Primary care providers' approaches to mental health care for socially and economically disadvantaged adults with chronic disease

This study's purpose was to describe primary care providers' (PCPs) approaches to mental health care for socially and economically disadvantaged adults with chronic disease who receive their care in community health centers (CHC), and to identify factors that influence those approaches.; Because mental illness increases symptom burden, functional impairment, and medical costs, and impedes self care in people with chronic disease, management of mental disorders constitutes an important component of their care. Challenges in providing integrated physical and mental health care are magnified for PCPs whose patients are from culturally diverse backgrounds, live in poverty, and tend to have poorer physical and mental health than the general population. This study sought to provide better insight into current mental health care practices in these settings as a means to help identify opportunities for improvement.; This qualitative study was conducted in seven clinics representing three CHC systems in the Denver, Colorado metropolitan area. Interviews with 48 PCPs explored recognition and responses to patient psychosocial issues in the context of chronic disease management. Observation of clinic activity and interviews with 12 non-PCP clinic staff providing psychosocial services in the three systems provided additional insight into influences on the process of care.; A systematic analysis of PCPs' descriptions of their thoughts and actions in specific patient situations revealed the practice of "reluctant psychiatry"---a PCP's approach to mental health care when the patient's needs are exceptionally complex and the PCP is unable to refer the patient for specialty care. As specialty resources for low-income individuals with serious mental illness have become less and less accessible to patients and their PCPs due to cuts in public mental health spending, PCPs face the dilemma of providing care that is outside their scope of expertise and/or struggling to manage chronic disease in patients who are otherwise unable to engage in self care.; Reluctant psychiatry exacts a toll on the individuals forced to practice it, the patients whose care is compromised for lack of appropriate specialty care, and the society that absorbs the cost of supporting increasing numbers of individuals whose physical and mental health are poorly, controlled.