With Lisa Brown
The first chapter in this book addressed the essential issue of the mind–body connection.
Primary care providers (PCPs) face the challenge of providing holistic care for their patients and acknowledge that separating the body and mind is contrary to their practice. They are not afforded the opportunity to say “that’s not my area”—everything is their “area.” Chapter 2 addresses key facets of mental health assessment and collaborative practice among PCPs and psychiatric professionals. In theory, it would be ideal to have mental health specialists readily available and even more wonderful if all patients with emotional needs were willing to seek specialized mental health services. Primary care providers know it is not that simple. This chapter offers a conceptual framework and tools to aid the PCP in assessing the urgency of mental health concerns, and provides language to help ease the transition of mental health services to a specialist when necessary.
In the physical realm, providers can rely on a variety of technological and other objective assessment and diagnostic tools. Although mental health assessment tools exist, they will never be as accurate as those utilized in diagnosing physical phenomena. The difference lies in the subjectivity of people’s emotional, cognitive, and spiritual response(s) to life events.
To illustrate: The indifferent attitude of a provider ordering laboratory tests for diagnosing a physical problem will not affect the objective laboratory results, although it may exacerbate a patient’s distress, whereas an indifferent attitude of a provider aiming to ascertain a depressed person’s risk for suicide may result in denial of suicidal plans and failure to obtain other data for assessing suicide risk. This means that in addition to structured assessment guides, the provider–patient relationship and the provider’s communication skills constitute the most essential “tools” in the psychiatric/mental health assessment process (Peplau, 1993).
• Overview of Assessment Methods
• Diagnostic and statistical manual of mental disorders (DSM-IV TR)
• The Global Mental Health Assessment Tool—Primary Care Version (GMHAT/
PC)
• Triage Tool: Assessing for Immediate Risk of Harm to Self and/or Others
• A Comprehensive Mental Health Assessment Tool (CMHA)
• CMHA and McHugh’s “Essentials”: Description and Commonalities
• Appendix
• References
Overview of Assessment Methods
Varied assessment tools are available to health and mental health providers. Most are specific to symptoms, such as mania scales, depression scales, etc. Many of these were designed as research tools and therefore are not always suitable for clinical practice. This is especially true in primary care settings or in high-risk situations where time is of the essence. The universal goal of thorough assessment is further challenged by the significant amount of work to be done in primary care—usually in a very limited time period.
In our overview and critique of assessment methods, we present six sources relevant to primary care practice: the Diagnostic and Statistical Manual of Mental Health Disorders (DSM); the International Classification of Diseases (ICD); the Global Mental Health Assessment Tool—Primary Care version (GMHAT-PC); a 5-question Triage/Risk assess-ment tool; the Comprehensive Mental Health Assessassess-ment (CMHA) tool; and psychiatrist Dr. Paul McHugh’s “essentials” approach to psychiatric diagnosis (at Johns Hopkins Medical School, an alternative to the DSM). The “essentials” framework is highly complementary to the CMHA and its emphasis on holism and basic life functions, and their disruptions by physical illness and/or psychiatric disorders. We illustrate use of the CMHA and service plan-ning with a case example in primary care, thus laying the foundation for its use in subsequent chapter topics.
Diagnostic and statistical manual of mental disorders (DSM-IV TR)
The Diagnostic and statistical manual of mental disorders (DSM) is currently published in its fourth edition with revisions (DSM-IV TR). Diagnostic and statistical manual, 5thEdition (DSM-V) is expected to be released in the year 2012. The DSM was originally intended for psychiatrists, and later, for advanced practice psychiatric nurses, social workers, and psy-chologists as a guide for diagnosing mental disorders. But (as noted in Chapter 1), today in the U.S. and other countries the bulk of treatment (including psychotropic drug monitoring) of patients discharged from in-patient psychiatric care is done by primary care providers in general medical settings. Further, in the U.S., a DSM diagnosis is required as a basis for insu-rance reimbursement for mental health services. It is therefore important for primary care providers to be familiar with the DSM, including its benefits and limitations in practice.
The DSM was first published in 1952 and was a compilation of diagnostic categories with a description of each. The word reaction was utilized with each description, reflecting the influence of Adolf Meyer’s psychobiologic approach and his belief that each disorder was a reaction to psychological, social, or biological factors, or a combination thereof. The DSM-II eliminated the word reaction, thereby removing discussion of “cause” and ultimately the mind–body connection.
In 1980, the DSM-III was published. This edition included explicit diagnostic criteria, a multiaxial system and a “descriptive approach that attempted to be neutral with respect to theories of etiology” (American Psychiatric Association, 2000, p. 26). One of the primary goals in creating this edition was to provide a medical nomenclature for researchers and clin-ical providers in psychiatry. The DSM-IV was published in 1994, the fourth edition with text revisions in 2000.
Healthcare analysts and social scientists have noted that each edition of the DSM contains new psychiatric “disorders,” while also dropping, for example, the diagnosis of “homosexu-ality” from its nomenclature in response to growing concern about attaching a psychiatric label to a phenomenon—in this case, sexual identity—that is not mental illness (see Caplan, 1995; Cooksey & Brown, 1998 regarding the social construction of mental illness). The DSM –IV-TR contains 943 pages (hundreds more since its first edition), with 10.5 pages of codes.
We might well ask: Does this represent an evidence-based increase in mental illness, or perhaps the “social construction” of mental illness (Hoff, Hallisey, & Hoff, 2009, pp. 71–77)
—overall, a lot to master, especially for PCPs without specialty psychiatric training.
The DSM-IV has been widely accepted in clinical and research settings. Significant controversy surrounded the development of the DSM-III and the revised text (Caplan, 1995;
Cooksey & Brown, 1998; Luhrmann, 2000). The controversy appears to have abated with the fourth edition with text revision (APA, DSM-IV-TR, 2000) and although there is dialogue in the medical literature regarding the upcoming DSM-V, there is very little thought provoking discourse.
In a 2007 article, Regier, vice-chair of the task force to develop DSM-V describes the DSM as “a dictionary of mental disorder diagnoses that describes the characteristics of each mental disorder diagnosis” (p.1). He states the DSM-V will pay greater attention to “measurement based care” (p. 2). Regier emphasizes the need for this tool in research, reminding us that although the DSM is used in clinical practice, the DSM-III, IV and IV-TR were all primarily designed with research in mind. Another important goal of the DSM-V is to attempt to be more congruent with the International Classification of Diseases (ICD).
The International Classification of Diseases is currently published in its 9thedition with the 10thedition due for publication in 2014. The ICD is published by the World Health Organization and used worldwide for morbidity and mortality statistics, as well as in reim-bursement systems. This system is designed to promote international comparability in the collection, classification, and presentation of disorder.
The ICD includes a section classifying mental and behavioral disorders. This has been developed alongside the Diagnostic and statistical manual of mental disorders and the two manuals seek to use the same codes. According to Regier (2007), the goal is to achieve close to 90% congruence between the DSM-V and the ICD 10thedition. Currently there are significant differences; for example, the ICD includes personality disorders on the same axis as other mental disorders whereas the DSM lists personality disorders on a separate axis/category. According to Mezzich (2002, p. 75) “A recent international survey across 66 countries has found ICD-10 more frequently used for clinical diagnosis and training, and DSM-IV more used for research.”
The five axes of the multiaxis systems of the DSM-IV-TR are as follows:
• Axis I: Clinical disorders, such as major depression and schizophrenia. Other conditions, such as alcohol dependence, that may be a focus of clinical attention.
• Axis II: Personality disorders and mental retardation.
• Axis III: General medical conditions, for example: HIV infection may cause dementia (Axis I), or alcohol dependence (Axis I) may cause cirrhosis (Axis III).
• Axis IV: Psychosocial and environmental problems—includes events and stressors that may precipitate, result from, and/or affect mental status and treatment outcomes.
• Axis V: Global assessment of functioning scale. This axis indicates the patient’s overall level of function, including psychologic, social, and occupational well-being. The scale ranges from 0–100 with the higher number correlating with higher functioning (APA, 2000, p. 27; O’Brien, Kennedy, & Ballard, 1999, pp. 64–65).
The Comprehensive Mental Health Assessment tool (CMHA) also assesses for all the above with a more extensive focus on overall functionality and its effect on activities of daily living.
Axis V correlates most closely with the CMHA, but its “global” score does not discriminate between low, moderate, and high functioning levels in particular life areas such as family relations, financial stability, problem solving ability, etc.—significant factors affecting mental and emotional health. Another advantage of the CMHA rating scale (in contrast to
Axis V global score) is its use for charting a client’s progress from admission to discharge in assessed areas of concern (see Appendix in this chapter).
The broad acceptance of the DSM-IV, often referred to as the “bible” of psychiatry, is evident in the paucity of literature discussing its use, benefits and limitations (Cooksey
& Brown, 1998, p. 526). Despite its questionable value based on scientific evidence, it is widely used worldwide. Ethan Watters (2010) cites its role in marketing diseases as well as pharmaceutical profit in Hong Kong, the island of Zanzibar, Sri Lanka, and Japan and in
“homogenizing” the diversity of “madness” as defined across cultures.
Its controversial status is most obvious in the areas of nursing and the social sciences. A limited amount of discussion and objective evaluation can be found in the medical literature and among psychiatric practitioners. Many clinicians simply accept the DSM at face value without critique, or with resignation: “That’s all there is.”
This stance signifies a growing acceptance of “pathologizing” (i.e., diagnosing and there-fore “treating”) more and more aspects of everyday life, its normal challenges, and problems (see Brownlee, 2007). To paraphrase social psychologist Anton Antonovsky (1988) vis-à-vis preventive care: Our assessments should include more often the question “What keeps people healthy?” rather than focusing excessively on what makes them sick. Or, as a medical geron-tologist noted to PCPs in a workshop on mental health: Would you please do a functional assessment, and not send an 80-year-old to his/her grave with a psychiatric diagnosis? That is, what supports (and perhaps which sleep aid) does such a patient need while mourning the loss of a spouse and facing alone the twilight of life?
This is not meant to minimize the fact of the real, deep, and long-lasting psychic pain of depression and/or a brain disease like schizophrenia (formerly attributed to dysfunctional mothering) that require specialized psychiatric treatment. But not every psychosocial prob-lem merits a DSM diagnosis. For example: But for the activism of women psychiatrists and psychologists at the DSM revision proceedings, the criminal act of rape would have been added to the DSM with the diagnosis, “rapism.” In short, designating a DSM diagnosis is a reality in primary care practice today in the U.S., but caution should be used in the context of the age-old legacy of social bias against those carrying the label of a psychiatric diagnosis, when support and counseling for psychosocial problems may suffice.
Cooksey and Brown (1998) note nurses’ criticism of the DSM in its inadequacy in pro-viding information regarding the patient’s individual experience. This is an important concept for a PCP to ponder: in contrast to having a standard of care for a patient with a diagnosis of diabetes, there is no “standard of care” for the patient with both diabetes and bipolar I disorder, for example. The diagnosis of bipolar I may or may not have a significant impact on the same patient’s diabetes, but conversely, the question remains: “What impact does a diagnosis of bipolar I disorder have on your ability to manage your diabetes?” It can be assumed that laboratory work for diabetes will be required. What cannot be assumed is the impact of the mental health diagnosis on the overall health of the individual patient. As a group, however, it is clear that persons with severe mental illness endure more physical health hazards as a result of their cognitive and emotional impairment and related sequelae such as poverty and self-care deficits (Ustan, 1999).
The Global Mental Health Assessment Tool: Primary Care Version (GMHAT/PC)
This computerized assessment tool was developed to detect psychiatric disorders in patients served by general practitioners in the UK who—as in the U.S., Canada, and other countries—
increasingly are seen in primary care settings (Sharma, et al., 2004). It focuses on identifying the most common as well as more serious psychiatric conditions. Several computer screens
offer a series of questions appearing in a tree-branch structure with one or two questions for each disorder.
This tool also allows for rating the severity of symptoms—a clear advantage over the DSM that has no rating scales. It includes risk of self-harm assessment and drug misuse, and automatically produces a referral letter to psychiatric services. Its design draws on the ICD-10 (2004), the international classification system in general medicine that reveals interrelated clinical disorders that affect fundamental body functions as in the vascular, gastrointestinal, and musculoskeletal systems. It thus complements the “essentials perspective” vs. an
“appearance-driven” (i.e., symptoms) approach to diagnosis that McHugh and Clark (2006) propose as an alternative to the DSM. This tool is also complementary to the CMHA tool’s focus on assessing and rating basic life functions such as family and occupational stability which typically are interrelated to mental illness and histories of violence and/or sexual abuse.
At this point, we expect the reader may be thinking “Yes! But how can I now be expected to do a mental health assessment too?” In reality you are always doing a mental health assessment whether it is acknowledged or not. As you interview and examine your patient, you unknowingly are establishing the person’s level of orientation, mood, affect, and ability to comprehend. It is also well known that most patients come to their PCP first with their mental health concerns—whether directly with complaints of change in mood or indirectly with somatic complaints.
Triage Tool: Assessing for Immediate Risk of Harm to Self and/or Others This area of questioning may or may not be comfortable for you. Often providers are reluctant to ask these questions out of the misguided fear that inquiring about risk of suicide or violence will “put the idea into their head.” Or you may be concerned about “opening up a can of worms that I don’t have time or expertise to deal with” (see Sugg & Inui, 1992; and Chapters 3, 4, and 5 of this book).
Discussing thoughts of suicide, risk of harm by a partner, or fantasies of harming someone else do not influence the person to commit the act. Conversely, it opens up dialogue that more likely will prevent an act of harm toward self or others. PCPs are generally given “carte blanche” by patients to ask about their most intimate experiences including sexual practices and bodily functioning; assessing for one’s safety is not any more intrusive or less important to holistic care.
Safety assessment, if not part of a routine visit or complete physical examination, should be incorporated into basic intake protocols in order to address any serious concerns imme-diately. The question can simply be framed from observation, e.g. “Ms. Green, I’m concerned about the bruises on your upper arms, how did they occur?” or, to Mr. Brady, “I sense from your symptoms and what you said on the admission form, that you may be depressed. I want to talk more about that, but first I want to talk about your safety.”
This risk assessment presumes an initial contact information form, administered either by telephone, or on arrival at the primary care setting.
Initial Contact Form
Today’s Date: ____2/5/2008__________ ID#: ________________________
Name: ___Bob Brady__
Age: 47 Relationship Status: Married _ X _ Single_
Other
Address: 23 Any Street, Anytown, USA Telephone: 887-532-4563__
Have you talked with anyone about your problem? No X____ Yes If yes, who? Date of last contact
Significant other (name & phone): Sue Brady—wife –same information Are you taking any medication now? No X____ If yes,
What?
Crisis rating: 1 2 (3) 4 5 Not urgent Very urgent
Probability of engaging for follow-up treatment & counseling (1= high; 5= low) 1 2 (3) 4 5
Summary of Presenting Situation or Problem and Help-seeking Goal:
My wife thinks I need psychiatric help. Maybe I do, I know I haven’t felt like myself in some time.
Date of next contact/appointment: ___________________________
Signature (intake/triage person): ________________________ Date: ____________
BOX 2.1 Essential Triage Questions
The following five triage questions draw on research with abused women using the CMHA tool (Hoff, 1990) and are adapted from research by Hoff & Rosenbaum (1994).
They provide the PCP with a sample tool that illustrates a safety assessment of Mr.
Brady.
1. Have you been troubled or injured by any kind of abuse or violence? (e.g., hit by partner, forced sex)
Yes __X______ No_________ Not sure_________ Refused___________
If yes, check one: By someone in your family_____________ By an acquaintance or stranger _________ Describe: Beaten by father as a kid
Figure 2.1 Initial Contact Form
______________________________________
If a risk of danger is assessed, an immediate referral to the local crisis service is required.
Referral to a hospital emergency department is appropriate only if the department staff includes on-site or on-call mental health specialists. It is important to note that self injurious behavior such as excessive alcohol consumption is not necessarily an indication of suicide risk. Based on Triage assessment, in the case of Mr. Brady, an immediate referral to mental health is not indicated. Mr. Brady is given information about mental health services, and strongly recommended to make an appointment soon with a counselor to consider his and his wife’s concerns beyond what the PCP can provide. Mr. Brady states he is not willing to go see a counselor and would like to “just see you.” We will return to discussing Mr. Brady after further review of the CMHA.
A Comprehensive Mental Health Assessment Tool (CMHA)
The Comprehensive Mental Health Assessment Tool (CMHA) was developed and tested in the 1970s in the Erie County Mental Health System, Buffalo, NH (see Hoff, Hallisey, & Hoff, 2009, pp. 97–104). A major impetus for this tool came from the New York State govern-ment’s need for a record system to track the incidence of mental disorders, as well as the effectiveness of community-based services for a range of people in distress and crisis, or with serious mental illness. The tool’s origin coincided with a nationwide development of the community mental health system following Congressional legislation in 1963 and 1965.
The entire CMHA record system consists of ten forms. Our goal is to provide an easy-to-use tool that PCPs can easy-to-use for initial psychosocial and psychiatric screening as a foundation
2. If yes: Has something like this ever happened before?
Yes ______ No__X___ If yes, when?________. Describe__________________
3. Do you have anyone you can turn to or rely on now to protect you from possible further injury?
Yes__X________ No_________ If yes, who? Wife, Sue
4. Do you feel so badly now that you have thought of hurting yourself/suicide?
Yes__Vaguely________ No__________,
If yes: What have you thought about doing? Not sure_____________________.
If yes: Have you ever hurt yourself in the past?
Yes_______________ No____X___________
5. Are you so angry about what’s happened that you have considered hurting someone else?
Yes___________ No___X______
If yes: have you ever threatened or hurt someone in the past?
and linkage to follow-up mental health specialty services that may be needed. After further review of the CMHA, its purpose, and its relevance to primary care, we illustrate its use with the case example of Mr. Brady.
The CMHA forms provide a structured guide to the intake interview, assessment, and ser-vice planning process with patients. Their intended use is within a health serser-vice system that recognizes the intrinsic relationship between physical, emotional, and sociocultural factors affecting the mental health status of individuals. The underlying philosophy of this record system emphasizes three key assumptions:
1. The person in distress or crisis is a member of a social network.
2. The stability of a person’s social attachments and gratification of basic human needs strongly influences his or her physical, emotional, and mental health, and one’s related ability to function within the community.
3. The provision of crisis prevention, early intervention, and social support services will conserve costly healthcare dollars by restoring and maintaining people in non-institutional settings and preventing readmission to psychiatric facilities whenever possible.
The current CMHA version builds on Hoff’s (1990) research with abused women, in which the tool was used to assess mental heath sequelae of violence and victimization. Its updated edition was developed and pilot-tested by Lee Ann Hoff and psychiatric nursing graduate students at the University of Massachusetts Lowell (Hoff, Hallisey, & Hoff, 2009). Clinicians in this pilot study were from an emergency medical department in Boston and a community-based crisis service in Ontario, Canada.
The CMHA assessment and planning tool emphasizes client-centered, goal-oriented treat-ment. It utilizes a five-point Likert-like scale (1=excellent/very high functioning, 3=fair; 5=
very poor/very low functioning) to ascertain client stress level in 21 areas of biopsychosocial functioning, through active collaboration with the client and significant others. It also allows for systematic evaluation of treatment outcomes and follow-up planning.
The CMHA tool is designed to assist in the achievement of several mental health service objectives:
1. To provide health/mental health providers, clients, and collaborating agencies a stan-dardized framework for gathering data, while including subjective, narrative-style information from the client and significant others that is relevant to mental health across the life cycle.
2. To organize this information in a way that sharply defines their client’s level of func-tioning (emotional, cognitive, and behavioral) and life-threatening risk, and outlines complementary treatment goals and methods to evaluate progress toward desired outcomes in specified functional areas.
3. To assist in fostering continuity between service during acute crisis states and the longer-term mental health treatment needed by some clients. (This objective is especially relevant vis-à-vis the issue of “socially constructed suicidality” that is sometimes used as the only “ticket” to psychiatric in-patient admission when health system economic factors supersede client need in clinical decision making.)
4. To provide supervisory staff with the information necessary to monitor service and assure quality and continuity of client care.
5. To provide administrative staff with information for monitoring and evaluating achieve-ment of crisis intervention, counseling or psychotherapy, and related services for individual clients and cumulative data revealing service outcomes in relation to agency objectives.