Chapter 87
Primary Care Approachesto
Behavioral Health
Elizabeth Hutson, PhD, APRN-CNP, PMHNP-BC
Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP
The relationship between the mind and body is complex and not fully
understood. As health-care providers, we often separate body systems
without recognizing their ability to interact with and affect one another. This
is especially true when mental health conditions exist along with physical
health conditions, as they often do. Common mental health disorders, such as
anxiety and depression, are frequently encountered in chronic conditions,
such as diabetes, chronic obstructive pulmonary disease (COPD), and
cardiovascular disease (Herbst et al, 2007; Matte et al, 2016; Semenkovich et
al, 2015). Examining the prevalence of depression reveals that 3.91% of
individuals with no chronic physical health conditions also have depression;
5.88% of those with one chronic physical health condition have it; and
21.14% of patients with multiple chronic health conditions also experience
depression (Read et al, 2017). Depression and cardiovascular disease, on their
own, are two of the leading causes of death and disability worldwide
(Collaborators, 2018). When these two conditions are comorbid, patients can
be left with even worse health outcomes, loss of function, and exponentially
increasing health-care costs (Stein et al, 2006; Unützer et al, 2009).
An increasing prevalence of mental health concerns is being managed in
primary care (Olfson et al, 2014). A study by Smith et al (2014) noted that
25% of patients in outpatient clinics met criteria for a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, Text Edition (DSM-5-
TR) diagnosis, making psychiatric diagnoses more common than
hypertension and diabetes mellitus combined. These authors argue for
, improved management of mental health symptomatology and make the case
for modification of educational curricula for health-care trainees with
increased attention to mental health diagnoses and treatment (Smith et al,
2014).
STRESS
Besieged by psychosocial stressors in these times, patients seek relief for
troubled relationships, stressful life events, recent losses, and economic
strain. Therefore, primary care teams are tasked with beginning the treatment
of many mental health disorders, such as depression and anxiety. Health-care
providers, especially advanced practice registered nurses (APRNs), can no
longer provide their treatment in silos, where mental health is separate from
physical health. Although most providers agree that a thorough assessment of
these contextual influences is important, the pressures of time-sensitive
patient encounters create barriers to comprehensive and person-centered care.
The Effects of COVID-19
It is unsurprising that patients present for primary care visits reporting
psychological concerns. These concerns were compounded when the global
epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the
coronavirus disease 2019 (COVID-19), began. The threat of COVID-19,
especially for health-care providers who are on the front lines of the
pandemic, has the potential to cause many stress-related reactions, including
anxiety, irritability, insomnia, and changes in concentration (Vinkers et al,
2020). Additionally, stress-related reactions can also occur from quarantine,
including loneliness, anxiety, fear of being infected, and stigma (Brooks et al,
2020).
Given the significant impact of psychosocial factors on the prognosis of
disease, building psychotherapeutic skills is critical for primary-care
providers. APRNs, in all specialties, can be taught cognitive behavioral skills
building (CBSB) and motivational interviewing (MI) techniques that can be
used even in brief focused assessments. Techniques such as reflective
listening, validating emotions, and encouraging patient empowerment are
easily used during short office visits. This chapter highlights the various
modalities through which providers can assess and address acute stress and
maladaptive responses that predict poorer prognosis of disease states; several
Primary Care Approachesto
Behavioral Health
Elizabeth Hutson, PhD, APRN-CNP, PMHNP-BC
Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP
The relationship between the mind and body is complex and not fully
understood. As health-care providers, we often separate body systems
without recognizing their ability to interact with and affect one another. This
is especially true when mental health conditions exist along with physical
health conditions, as they often do. Common mental health disorders, such as
anxiety and depression, are frequently encountered in chronic conditions,
such as diabetes, chronic obstructive pulmonary disease (COPD), and
cardiovascular disease (Herbst et al, 2007; Matte et al, 2016; Semenkovich et
al, 2015). Examining the prevalence of depression reveals that 3.91% of
individuals with no chronic physical health conditions also have depression;
5.88% of those with one chronic physical health condition have it; and
21.14% of patients with multiple chronic health conditions also experience
depression (Read et al, 2017). Depression and cardiovascular disease, on their
own, are two of the leading causes of death and disability worldwide
(Collaborators, 2018). When these two conditions are comorbid, patients can
be left with even worse health outcomes, loss of function, and exponentially
increasing health-care costs (Stein et al, 2006; Unützer et al, 2009).
An increasing prevalence of mental health concerns is being managed in
primary care (Olfson et al, 2014). A study by Smith et al (2014) noted that
25% of patients in outpatient clinics met criteria for a Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, Text Edition (DSM-5-
TR) diagnosis, making psychiatric diagnoses more common than
hypertension and diabetes mellitus combined. These authors argue for
, improved management of mental health symptomatology and make the case
for modification of educational curricula for health-care trainees with
increased attention to mental health diagnoses and treatment (Smith et al,
2014).
STRESS
Besieged by psychosocial stressors in these times, patients seek relief for
troubled relationships, stressful life events, recent losses, and economic
strain. Therefore, primary care teams are tasked with beginning the treatment
of many mental health disorders, such as depression and anxiety. Health-care
providers, especially advanced practice registered nurses (APRNs), can no
longer provide their treatment in silos, where mental health is separate from
physical health. Although most providers agree that a thorough assessment of
these contextual influences is important, the pressures of time-sensitive
patient encounters create barriers to comprehensive and person-centered care.
The Effects of COVID-19
It is unsurprising that patients present for primary care visits reporting
psychological concerns. These concerns were compounded when the global
epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the
coronavirus disease 2019 (COVID-19), began. The threat of COVID-19,
especially for health-care providers who are on the front lines of the
pandemic, has the potential to cause many stress-related reactions, including
anxiety, irritability, insomnia, and changes in concentration (Vinkers et al,
2020). Additionally, stress-related reactions can also occur from quarantine,
including loneliness, anxiety, fear of being infected, and stigma (Brooks et al,
2020).
Given the significant impact of psychosocial factors on the prognosis of
disease, building psychotherapeutic skills is critical for primary-care
providers. APRNs, in all specialties, can be taught cognitive behavioral skills
building (CBSB) and motivational interviewing (MI) techniques that can be
used even in brief focused assessments. Techniques such as reflective
listening, validating emotions, and encouraging patient empowerment are
easily used during short office visits. This chapter highlights the various
modalities through which providers can assess and address acute stress and
maladaptive responses that predict poorer prognosis of disease states; several
