Managing Behavioral Health Issues in Primary Care

Most patients seen in primary care will experience one or more psychological or behavioral health issues during their lifetimes. Although some patients need specialized care for psychological or behavioral health issues, primary care physicians should recognize the potential positive impact of using brief behavioral interventions during appointments with patients who struggle emotionally or face life crises.¹

An article from the American Academy of Family Physicians notes that by demonstrating emotional openness, listening carefully, and instilling hope, primary care physicians can provide a supportive environment in which to care for patients experiencing behavioral health issues. “When referrals are necessary, physicians can greatly influence patients’ willingness to follow through by highlighting the potential benefits of behavioral health services and explicitly addressing patients’ ambivalence and concerns.”²

The primary care physician’s role in addressing behavioral health issues also involves a team approach. According to Deanna Willis, M.D., MedPro Group Advisory Board member, “Primary care physicians provide important access to care for patients with behavioral health needs. Using active listening, empathy, and emotional support strategies help patients feel free from judgment and creates a psychologically safe space. It is essential, however, that both the providers and their entire office team screen for and recognize psychological emergencies, confidentially and effectively manage common behavioral health conditions, and connect patients to appropriate resources in a timely manner.”

Fifteen specific strategies for primary care physicians to employ when addressing behavioral health issues are included in the following pages.

1. Be present and allow yourself to be emotionally available to the patient. Use appropriate physical touch and open body language (e.g., turn away from the computer when speaking to the patient). Assure the patient about confidentiality.
   
2. Listen to the patient without interruption or judgment, and use active listening skills such as paraphrasing and reflecting the patient’s feelings. Express empathy in a genuine, natural manner to foster a stronger patient-provider relationship.
   
3. Normalize the patient’s emotional response and express empathy/concern. Focus on the specific issue you’re observing, but avoid labels and psychiatric diagnoses.
   
4. Explain to the patient how to use breathing and mindfulness exercises. Breathing and mindfulness exercises are easy to learn and can be very effective, but be sure to check in with the patient at each clinic visit to reinforce their use.
   
5. Recommend physical exercise to patients who have behavioral health issues. Explain to the patient how behavioral health is related to physical health concerns. Encourage behavioral activation by helping the patient create a routine or schedule.
   
6. Devise a protocol/plan to manage psychiatric and social emergencies that may occur in your practice. Prepare your team for behavioral health emergencies by learning about the petitioning process for involuntary evaluation in your area. Safety of the patient, yourself, and your staff is a top priority.³
   
7. Periodically assess the quality of care your practice provides to patients who have behavioral health issues and take action to improve care.
   
8. Routinely screen patients for behavioral health and substance abuse problems. Use acute care visits to elicit behavioral health concerns.
   
9. Work with behavioral and mental health professionals whenever possible to ensure the best care for your patients. This can range across a continuum, including collaboration and partnerships, co-locating services, or even full integration within one single care plan. Support patients and families in the referral process.
   
10. Educate yourself about behavioral health practices, including staying up-to-date on screening recommendations for behavioral health; behavioral health and primary care integration models; trauma-informed care; telehealth and telepsychiatry; and behavioral health disparities and high-risk populations.
    
11. Participate in relevant continuing medical education, rely on evidence-based clinical guidelines, use objective screening and diagnostic tools, and implement practice resources.
    
12. Be sure to document all behavioral health issues in the patient’s health record along with any specialist recommendations and/or referrals. Be sure to track referrals and reports and follow up appropriately.
    
13. Offer interpreters and auxiliary aids to assist with patient communication and comprehension for patients who have limited English proficiency or disabilities that impair communication.
    
14. Become familiar with your local behavioral health resources, including your local community behavioral health center and safety net behavioral health providers. Provide patients with written and verbal information about how to access these resources. Document the specific information provided in the patient’s health record.
    
15. Recognize that stereotypes and bias about behavioral health are common and problematic.⁴ Find ways to learn more about implicit bias and how this can impact your patients.

Resources

• Ask Suicide-Screening Questions (ASQ) Toolkit (National Institute of Mental Health)
  
• A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations from Exemplary Sites (Agency for Healthcare Research and Quality)
  
• Implicit Bias: The Influence of your Unconscious Mind Training (Centers for Disease Control and Prevention)
  
• Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary Care: A Literature Review (Agency for Healthcare Research and Quality)

Endnotes

¹Sherman, M. D., Miller, L. W., Keuler, M., Trump, L., & Mandrich, M. (2017). Managing behavioral health issues in primary care: Six five-minute tools. Family Practice Management, 24(2):30-35. Retrieved from https://www.aafp.org/fpm/2017/0300/p30.html

²Ibid.

³Johnson, J.M., & Stern, T.A. (2014). Involuntary hospitalization of primary care patients. The Primary Care Companion for CNS Disorders, 16(3):PCC.13f01613. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195632/

⁴Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., . . . Thornicroft, J. (2014). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1):11-27. Retrieved from https://www.cambridge.org/core/journals/psychological-medicine/article/what-is-the-impact-of-mental- healthrelated-stigma-on-helpseeking-a-systematic-review-of-quantitative-and-qualitative- studies/E3FD6B42EE9815C4E26A6B84ED7BD3AE

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