INTRODUCTION

There is an inextricable connection between physical and mental disorders. Consequently, the need for every medical provider to have some fundamental skills in behavioral health. The mind undoubtedly affects the body, but the body also affects what happens to the mind, also known as the mental well-being of the individual. Worldwide, the prevalence of major depression and anxiety disorders is quite common, and mental disorders account for nearly 25% of all health-related disability.¹ Depression is present in 5.6% of individuals, while anxiety occurs in 4% of the worldwide population.¹

Instead of seeing a mental health specialist for mental disorders, many patients prefer to receive treatment from providers with whom they already have an established health care relationship.³ Hence, fewer than one in four adults with a diagnosable mental disorder receive care from a mental health professional in any given year and instead prefer to receive treatment in the primary care setting.³ Depression and anxiety are each present in 10% of primary care patients in the US² and are the first and fifth most common causes of years lived with disability among all diseases.⁴ Not only will pharmacists have contact with most of these patients, they are also at a pivotal place to establish a consistent and safe relationship with their patients and are faced with a substantial need to understand the complexities related to behavioral health.

BEHAVIORAL HEALTH VERSUS MENTAL HEALTH

The terms behavioral health and mental health have been used interchangeably; however, there are important differences between the two. While there is no universally accepted definition of mental health, a general definition is related to the health and functioning of the mind. It relates to a person’s psychological and emotional well-being. This would encompass how that individual adjusts to society and the ordinary stressors of everyday life. It is the subjective feeling of contentment and life satisfaction despite the problems, challenges, and upheavals of life. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”⁵

Mental health is influenced by both genetics and environment and encompasses emotional, psychological, and social well-being. Emotional well-being includes happiness, interest, and satisfaction in life. Psychological well-being includes liking most parts of one’s own personality, successfully managing daily responsibilities, and having successful relationships with others. Social well-being encompasses contributing to society, feeling part of a community, believing that society is becoming a better place for all people, and processing that the way society works makes sense to them.⁶

Behavioral health describes the connection between behaviors and the health and well-being of the mind, body, and spirit. Behavioral health looks at how behaviors impact someone’s health—both physical and mental. It is broader than mental health alone and thus some behavioral issues and topics do not fall into the mental health category. For instance, a behavioral health professional may look at how an individual’s behavior has contributed to obesity. This is an issue that primarily affects someone’s physical health. For those who experience mental illness or addiction who have felt that these diseases were a permanent part of their lives, behavioral health can give them hope that changing certain behaviors may help to promote improved health and wellness. Behavioral health includes not only ways of promoting well-being by preventing or intervening in mental illness, such as anxiety and depression, but also aims to prevent or intervene in substance abuse or other addictions.

The link between behavioral health and mental health varies depending on the unique case and patient characteristics. For example, patients who suffer from chronic conditions such as diabetes or cardiac disease often experience depression as well.² However, those who suffer from depression may exhibit no outward physical signs of an illness, making the treatment mental health based instead of behavioral.

In order to take a comprehensive approach to treating mental health and promoting wellness, one must integrate rather than partition the management of physical and psychological symptoms. A professional must have the skills and knowledge not only to care for the body, but also to give proportional attention to illnesses particularly associated with the mind. Medical and behavioral symptoms are two peas coexisting in a pod. Treating one category while ignoring the other is detrimental to the outcomes of both.⁷ This article will help the pharmacist address physical as well as psychological symptoms and begin to piece together the intricate connections between the mind and body.

THE THREE AXIOMS FOR MENTAL HEALTH CARE

There are three axioms for mental health care that can help clinicians identify the group of patients in whom they will most likely find mental disorders.

• Axiom 1: Mental and medical disorders often coexist, and the success in addressing one requires successively addressing both disorders.^8,9
• Axiom 2: Many mental health disorders present with chronic and disabling physical symptoms. There are no specific physical symptoms associated with mental disorders, and they may involve any body system. However, there is one unique feature: .¹⁰
• Axiom 3: There are two common types of chronic physical symptom presentations of a mental disorder: medical disease and medically unexplained symptoms (MUS). Many medical disorders pair with a chronic medical disease, in part because of its adverse psychological impact. For example, the dyspnea of chronic obstructive pulmonary disease (COPD) may lead to depression since the patient may not be able to enjoy the activities of daily living and various hobbies (eg, playing sports, doing housework, attending church). In this situation, the symptoms and disability of the chronic medical disease may be considered a “red flag” for the associated mental disorder. Many mental disorders also present with chronic MUS, defined as physical symptoms that have little or no identifiable disease or pathophysiologic basis.^11,12 Chronic unexplained physical symptoms such as fatigue or pain are often associated with anxiety or depression. In this instance, the physical symptoms are a red flag indicating an associated mental disorder.

Comorbidity of Mental and Medical Disorders

It has been well demonstrated that treating comorbid mental health problem improves the medical problem beyond the impact of medical treatment alone.^13,14 Rarely do the mental disorder and the associated disease act independently. Rather, they almost always interact. In demonstrating this phenomenon, consider that chronic diseases can lead to a mental disorder (Table 1).¹⁵ For example, depression is common among people with psoriasis, who often deal with discomfort and the social stigma related to their condition. Research has found that psoriasis patients diagnosed with depression were 37% more likely to also develop psoriatic arthritis than those without depression.¹⁶ In turn, a mental disorder can lead to (or worsen) a chronic disease. For example, it has been documented that treating comorbid depression in patients with diabetes improves control beyond just treating the diabetes.¹⁷ Typically, as they become less depressed, patients are better able to manage their medications and adhere to a diet.It is not surprising that when treating depression, patients are more apt at managing the day-to-day activities required to monitor and treat their condition.

Pharmacists are quite aware that while medications are used to treat both physical and mental diseases, there are numerous other factors that come into play when looking at the overall effect a medication can have on an individual. Consider that disease treatment can lead to a mental disorder (Table 2).¹⁵ For example, β-blockers may lead to depression or thyroid medications can cause anxiety. In turn, mental disorder treatment can lead to a physical disease (Table 3). Many antipsychotic agents can lead to obesity, sexual dysfunction, or hyperlipidemia.¹⁵

Medically Unexplained Symptoms

There are often identifiable reasons to have a mental or physical symptom; however, treating mental disorders becomes more complex when incorporating the very common problem of chronic MUS presentations. While the patient still has psychological symptoms of a mental disorder, their physical symptoms do not reflect a medical disorder. Rather, the physical symptoms are not explained following a careful laboratory or physical exam and medical history. The mental health disorder symptoms are often less prominent than the unexplainable and chronic physical symptoms, making the diagnosis even more difficult. While there is debate as to why MUS occurs, ²⁰ There is no debate that chronic MUS is an indicator for an associated mental disorder. Research demonstrates that the greater the number and severity of unexplained chronic symptoms, the more likely there is an associated mental disorder.¹⁰

In order to provide comprehensive mental health care, it is necessary to focus on patients with chronic physical symptoms, whether due to MUS and/or a comorbid medical disease. Consider chronic, severe, and disabling physical symptoms of either type as red flags for an associated mental disorder. It is crucial to never underestimate the mind body connection when providing a comprehensive approach to promote the mental health and wellness of your patient.

MENTAL HEALTH CARE MODEL

The Mental Health Care Model (MHCM) is an overarching model for the treatment of mental disorders.²¹ The MHCM identifies aspects of treatment that are common across all mental disorders. As we discuss the MHCM you will find it is useful in all types of health care interactions but is especially useful in mental health due to the complexity of problems and the need for a basic framework. The MHCM consists of five dimensions²¹:

• Establish communication and an effective clinician-patient relationship (patient-centered interview process);
• Educate the patient;
• Obtain the patient’s commitment to treatment;
• Determine the patient’s goals; and
• Negotiate a specific treatment plan.

The MHCM does not focus solely on the patient’s diseases, but instead it attempts to integrate the patient’s psychological and social life into the biological and disease aspects.²¹ Instead of describing the patient in just disease terms, this model describes the patient from the biological (disease), psychological, and social perspectives. Once again, this reiterates the theme of how the mind and the body do not act alone but congruently. Critical to this model is the patient-centered interview (PCI), as opposed to the clinician-centered interview that has been traditionally used when focusing only on diseases. The MCHM focuses on patient autonomy.²² Good clinicians know that while they may be experts on the disease, patients are the experts in their own lives. While the model fosters self-management, it is critical to strengthen the patient’s self-efficacy or confidence in managing their symptoms. There is a central focus on the partnership with the patient in which there is a negotiated, rather than prescribed approach, to determine the goals and desired outcomes of therapy.²¹ These five principles will now be discussed in more detail, including how they can be incorporated into clinical practice.

Establish an Effective Patient-Centered Relationship

Having appropriate patient-centered skills may be the most fundamental requirement of all mental health interactions. Patient-centered skills focus on empathy as the key ingredient to all interactions. Literature searches reveal that PCI is associated with improved health outcomes as well as increased patient satisfaction and medication adherence.²³ There are five steps to the PCI (outlined in Figure 1), which are presented in detail in Smith’s Patient-Centered Interviewing—An Evidence-Based Method.²⁴

The value of being empathetic in PCIs is an acquired skill that takes practice. Some pharmacists were never taught how to appropriately show empathy and for that reason they might feel helpless or confused when a patient begins to express emotion. There are four empathic skills, sometimes descriptively called emotion-handling skills,²⁵ that can help clinicians respond to a patients’ emotions. Remember the mnemonic NURS²⁴:

• Name the emotion
• Understand the emotion
• Respect the emotion
• Support the emotion

A general script for pharmacists detailing NURS skills might sound like the following:

• “You were pretty fearful (naming).
• I can understand that (understanding) after all you have been through (respecting).
• Thank you for sharing that with me (respecting).
• This helps me to better meet your needs (supporting).”

Case Study

What might at an interaction between a pharmacist and a patient who is being counseled on starting a new medication for depression look like? In this scenario, the community pharmacist presents the patient with the new prescription and is ready to begin the counseling session. After initial greeting and introductions, the pharmacist asks the patient what she knows about the medication. The patient states, “I know it is being used to treat my depression. I am not sure I want to take the medication. My father had depression and tried many different medications. They had terrible side effects and they never seemed to help him.”

The pharmacist (using appropriate emotion-handling skills) says the following: “You are feeling apprehensive about taking this medication (naming). I can understand that (understanding) after seeing what your father experienced (respecting). Since I know more about your experience with this type of medication, this will help me be better able to answer your questions and discuss your concerns (supporting).”

These emotion-handling skills are used in Step 4 (Patient-Centered HPI) and illustrates what is meant by naming and responding to emotions. This is done throughout the course of the interview whenever emotions arise and not just applicable to Step 4. The more empathy you provide to your patients the more they will feel you are listening to their concerns and it will validate and honor the patient-centered relationship. While the PCI occurred at the start of the interview, we continue using open-ended and empathic skills (ie, NURS) periodically throughout the process. It is time to implement the remainder of the MHCM, which is described below.

Educate the Patient

Properly educating the patient involves implementing three steps, known as the ASK-TELL-ASK method.²¹ First, determine the patient’s present understanding of the problem (ASK). This requires a deeper dive into their understanding of the problem and what they think should be done. Some patients will be quite knowledgeable, while others will require more input from the clinician. Specifically, it is important to understand the patient’s view of the disease, treatment options, and the prognosis with or without treatment. Next, upon learning what they already know and think should happen, clarify any misunderstanding and inform them of the recommendation (TELL). At this point, the clinician should provide the information needed to correct any gaps in knowledge or any misunderstandings the patient may have. Provide the recommendation, making the most important point first, using short, clear statements and avoiding medical jargon. There may be times the patient does not agree with your recommendation and in that case, it is necessary to apply NURS skills to the emotion while remaining respectful and clear. If you sense anxiety or discontent on the patient’s part, use this as an opportunity to ask more open-ended questions to determine what the patient is thinking and feeling about what you have discussed up to this point. The final step is to determine the patient’s understanding of your input (ASK). At this point, if there are still misunderstandings, they can be clarified. Figure 2 summarizes a typical ASK-TELL-ASK interaction.²¹

Obtain Commitment to the Treatment

For treatment to be effective, the patient must take responsibility and become a partner in the plan.²⁶ This commitment agreement is a two-way street. The clinician agrees they will do their part in the treatment course and the patient needs to verbalize they will remain dedicated to their responsibilities. It is important that patients hear themselves verbalize that they are committed to the treatment.²¹ The pharmacist may later experience problems with nonadherence to medications or other aspects of the treatment, and this commitment must be reestablished.

What happens if there is a roadblock to this commitment? Clinicians should first evaluate themselves to be sure they are not adversely affecting their relationship with the patient.²¹ This might look like impatience on the clinician’s part, appearing disinterested, or being too stringent or lenient. Then, assuming the patient’s resistance is not due to the clinician’s role, the clinician needs to indicate to the patient that they cannot continue to fulfill their part of the agreement if the patient does not comply with their end of the agreement.²¹ This might look like a patient who is not coming for follow-up visits as agreed upon but continues to want refills for prescriptions or a patient who will not follow dietary or other lifestyle changes that were agreed upon. At this time, the clinician could implement a written contract with agreed upon behaviors and the appropriate reasons for discharge from care. Hopefully, discharging the patient from care will not be required, but there are occasional times when it may be necessary.

Determine Treatment Goals

Setting goals is important to effectively establish good mental health and to focus on change.²⁶ Goals should be generated by the patient, but the clinician facilitates the process of goal setting.²¹ Often patients feel overwhelmed by the magnitude of the illness, and this emotional overload can obscure other positive aspect of their lives. The clinician should encourage recognition of what makes the patient’s life worthwhile and enjoyable. The patient should be encouraged to share what is important to them and what they have had to sacrifice due to the illness. This helps to give the patient a clear view of what life could be if the illness were to be alleviated. Some common goals may include alleviated symptoms, improved relationships, returning to work, resuming their independence, or returning to previously enjoyed hobbies. These are the long-term goals, which will be conceptualized by the short-term goals of the treatment plan.²¹

Negotiate a Plan

The more things the clinician can get patients to do that are healthy, the greater success they will have with symptom management or abatement.²¹ Therefore, the treatment plan should not only include medication and specific medical interventions but other activities of daily living as well. Nonpharmacological treatments should be considered such as medication contracts, routine drug screening, or alternative forms of medicine (eg, reflexology, biofeedback, acupuncture, massage, hypnosis, meditation, yoga). Physical activity is a good idea for most mental health patients, including those who are quite disabled and deconditioned.²¹ Baseline physical activity needs to be established and then a regular activity schedule can be negotiated based on the patient’s willingness and physical limitations, if necessary. A check-in at each follow-up visit should be done to increase the activity, if possible. In the case of the deconditioned or debilitated patient, even slight recommendations are appropriate such as climbing the stairs once daily, walking to the mailbox, or standing instead of sitting all the time. The key with this type of smaller steps is to ask the patient to set goals for the next visit such as walking up the stairs twice daily or walking around the block after getting the mail. Baby steps should never be underestimated, and patients should be included in designing their own exercise routines. Other important things to consider as part of the plan include increased social activity, improved sleep hygiene, and dietary, tobacco, or alcohol counseling if necessary.²¹

A follow-up visit should always be scheduled, rather than on an as-needed basis.²⁶ Frequent visits or other contacts are necessary in cementing a strong, caring relationship as well as for adjusting medications and other negotiated treatments. It is helpful to provide a printout of what you have found and are recommending. Sometimes in providing such complex information or information loaded with emotion, it is helpful to audio-record the interaction or provide printed information so the patient can review it later or share it with significant others. These activities are necessary because patients forget up to 40% of routine information provided and even more of emotion- and stress-laden information.²⁷

Based on the MCMH model, the pharmacist should now have a good understanding of the overall treatment approach for mental disorders. These skills include providing patient education, getting their commitment to proceed with the treatment, setting goals, and negotiating a treatment plan—using patient-centered and NURS skills throughout the process. The following section will provide some tips and tools for conducting the patient interview.

TOOLBOX FOR PATIENT INTERVIEWS

All interviews should begin with the PCI. Following this patient-centered introduction, the pharmacist should then transition to develop the details of the chief concern. Even in patients with a mental disorder, this step will often involve physical and psychological symptoms, and you need to pin down these details as you normally would in any other type of medical interview. Physical symptoms may have already been uncovered in the PCI; however, there are times when you may not have discovered many psychological symptoms in the patient-centered component. In this case, you will need to actively inquire about them during the clinician-centered inquiry.²⁸ How might these psychological symptoms be elicited? Suggested questions to screen for a mental disorder during the clinician-centered interviewing process are displayed in Table 4.^28-34 Remember that the clinician-centered interviewing portion is your chance to summarize, check for accuracy, and obtain more information, if needed.

Key Interview Topics

During the clinician-centered HPI, it is important to obtain the chronology of both physical and mental symptoms. Many psychological disorders begin in childhood or adolescence; therefore, a detailed history of both positive and negative symptoms is important.²⁸The patient should provide a detailed course since then including all pertinent symptoms and other diagnoses if relevant. In all patients, there are certain key issues that need to be covered during the interview (Table 5).²⁸

Social history is important in all patients but more so in those suffering from mental disorders.²⁸ There are certain key areas to focus on that will help in providing a clear and concise history of the mental illness. Clinicians should address interpersonal relationships including the number and availability of those relations. Many patients will have a history of dysfunctional relationships,²⁸ which will greatly impact their illness or their ability to progress in treatment. This is important to uncover since many of these issues will likely need to be addressed and perhaps treated in therapy or counseling. The clinician should ask about the living circumstances of the individual. Are they homeless? It is also necessary to address any history of physical, sexual, or emotional abuse. Developmental history can provide some key information and thus examining what childhood was like can be of great value. Educational level and sibling social, and parental interactions may need to be addressed and relevant in certain patients. Other issues that may be adding stress to the patient include socioeconomic status and questions addressing their financial situation, employment, and insurance arrangements. This valuable background information will help the clinician obtain a holistic view of the patient’s circumstances.

A prescription drug monitoring program (PDMP) is an electronic database that tracks controlled substance prescriptions in a state. PDMPs can provide timely information about prescribing and patient behaviors and are a key area where pharmacists can provide valued information that may affect the treatment plan. PDMPs may be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk. PDMPs are not just concerned with legality. A number of states have expanded access to PDMPs so that not only do law enforcement, pharmacists, and physicians have access to the data but also to recovery programs and addiction treatment specialists. Along with reduced fraudulent and abusive behavior is the improvement of identification and treatment options for those spiraling into the addiction epidemic, perhaps the real noteworthy achievement of these programs. Having access to PDMP data may make it easier for clinicians to determine objectively if those patients who showed signs of addiction during in-person interviews or examinations were actually at risk of dangerous behaviors. In such cases, the PDMP can become a life-saving tool in which clinicians and patients can have the transparent conversations needed to kick-start recovery. As the pharmacist, consider integrating the results of what you find in the PDMP database and allowing it to be a guide along with the other key findings in the patient-clinician interaction to help determine a treatment plan for the patient.

CONCLUSION

Perhaps the most important reason for understanding the complexities related to behavioral health is that comorbid mental disorders make the management of chronic physical illnesses more difficult. Not only are the symptoms, functional status, and quality of life of patients with chronic illnesses much worse, their participation in their own health care is also impaired and they are not effective agents in their own care. Restoring this agency is a core responsibility of all health care practitioners. The pharmacist who is able to maintain a trusting and open patient-clinician relationship will have significant impact on a patient’s quality of life by being skilled at linking the significant interrelated relationship between the mind and body.

References

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