NURSING RESEARCH: Mental Health in Public Sector Primary Care

Primary care was first comprehensively defined by the World Health Assembly following a seminal conference in Alma-Ata in 1977 (Health for All by the Year 2000). Building upon the key aspects of Alma-Ata, the 1978World Health Organization emphasized the defining aspects of primary care as essential, first-level health care embedded in the community, available to all, evidence-based, socially acceptable, and
affordable. In the U.S., this optimistic vision for high-quality primary care has been only partially achieved. Ongoing challenges to high-quality primary care services are especially pronounced for public sector primary care. Public sector primary care services serve disproportionate of numbers health care users who have limited ability to pay for health services and experience significant health disparities. Both economic barriers to care and health disparities—inequalities in health care related to race and ethnicity (Institute of Medicine, 2003b)—are key priorities for research on improving health services. These issues cut across all areas of public health need, including mental health services.

mETAL hEALTH

Also in the late 1970s, the primary care setting became formally recognized as the de facto mental health services system in the U.S. Of the minority of individuals who receive needed mental health services, most receive their services in primary care instead of the mental health specialty sector. Many people seen in primary care for medical problems have significant clinical comorbid mental health conditions (Miranda, Hohmann, Attkinson, & Larson, 1994), especially anxiety, depression, and substance-misuse disorders.
The burden of unmet mental health needs is higher for racial and ethic minorities compared to whites (U.S. Department of Health and Human Services, 2001b). Significant barriers exist to accessing public sector health services, including the affordability of care, social stigma associated with mental illness, and fragmented care delivery systems acting as barriers to care when care is sought (U.S. Department of Health and Human Services).
Recent changes in the financing of public health care services for cost-containment reasons may have further exacerbated health disparities by creating heightened barriers to effective community-based care (Leigh, Lillie Blanton, Martinez, & Collins, 1999), including primary care services. These issues in the quality and access to primary health care services are particularly problematic in public sector primary care mental health.
A central goal of contemporary mental health services research is to generate new  knowledge directed to the transformation of mental health services to achieve high-quality, accessible, recovery-oriented care for all (President’s New Freedom Commission on Mental Health, 2003). Some significant progress toward this goal has been achieved over the past decade. Tests of interventions for primary care mental health care have been evolving in recent years from primarily efficacy assessments to effectiveness assessments.
In effectiveness assessments, understanding what approaches work for which populations and individuals under what set of circum-stances becomes of central importance. Effectiveness research also involves testing interventions in populations that experience significant health disparities and other barriers to high-quality health care. Examples of primary care research topics funded by the National Institute of Mental Health (NIMH) include incorporating sociocultural aspects of mental health care delivery, managing complex comorbid conditions, access to and acceptance of mental health services, effectiveness of mental health care delivered in “usual care” primary care settings, and quality of mental health care processes in relation to treatment guidelines and outcomes (NIMH, 2003). As primary care research continues to evolve to better address issues of health dis-parities and mental health care delivery models for primary care settings, there are key opportunities for nurse researchers. Nurse researchers have the potential to make significant contributions to mental health services and interventions research for redesigned primary care mental health services in two key areas. The first area concerns testing models of care for common mental health issues within the primary care setting that are tailored in ways acceptable for various high need patients populations and which can be shown to be both effective and cost-effective. In general, consistent with other bodies of clinical literature in medicine and other fields, the nursing literature on managing mental health issues in primary care (especially depression) has burgeoned over the past decade. However, there are still very few tests of nursing interventions using advanced practice nurses (such as nurse practitioners and mental health clinical nurse specialists) to manage mental health issues in “usual care” primary care and community-based settings. This is especially so for public sector primary care with populations that are most underserved and which experience health disparities. Recent examples of research with underserved populations include the work of Hauenstein (1996) to test a nursing intervention for managing major depression in rural women, and Torrisi and McDanel (2003) on the participation of two urban nurse-managed centers in a depression collaborative to improve care for depression.

The second area of research opportunity concerns evaluations of now rapidly evolving “blended roles” for advanced practice nursing, nursing roles in which medical and mental health skills are available in the same primary care provider (Williams, C. A., et al., 1998). Advanced practice nurses who effectively “blend” medical and mental health training are well-positioned to manage the holistic needs of the patients they see in primary care settings. For example, Lyles and others (2003) reported on the use of nurse practitioners trained to manage the medical and mental health needs of primary care patients with medically unexplained symptoms. These types of blended roles need additional research testing for combinations of comorbid health conditions most commonly seenin primary care settings.


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