Skip to main content

Advertisement

SpringerLink
Log in

Rethinking the Mental Health Treatment Skills of Primary Care Staff: A Framework for Training and Research

  • Original Paper
  • Published:
Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

Abstract

Health care reforms may offer several opportunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are organized on three levels: cross-cutting skills to build therapeutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This framework is intended to help inform future mental health training in primary care and catalyze research that examines the impact of such training.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of the therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 21(1), 1–33.

    Article  Google Scholar 

  • Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M., Murray, P., et al. (2005). Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. JAMA: The Journal of the American Medical Association, 293(3), 311–319.

    Article  CAS  Google Scholar 

  • Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230.

    Article  Google Scholar 

  • Bernstein, J., Chollet, D., Peikes, D., & Peterson, G. (2010). Medical homes: Will they improve primary care? (Mathematica issue brief no. 6). Washington, DC: Mathematica Policy Research. Retrieved December 1, 2010, from http://www.mathematica-mpr.com/publications/PDFs/Health/reformhealthcare_IB6.pdf.

  • Bickman, L. (2005). A common factors approach to improving mental health services. Mental Health Services Research, 7(1), 1–4.

    Article  PubMed  Google Scholar 

  • Bohart, A. C. (2000). Paradigm clash: Empirically supported treatments versus empirically supported psychotherapy practice. Psychotherapy Research, 10, 488–493.

    Article  PubMed  CAS  Google Scholar 

  • Bower, P., Gilbody, S., Richards, D., Fletcher, J., & Sutton, A. (2006). Collaborative care for depression in primary care. Making sense of a complex intervention: Systematic review and meta-regression. British Journal of Psychiatry, 189, 484–493.

    Article  PubMed  Google Scholar 

  • Brown, J. D., Riley, A. W., & Wissow, L. S. (2007a). Identification of youth psychosocial problems during pediatric primary care visits. Administration and Policy In Mental Health, 34(3), 269–281.

    Article  PubMed  Google Scholar 

  • Brown, J. D., Wissow, L. S., Gadomski, A., Zachary, C., Bartlett, E., & Horn, I. (2006). Parent and teacher mental health ratings of children using primary-care services: Interrater agreement and implications for mental health screening. Ambulatory Pediatrics: The Official Journal of the Ambulatory Pediatric Association, 6(6), 347–351.

    Article  Google Scholar 

  • Brown, J. D., Wissow, L. S., Longway, S., Caffery, E., Pefaure, C., & Cook, B. L. (2011). Mental health skills training for paraprofessional medical assistants in pediatric primary care. Paper presentation for the National Institute of Mental Health Research Conference on Mental Health Services Research, Washington, DC, July 2011.

  • Brown, J. D., Wissow, L. S., & Riley, A. W. (2007b). Physician and patient characteristics associated with discussion of psychosocial health during pediatric primary care visits. Clinical Pediatrics, 46(9), 812–820.

    Article  PubMed  Google Scholar 

  • Brown, J. D., Wissow, L. S., Zachary, C., & Cook, B. L. (2007c). Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes. Medical Care, 45(11), 1076–1082.

    Article  PubMed  Google Scholar 

  • Bussing, R., Zima, B. T., Mason, D., Hou, W., Garvan, C. W., & Forness, S. (2005). Use and persistence of pharmacotherapy for elementary school students with attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 15(1), 78–87.

    Article  PubMed  Google Scholar 

  • Butler, M., Kane, R. L., McAlpine, D., Kathol, R., Fu, S., Hagedorn, H., et al. (2008). Integration of mental health/substance abuse and primary care (AHRQ publication no. 09-E003). Rockville, MD: Agency for Healthcare Research and Quality.

  • Cape, J., Barker, C., Buszewicz, M., & Pistrang, N. (2000). General practitioner psychological management of common emotional problems (II): A research agenda for the development of evidence-based practice. British Journal of General Practice, 50(454), 396–400.

    PubMed  CAS  Google Scholar 

  • Cormier, S., & Nurius, P. S. (2003). Interviewing and change strategies for helpers: Fundamental skills and cognitive-behavioral interventions (5th ed.). Pacific Grove, CA: Brooks/Cole.

    Google Scholar 

  • Croghan, T., & Brown, J. D. (2010). Integrating mental health in the patient-centered medical home. Washington, DC: Mathematica Policy Research. Retrieved December 1, 2010, from http://pcmh.ahrq.gov/portal/server.pt/gateway/PTARGS_0_11787_913654_0_0_18/Mental%20Health%20in%20the%20PCMH-July1.pdf.

  • Cunningham, P. J. (2009). Beyond parity: Primary care physicians’ perspectives on access to mental health care. Health Affairs (Project Hope), 28(3), w490–w501.

    Article  Google Scholar 

  • Daleiden, E. L., Chorpita, B. F., Donkervoet, C., Arensdorf, A. M., & Brogan, M. (2006). Getting better at getting them better: Health outcomes and evidence-based practice within a system of care. Journal of the American Academy of Child and Adolescent Psychiatry, 45(6), 749–756.

    Article  PubMed  Google Scholar 

  • Dietrich, A. J., Oxman, T. E., Williams, J. W., Jr., Kroenke, K., Schulberg, H. C., Bruce, M., et al. (2004). Going to scale: Re-engineering systems for primary care treatment of depression. Annals of Family Medicine, 2(4), 301–304.

    Article  PubMed  Google Scholar 

  • Donohue, J., Garfield, R., & Lave, J. (2010). The impact of expanded health insurance coverage on individuals with mental illnesses and substance use disorders [White paper]. Office off the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.

  • Ellis, A. R., Konrad, T. R., Thomas, K. C., & Morrissey, J. P. (2009). County-level estimates of mental health professional supply in the United States. Psychiatric Services (Washington, D.C.), 60(10), 1315–1322.

    Article  Google Scholar 

  • Foley, D. L., Rutter, M., Angold, A., Pickles, A., Maes, H. M., Silberg, J. L., et al. (2005). Making sense of informant disagreement for overanxious disorder. Journal of Anxiety Disorders, 19(2), 193–210.

    Article  PubMed  Google Scholar 

  • Foy, J. M., & American Academy of Pediatrics Task Force on Mental Health. (2010). Enhancing pediatric mental health care: Algorithms for primary care. Pediatrics, 125(Suppl 3), S109–S125.

    Article  PubMed  Google Scholar 

  • Foy, J. M., & Earls, M. F. (2005). A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics, 115(1), e97–e104.

    PubMed  Google Scholar 

  • Fremont, P., Gerard, A., Sechter, D., Vanelle, J. M., & Vidal, M. (2008). The therapeutic alliance in the initial stages of the management of depression by the general practitioner [L’alliance thérapeutique au dÉbut d’une prise en charge pour dépression par le généraliste]. L’Encéphale, 34(2), 205–210.

    Article  PubMed  CAS  Google Scholar 

  • Gask, L., Bower, P., Lovell, K., Escott, D., Archer, J., Gilbody, S., et al. (2010). What work has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the normalization process model. Implementation Science, 5, 15.

    Article  PubMed  Google Scholar 

  • Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care: A systematic review. JAMA: The Journal of the American Medical Association, 289(23), 3145–3151.

    Article  Google Scholar 

  • Greenfield, S., Kaplan, S., & Ware, J. E., Jr. (1985). Expanding patient involvement in care: Effects on patient outcomes. Annals of Internal Medicine, 102(4), 520–528.

    PubMed  CAS  Google Scholar 

  • Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372–378.

    Article  Google Scholar 

  • Harrington, J., Noble, L. M., & Newman, S. P. (2004). Improving patients’ communication with doctors: A systematic review of intervention studies. Patient Education and Counseling, 52(1), 7–16.

    Article  PubMed  Google Scholar 

  • Hawaii Evidence Based Services Committee. (2004). Summary of effective interventions for youth with behavioral and emotional needs. 2004 Biennial report. Retrieved December 1, 2010, from http://hawaii.gov/health/mental-health/camhd/library/pdf/ebs/ebs011.pdf.

  • Heywood, S., Stancombe, J., Street, E., Mittler, H., Dunn, C., & Kroll, L. (2003). A brief consultation and advisory approach for use in child and adolescent mental health services: A pilot study. Clinical Child Psychology and Psychiatry, 8(4), 503–512.

    Article  Google Scholar 

  • Hoagwood, K., Burns, B. J., Kiser, L., Ringeisen, H., & Schoenwald, S. K. (2001). Evidence-based practice in child and adolescent mental health services. Psychiatric Services (Washington, D.C.), 52(9), 1179–1189.

    Article  CAS  Google Scholar 

  • Hodges, B., Inch, C., & Silver, I. (2001). Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950–2000: A review. The American Journal of Psychiatry, 158(10), 1579–1586.

    Article  PubMed  CAS  Google Scholar 

  • Jensen, P. S., Rubio-Stipec, M., Canino, G., Bird, H. R., Dulcan, M. K., Schwab-Stone, M. E., et al. (1999). Parent and child contributions to diagnosis of mental disorder: Are both informants always necessary? Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), 1569–1579.

    Article  PubMed  CAS  Google Scholar 

  • Jensen, P. S., Weersing, R., Hoagwood, K. E., & Goldman, E. (2005). What is the evidence for evidence-based treatments? A hard look at our soft underbelly. Mental Health Services Research, 7(1), 53–74.

    Article  PubMed  Google Scholar 

  • Katon, W., Von Korff, M., Lin, E., & Simon, G. (2001). Rethinking practitioner roles in chronic illness: The specialist, primary care physician, and the practice nurse. General Hospital Psychiatry, 23(3), 138–144.

    Article  PubMed  CAS  Google Scholar 

  • Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., et al. (1995). Collaborative management to achieve treatment guidelines. impact on depression in primary care. Journal of the American Medical Association, 273(13), 1026–1031.

    Article  PubMed  CAS  Google Scholar 

  • Kerwick, S., Jones, R., Mann, A., & Goldberg, D. (1997). Mental health care training priorities in general practice. The British Journal of General Practice, 47(417), 225–227.

    PubMed  CAS  Google Scholar 

  • Kisely, S., Duerden, D., Shaddick, S., & Jayabarathan, A. (2006). Collaboration between primary care and psychiatric services: Does it help family physicians? Canadian Family Physician Médecin De Famille Canadien, 52, 876–877.

    PubMed  Google Scholar 

  • Klinkman, M. S., Coyne, J. C., Gallo, S., & Schwenk, T. L. (1998). False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Archives of Family Medicine, 7(5), 451–461.

    Article  PubMed  CAS  Google Scholar 

  • Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., et al. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64(3), 532–539.

    Article  PubMed  CAS  Google Scholar 

  • Lambert, M. J., & Barley, D. E. (2002). Research summary on the therapeutic relationship and psychotherapy outcome. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness of patients (pp. 17–32). Oxford: Oxford University Press.

    Google Scholar 

  • Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lamber (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 139–193). New York: Wiley.

  • Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health Affairs, 29(7), 1310–1318.

    Article  PubMed  Google Scholar 

  • Levinson, W., & Roter, D. (1993). The effects of two continuing medical education programs on communication skills of practicing primary care physicians. Journal of General Internal Medicine, 8(6), 318–324.

    Article  PubMed  CAS  Google Scholar 

  • Lopez-Stewart, C., Lara, M. G., Amighetti, L. D., Wissow, L. S., Gutierrez, M. I., Levav, I., et al. (2000). Parenting and physical punishment: Primary care interventions in Latin America. Pan American Journal of Public Health, 8(4), 257–267.

    Article  PubMed  CAS  Google Scholar 

  • Marcinowicz, L., Konstantynowicz, J., & Godleski, C. (2010). Patients’ perceptions of GP non-verbal communication: A qualitative study. British Journal of General Practice, 60, 83–87.

    Article  PubMed  Google Scholar 

  • Marvel, M. K., Epstein, R. M., Flowers, K., & Beckman, H. B. (1999). Soliciting the patient’s agenda: Have we improved? JAMA: The Journal of the American Medical Association, 281(3), 283–287.

    Article  CAS  Google Scholar 

  • Mast, M. S. (2007). On the importance of nonverbal communication in the physician-patient interaction. Patient Education and Counseling, 67, 315–318.

    Article  PubMed  Google Scholar 

  • Mauch, D., Kautz, C., & Smith, S. (2008). Reimbursement of mental health services in primary care settings (HHS publication no. SMA-08-4324). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

  • McGary, J., McNicholas, F., Buckley, F., Kelly, B. D., Atkin, L., & Ross, N. (2008). The clinical effectiveness of a brief consultation and advisory approach compared to treatment as usual in child and adolescent mental health services. Clinical Child Psychology & Psychiatry, 13, 365.

    Article  Google Scholar 

  • Moses, E. B., & Barlow, D. H. (2006). A new unified treatment approach for emotional disorders based on emotion science. Current Directions in Psychological Science, 15(3), 146–150.

    Article  Google Scholar 

  • Olson, A. L., Kelleher, K. J., Kemper, K. J., Zuckerman, B. S., Hammond, C. S., & Dietrich, A. J. (2001). Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambulatory Pediatrics, 1(2), 91–98.

    Article  PubMed  CAS  Google Scholar 

  • Platt, F. W., & Keller, V. F. (1994). Empathic communication: A teachable and learnable skill. Journal of General Internal Medicine, 9(4), 222–226.

    Article  PubMed  CAS  Google Scholar 

  • Pulido, R., Monari, M., & Rossi, N. (2008). Institutional therapeutic alliance and its relationship with outcomes in a psychiatric day hospital program. Archives of Psychiatric Nursing, 22(5), 277–287.

    Article  PubMed  Google Scholar 

  • Pyne, J. M., Rost, K. M., Farahati, F., Tripathi, S. P., Smith, J., Williams, D. K., et al. (2005). One size fits some: The impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention. Psychological Medicine, 35(6), 839–854.

    Article  PubMed  Google Scholar 

  • Riddle, M. & DosReis, S. (2011). A guide to psychopharmacology for pediatricians. http://web.jhu.edu/pedmentalhealth/Psychopharmacolog%20use.html.

  • Robinson, J. W., & Roter, D. L. (1999). Psychosocial problem disclosure by primary care patients. Social Science and Medicine, 48(10), 1353–1362.

    Article  PubMed  CAS  Google Scholar 

  • Roter, D. L., Frankel, R. M., Hall, J. A., & Sluyter, D. (2006). The expression of emotion through nonverbal behavior in medical visits: Mechanisms and outcomes. Journal of General Internal Medicine, 21, S28–S34.

    Article  PubMed  Google Scholar 

  • Roter, D. L., Hall, J. A., Kern, D. E., Barker, L. R., Cole, K. A., & Roca, R. P. (1995). Improving physicians’ interviewing skills and reducing patients’ emotional distress: A randomized clinical trial. Archives of Internal Medicine, 155(17), 1877–1884.

    Article  PubMed  CAS  Google Scholar 

  • Simon, G. E., Katon, W. J., VonKorff, M., Unutzer, J., Lin, E. H., Walker, E. A., et al. (2001). Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. The American Journal of Psychiatry, 158(10), 1638–1644.

    Article  PubMed  CAS  Google Scholar 

  • Stein, R. E., Horwitz, S. M., Storfer-Isser, A., Heneghan, A., Olson, L., & Hoagwood, K. E. (2008). Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambulatory Pediatrics: The Official Journal of the Ambulatory Pediatric Association, 8(1), 11–17.

    Article  Google Scholar 

  • Thuppal, M., Carlson, G. A., Sprafkin, J., & Gadow, K. D. (2002). Correspondence between adolescent report, parent report, and teacher report of manic symptoms. Journal of Child and Adolescent Psychopharmacology, 12(1), 27–35.

    Article  PubMed  Google Scholar 

  • Van Os, T. W., Van den Brink, R. H., Tiemens, B. G., Jenner, J. A., Van der Meer, K., & Ormel, J. (2005). Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. Journal of Affective Disorders, 84(1), 43–51.

    Article  PubMed  Google Scholar 

  • Waitzkin, H., Getrich, C., Heying, S., Rodriguez, L., Parmar, A., Willging, C., et al. (2011). Promotoras as mental health practitioners in primary care: A multi-method study of an intervention to address contextual sources of depression. Journal of Community Health, 36(2), 316–331.

    Google Scholar 

  • Walitzer, K. S., Dermen, K. H., & Connors, G. J. (1999). Strategies for preparing clients for treatment: A review. Behavior Modification, 23(1), 129–151.

    Article  PubMed  CAS  Google Scholar 

  • Ware, N. C., Tugenberg, T., Dickey, B., & McHorney, C. A. (1999). An ethnographic study of the meaning of continuity of care in mental health services. Psychiatric Services (Washington, D.C.), 50(3), 395–400.

    CAS  Google Scholar 

  • Wasserman, R. C., Inui, T. S., Barriatua, R. D., Carter, W. B., & Lippincott, P. (1984). Pediatric clinicians’ support for parents makes a difference: An outcome-based analysis of clinician-parent interaction. Pediatrics, 74(6), 1047–1053.

    PubMed  CAS  Google Scholar 

  • Weiss, M., Gaston, L., Propst, A., Wisebord, S., & Zicherman, V. (1997). The role of the alliance in the pharmacologic treatment of depression. The Journal of Clinical Psychiatry, 58(5), 196–204.

    Article  PubMed  CAS  Google Scholar 

  • Weissman, M. M., Pilowsky, D. J., Wickramaratne, P. J., Talati, A., Wisniewski, S. R., Fava, M., et al. (2006). Remissions in maternal depression and child psychopathology: A STAR*D-child report. JAMA: The Journal of the American Medical Association, 295(12), 1389–1398.

    Article  CAS  Google Scholar 

  • Wells, K. B., Sherbourne, C. D., Miranda, J., Tang, L., Benjamin, B., & Duan, N. (2007). The cumulative effects of quality improvement for depression on outcome disparities over 9 years: Results from a randomized, controlled group-level trial. Medical Care, 45(11), 1052–1059.

    Article  PubMed  Google Scholar 

  • Williams, J. W., Jr., Bhogte, M., & Flinn, J. F. (1998). Meeting the needs of primary care physicians: A guide to content for programs on depression. International Journal of Psychiatry in Medicine, 28(1), 123–136.

    Article  PubMed  Google Scholar 

  • Wissow, L., Anthony, B., Brown, J., DosReis, S., Gadomski, A., Ginsburg, G., et al. (2008a). A common factors approach to improving the mental health capacity of pediatric primary care. Administration and Policy in Mental Health and Mental Health Services Research, 35(4), 305–318.

    Article  PubMed  Google Scholar 

  • Wissow, L. S., Gadomski, A., Roter, D., Larson, S., Brown, J., Zachary, C., et al. (2008b). Improving child and parent mental health in primary care: A cluster-randomized trial of communication skills training. Pediatrics, 121(2), 266–275.

    Article  PubMed  Google Scholar 

  • Wissow, L. S., Gadomski, A., Roter, D., Larson, S., Lewis, B., & Brown, J. D. (2011). Aspects of mental health communication skills training that predict child and parent outcomes in pediatric primary care. Patient Education and Counseling, 82, 226–232.

    Article  PubMed  Google Scholar 

  • World Health Organization. (2008). Mental health gap action programme: Scaling up care for mental, neurological, and substance use disorders. Geneva: World Health Organization Press.

    Google Scholar 

  • World Health Organization. (2010). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization Press.

    Google Scholar 

  • Wulsin, L. R., Sollner, W., & Pincus, H. A. (2006). Models of integrated care. The Medical Clinics of North America, 90(4), 647–677.

    Article  PubMed  Google Scholar 

  • Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Who are the comorbid adolescents? Agreement between psychiatric diagnosis, youth, parent, and teacher report. Journal of Abnormal Child Psychology, 31(3), 231–245.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

This work was supported by National Institute of Mental Health grant P20 MH086048.

Author information

Authors and Affiliations

  1. Mathematica Policy Research, Inc., 600 Maryland Ave., SW, Suite 550, Washington, DC, 20024, USA

    Jonathan D. Brown

  2. Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA

    Lawrence S. Wissow

Authors
  1. Jonathan D. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lawrence S. Wissow
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jonathan D. Brown.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brown, J.D., Wissow, L.S. Rethinking the Mental Health Treatment Skills of Primary Care Staff: A Framework for Training and Research. Adm Policy Ment Health 39, 489–502 (2012). https://doi.org/10.1007/s10488-011-0373-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10488-011-0373-9

Keywords

Search

Navigation