Betsy Q. Cliff / The Bulletin

When Dr. Dan Murphy, a family practice physician in Redmond, was treated for depression, he got the standard care: a prescription from his primary care physician without much follow-up.

Like many people, it didn’t work for him. He dropped the medication and tried to deal with the condition on his own.

Murphy said he thinks there’s a better way.

Now, his clinic and a handful of others around Central Oregon are experimenting with something that tries to improve care for some patients with mental health issues.

St. Charles Family Care clinics in Redmond and Prineville and Mosaic Medical clinics throughout the area have begun employing psychologists and other mental health professionals to see patients in conjunction with their primary care.

“At least 40 percent of the people who present for primary care have significant behavioral health issues that need to be addressed,” Murphy said. “In the past, my ability to refer for care was very limited.”

Mind, body connection

Patients are notoriously bad at scheduling follow-up care. When a doctor refers someone to a specialist or to a lab for tests, many will not follow up.

In mental health, it can be even worse. Ryan Dix, a psychologist in a primary care clinic in Prineville said that only about half of patients referred to care will actually get it. “Some of the folks that I see just weren’t getting services because they just weren’t going because of the stigma associated with going to a mental health clinic.”

Having his office directly in the primary care clinic, Dix said, has helped. “Patients check in at the same spot they check in to see the primary care, they wait in the same room, they are called back by the same people. The only people that know who they are coming to see are me and the patient.”

Typically, Dix and others in this setting see patients after their primary care physician refers them. Sometimes, said Kim Swanson, a resident psychologist working in Redmond, she sees patients during the same visit.

The issues treated are numerous, and perhaps wider than many people’s notions of what might be treated by a psychologist.

Mental issues like anxiety and depression frequently occur with chronic illnesses. “Depression is one of the more common psychiatric symptoms associated with diabetes, even for people who have never had depression in their life,” said Swanson.

It occurs, Swanson said, because of metabolic changes in the body that come with diabetes and because of the adjustment to living with the disease. “Life is different from that point forward. You can’t eat cake, you get to exercise even if you didn’t like that. Most people have a hard time really adapting to those lifestyle changes.”

That, in turn, can affect how people deal with the disease, making the physical symptoms worse and starting a vicious cycle. “A depressed person isn’t just depressed,” said Dix. “They also don’t follow through with their diabetes management.”

Swanson said she also sees people who come in for a physical symptom, such as a headache or stomach pain, that is a symptom of a mental illness.

With these patients, Swanson said, she has to help people dispel the myth that the doctor thinks it’s all in their head. “To me, it’s all interconnected, we don’t have physical and mental symptoms that live separately.”

While some patients still feel they are being labeled crazy when the primary care physician invites the psychologist in, Swanson said, there is an advantage of her being right there in the clinic. “They don’t have to go home and stew about it. I can address those things right there.”

‘50 minutes and a fern’

The type of treatment that Swanson and others in this setting offer is not typical of many psychologists.

It’s not “50 minutes and a fern,” said Robin Henderson, director of behavioral health services at St. Charles Health System, referring to the length of a therapy visit and the vegetation often found in psychologists’ offices.

“This isn’t about going in and sorting through your cottage cheese container of emotions,” she said. It’s a much more targeted intervention, aimed at addressing a patient’s specific problem.

For example, Swanson said, if a patient is having issues with anxiety, she’ll teach them a specific breathing technique meant to relax the body and the nervous system.

“My interventions are specifically for functional restoration,” she said. “I want to give them the skills to feel empowered on how to manage their symptoms so they can feel in control of their bodies.”

For people who do need more work, perhaps traditional counseling sessions, Swanson will often make referrals to a different mental health professional.

Murphy said that being able to use Swanson and the interventions she brings to the clinic has changed his prescribing habits with his patients. “When I was in the room and I knew the person was going to have a hard time hooking up with (a mental health clinic) I felt the need to come up with a quick solution, often pharmacological in nature.”

He said he had a hard time following up with people and knew that some of the medications he was prescribing had the potential for addiction. Now, he’ll often refer a patient to Swanson. “I’m much more comfortable saying we have this resource that I think will help you more than a prescription.”

Murphy said that patients, too, typically say they’re happier to be able to deal with the issues on their own.


rends in mental health

Central Oregon is not the first place where psychologists have been used in a primary care setting. The military has used it in clinics for a long time. And large health systems that integrate inpatient and outpatient care have also begun adopting this model.

But, said Henderson, Central Oregon is one of the first places to use it in a community setting, in practices that are not all owned by the same entity.

There’s a lot of interest in the work, said Henderson. She’s talked to health providers in both Washington state and Michigan about how to set up similar arrangements.

Henderson has also worked with health insurers to get the visits paid under a medical benefit. Most, she said, will bill the visit under a physical diagnosis, rather than as a mental health consultation. That circumvents the problem of some plans, which don’t cover, or cover to a lesser degree, mental health interventions.

The psychologists are typically employees of the clinic and patients usually receive one bill for the entire service.

“It’s fairly cutting-edge billing that requires a partnership between provider and payers,” said Henderson.

Overall, patients have been very receptive to the psychologists in clinics, providers said. The patients feel like “I’m finally getting a handle on this stuff,” Murphy said. “I’m a big fan. I think this is a great way to do this.”