Adapting Psychosocial Intervention Research to Urban Primary Care Environments: A Case Example

I would like to add my thanks and convey my respect for the contribution of Zayas et al. Their conclusions provide a useful outline for those of us who desire to improve quality of care in clinical settings. While their study focuses on a specific population, the conclusions probably apply to any provider- patient-family community, particularly where treating mental illness is the target. The stigma that is felt by patients and providers may represent an added barrier to clinician adoption and patient engagement. Elizabeth Lin and colleagues document the difficulty in sustaining change in provider behavior after a successful research trial and educational intervention to improve care for patients suffering from depression in primary care (1, 2).

The comments by Aikens and reply by Zayas address the gulf that exists between the scientific community and the clinic-patient/ family community. Unless funding organizations employ mechanisms that stimulate clinician and consumer curiosity in quality improvement and promote shared ownership of systems change, quality improvement may be hard to sustain.

I had the privilege and challenge of spending one year in a primary care clinic serving only low income, uninsured adults. One half of the patients had one or more mental disorders (3) and the most common problem that patients wanted to discuss with their providers was “problems with mood (4). My job was to integrate a new way of addressing mental disorders. Any lasting successful change in this clinic came because the surrounding community, board of directors, executive director, clinicians, staff and patients were and continue to be involved in defining the problems, owning mistakes, creating solutions, examining more mistakes and bringing in outside consultation to stimulate new solutions. In 2002 we described the phases of integration (5) of mental health care , including pitfalls, missteps and improvements and are currently evaluating changes in quality of care between 1999 and 2004. The lessons from our experience and from the Zayas et al study replicate the lessons I have learned from 20 years of practice as a psychotherapist. When significant change occurs patients and families own the problem, and own the solution.

1. Lin EH, Katon WJ, Simon GE, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care. 1997;35(8):831-842.

2. Lin EH, Simon GE, Katzelnick DJ, Pearson SD. Does physician education on depression management improve treatment in primary care? J Gen Intern Med. Sep 2001;16(9):614-619.

3. Mauksch, Tucker SM, Katon WJ, et al. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract. Jan 2001;50(1):41-47.

4. Mauksch LB, Katon WJ, Russo J, Tucker SM, Walker E, Cameron J. The content of a low-income, uninsured primary care population: including the patient agenda. J Am Board Fam Pract. Jul-Aug 2003;16(4):278-289.

5. Cameron J, Mauksch L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health. 2002;20(4):343-363.

Competing interests:   None declared