A MENTAL HEALTH FORWARD MODEL OF PRIMARY CARE

Ken Lakritz, Ph.D.

2022

THE MENTAL HEALTH FORWARD MODEL

Primary care health delivery models have traditionally been organized

around the assumption that both mental and physical illnesses should be

managed within a medical model structure of diagnosis and treatment.

Developments within the field of psychoneuroimmuninology (PNI), and the

deepening understanding of the links between psychological stress and

disease, have shed light on the profound interrelationships between

foundations of mental and physical health. Accordingly, a mental health

forward (MHF) framework of primary care operates differently and can

function as a complement to a traditional medical model. It’s frame of

reference is more integrative regarding an appreciation of the root causes

of disease, and does not confine causal factors of illness to physiological

correlates alone. A MHF model actively addresses the links between

psychosocial factors and chronic disease development. It does not,

however, subordinate or preclude allopathic approaches, nor does it

minimize the importance and efficacy of traditional medical treatments.

Instead, it embraces both traditional and integrative approaches within a

person-centered framework that elevates the role of mental health in

overall wellness.

The MHF model holds within its values and perspectives the whole

individual from the standpoint of culture, ethnicity, environmental factors,

socioeconomics, early childhood psychological development, family

dynamics, community support systems, nutrition, vocation, spiritual

practice, and other epigenetic variables that impact physical disease

development. I’d like to reference Gabor Mate’, MD’s psychobiological,

PNI perspective (Scattered Minds, In the Realm of Hungry Ghosts, and

when The Body Says No) within which he makes deep and salient connections between early psychological and neurobiological development in the onset of chronic disease processes. Dr. Mate’ does the very important service of bringing medicine back into context with the

biopsychosocial environment in which the body and brain evolve and

exist. By viewing health and diseases from this frame, we can more clearly

understand the genesis of ADHD, addiction, chronic autoimmune

disorders, neurological, gut issues, cancer, etc. as physiological correlates

of whole system stresses.

PREVENTION FRAMEWORKS

Whole person health is a multi-disciplinary pursuit, and one that

requires a framework from primary prevention to tertiary management of

health challenges. Often, it is at the tertiary disease level that these

challenges come to the attention of health care providers. At these points

within the progression of illness, issues that may have their roots in

psychological stress, anxiety, depression, nutrition or other epigenetic

factors have now advanced into chronic medical conditions requiring

chronic management or life saving measures. Dean Ornish, MD, uses the

brilliant example of water flowing from a faucet. He contends, “ do you

continue to spend your time mopping up the water on the floor or do you

focus on turning off the faucet”? Prevention of illness progression is

thought to operate within three phases:

1)The primary prevention approach focuses on preventing disease

before it develops;

2) Secondary prevention attempts to detect a disease early and

intervene early;

3) Tertiary prevention is directed at managing established disease in

someone and avoiding further complications.

A MHF model of care holds the perspective of the proper roles of all

practitioners within the person centered approach of assessment and

treatment. The majority of healthcare, whether for physical or mental

health purposes, usually begins when symptoms and suffering are severe

enough to bring individuals into the clinic for diagnosis and intervention.

Regardless of the root causes of presenting conditions, the first measure is

generally to address surface symptomatology, stabilize, manage, reduce

suffering, and prevent future exacerbations. Only then, can practitioners

begin to address deeper causes, psychological patterns, and lifestyle

issues that contribute to the genesis of mental and physical conditions that

have now progressed to more existential levels of severity. It is the rare

individual who comes for assistance at the primary prevention level, and,

from an health insurance standpoint, there has, historically, been great

reticence on the part of third party payers to reimburse for treatment of

potential health conditions that have yet to present.

A STEPPED CARE APPROACH

Because of the way that western medicine (and insurance companies)

views healthcare, we tend to approach the three levels of prevention in

reverse. Therefore, given this inclination, we tend to approach a

progression from disease to wellness from within the following structure:

Given these circumstance, a MHF system of approaches would

operate similarly. In primary care medicine, the role of the mental health

(MH) clinician would likely be of secondary or ancillary support until medical

stability is achieved. At these times, the role of the MH clinician is generally

to assist with symptom management and reduction. In the optimization

phase, more attention can be payed to understanding root causes and

developing new strategies for addressing health challenges and

psychological coping. The wellness phase is not only characterized by

continued healing of root cause issues, but also by augmentation of healthy

lifestyle conditions and support for psychological and spiritual growth.

Integrative medicine and mental health support play increasingly significant

roles beyond stabilization within the optimization and wellness phases.

PRIMARY CARE IN MENTAL HEALTH

Within the psychological clinical practice setting, mental health

challenges often present with multiple co-morbitities. Chronic health

issues such as addiction, cardiovascular disorders, dementia, autoimmune

disorders, psychiatric disorders, weight management, pain, neurological

disorders, etc. are ubiquitous in mental health practice. Presenting Mental

health issues are multifactorial relative to causes and interactions with co-

morbid conditions. That is, they might be both a secondary reaction to

another heath condition or they may contribute to the onset of a medical

condition due to prolonged and severe psychological stress. Given the

integral role that mental health plays in the treatment and management of

physical conditions, a well coordinated network of integrated practice

among health professionals is indicated for optimal client care. Mental

health practitioners operating with this perspective understand that

comprehensive, whole person care may require a village of practitioners to

address the multifaceted needs of their clients.

As our knowledge about the interrelationships between mental and

physical health continues to deepen, future healthcare delivery models will

require greater integration with complementary approaches to adequately

address patient care. A holistic, person-centered approach, that designs

individualized treatment based upon roots cause evaluation, will provide

the the most forward thinking integration of mental health models within

overall primary care coordination and management. Rather than a one-

size-fits-all approach, stepped-care, as a central pillar of treatment

planning, addresses the changing needs of individuals as they progress

from stabilization to an ultimate goal of wellness. It is this orientation that

demands a rethinking of the organization and delivery of existing

healthcare models.

References

Robert Ader, psychoneuroimmunology, 1981

Gabor Mate, In the realm of Hungry Ghosts, 2010, Scattered Minds,

2000, When the Body Says No, 2011, the Myth of Normal, 2022.

Psychoneuroimmunology and health psychology: An integrative model.

Susan K. Lutgendorf * and Erin S. Costanzo, 2003

The Efficacy and Cost-Effectiveness of Stepped Care Prevention and

Treatment for Depressive and/or Anxiety Disorders: A Systematic Review

and Meta-Analysis, PUBMED, Published online 2016 Jul 5