practice guidelines to PCPs, the topics covered by those practice guidelines, and whether there were differences in the distribution of guidelines depending on screening requirements.

Overall, guidelines were distributed in 51% of products, with PPO products less likely to do so (Table V.1). In addition, products with comprehensive contracts were less likely than either products with specialty contracts or those with internal provision of mental health services to distribute guidelines. For products that distribute practice guidelines, we compared the topics covered in the guidelines for those products that require screening and those that do not (Table V.2). Among products with required mental health screening, 85% or more distribute guidelines addressing the provision of brief interventions, consultations with specialty practitioners, and patient education. Only 66% distribute guidelines addressing the prescribing and monitoring of psychotropic medications. The proportion of products distributing each guideline topic was
not significantly different between products that did and did not require screening.

Discussion

Few MCO commercial products require mental health screening activities in primary care settings. MCO executives did not find the national statistics on screening to be surprising. According to an MCO executive, "There is very low attention to the detection of mental health and substance abuse problems. Welcome to the real world."

The medical literature includes recent review articles supporting the effectiveness of primary care screening in identifying individuals with mental health problems such as depression (Williams et al., 2002) and providing guidance for treatment in primary care settings (Whooley & Simon, 2000; Pignone et al., 2002). Thus, the infrequent requirement for mental health screening by MCO products represents a lost opportunity to identify people whose mental problems otherwise may go unnoticed and untreated.

Discussions with MCO representatives also shed light on why mental health screening is not more often required. Among reasons for low screening rates, MCO executives reported that many believe that it is difficult to find a screening instrument that is brief, easy to score, and easy to interpret. Also, they reported that it is difficult to monitor whether screening is done in primary care and that PCPs may not feel competent to address mental health issues once those issues are detected. Nonetheless, with the recent publication of national recommendations endorsing screening for depression in primary care, MCOs may now feel a stronger imperative to require screening than they did at the time of our survey in 1999.

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