Behavioral Health Assessments with Depression, Alcohol and Abuse Screening

 

Behavioral Assessment of the General Medical Patient

Epidemiologic data indicate that over one half of U.S. patients receive mental health care exclusively in the primary care setting.1 The primary care physician who can readily detect and manage behavior problems will be better equipped to manage this growing demand.

The American Psychiatric Association's Practice Guideline for Psychiatric Evaluation of Adults provides a comprehensive overview of elements essential to thorough psychiatric evaluation.2 Expecting the primary care physician's strict adherence to the Guideline is unrealistic and impractical. Time does not permit all areas to be addressed, nor is it necessary in most cases.

The purpose of this chapter, therefore, is to draw on the Guideline as well as other resources3-5 to develop a succinct and targeted summary of elements essential to efficient behavioral assessment by the primary care physician. Developing this skill set is especially important because behavioral disorders are among the most prevalent and treatment-responsive problems encountered in primary care.

Evaluating the Primary Care Patient

A behavioral disorder should be included in the differential diagnosis of any patient who presents with repeated complaints, especially fatigue, insomnia, pain, or just feeling overwhelmed. For a variety of reasons, this demands that the primary care physician maintain a high index of suspicion for behavioral disturbance in her or his patients. The patient and physician typically focus on identifying a physical cause for the problem at hand. Failure to find a physical or physiologic basis can leave one or both with the nagging concern that something has been missed. Physicians' time constraints interfere with recognition, thorough assessment, and optimal management of behavioral disturbances.

Patients themselves are also inclined to minimize or ignore behavioral considerations. Psychological symptoms are typically viewed as evidence of weakness or personal failure, so that even under ideal circumstances, patients are unlikely to entertain or accept a behavioral explanation for their distress. The language used to describe symptoms can therefore be problematic, and labeling with psychiatric symptoms or diagnoses can alienate rather than recruit the patient.

The primary care physician must also be aware of and deal with her or his own misgivings about behavioral disorders. The stigma of mental illness is pervasive and originates in each of us. That is, none of us is comfortable with self disclosure, especially when it can result in being labeled crazy or mentally unfit. The primary care physician must overcome her or his own resistance to engage the patient in self revelation that can trigger fear, embarrassment, or shame.

Interview Techniques

Ideally, the primary care physician creates an environment that facilitates disclosure of sensitive, personal information. Effective interviewing that achieves this goal also helps maximize data gathering. Effective time management depends on having the skill not only to facilitate but also to tactfully limit patient self-disclosure or somatic preoccupation.

General Approach

The most comprehensive and accurate information is obtained when the examination begins with open-ended questions and active listening followed by structured inquiry about specific symptoms and events. Open-ended questions give the patient the opportunity to tell things from his or her perspective, and active listening helps verify and enrich the patient's report. Active listening involves periodic feedback to the patient of what the clinician has understood so as to ascertain and clarify what the patient has said. It can also serve to limit and redirect the rambling of an unfocused patient. Active listening facilitates the assimilation of a comprehensive database, and it also conveys to the patient the clinician's sincere effort to understand and to empathize with the patient's circumstances. The clinician's listening attitude helps to establish trust and a collaborative, problem-solving partnership between patient and clinician.

The BATHE Technique

A widely accepted format for organizing the findings of medical examination is the acronym SOAP (subjective, objective, assessment, plan). An alternative that focuses attention on behavior and emotional symptoms occurring in the context of the patient's life circumstances is captured by the acronym BATHE

 

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Electronic Behavioral Health Screens

Depression Screening and Alcohol and Substance Abuse Screening under the Affordable Care Act is allowed once per year per patient. Both of them are 100% covered by the ACA with $0 patient responsibility for Medicare and most PPOs. Reimbursement for each screenings ranges from about $16 - $21 for Medicare and up to $45 for PPOs. The screenings are administered by office staff (takes about 5 minutes) and then reviewed by a PA, NP, MD or DO. Additional electronic screens to follow-up a behavioral health treatment plan are covered based on medical necessity.

 

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