Monday, August 21, 2017 12:00 AM

Teaching doctors to spot the warning signs

The World Health Organization counts depression as the leading cause of disability worldwide. “Yet in three years of the typical internal medicine residency there are zero minutes of required mental health training,” said Shawn Hersevoort, a psychiatrist with UCSF Fresno. “And the OB residents get zero minutes to learn how to medically manage the most dangerous time for a women to have psychosis or serious depression” after childbirth.

Dr. Hersevoort is determined to change that. He heads a collaboration between Community Regional, UCSF Fresno and Fresno County Department of Behavioral Health. It started in 2014 to increase access to mental health care in a region that has the fewest psychiatrists per population in California. The Valley has 8 psychiatrists for every 100,000 people compared to 19 per 100,000 statewide and 32 psychiatrists for every 100,000 people in the Bay Area. Medi-Cal patients here wait up to 90 days to see a psychiatrist.
As director of the Integrated Mental Health Program, Dr. Hersevoort trains primary care and OB/Gyn residents how to identify and treat mild-to-moderate depression, anxiety and other mental health issues in patients visiting the downtown Fresno hospital’s primary care and children’s clinics.

Increasing mental health access in area with greatest shortage of psychiatrists

Besides the 24 psychiatry residents who train annually at Community’s hospitals, Dr. Hersevoort’s program uses the IMPACT model to train 16 OB/Gyn residents, 50 pediatric residents and 131 primary care residents how to spot the signs of mental illness, prescribe appropriate medications and refer to adjunct treatments.

“We’ve graduated four years of residents in four specialties through this program, which means there are 197 doctors out in the world trained in primary care psychiatry from UCSF Fresno,” said Dr. Hersevoort.
“If we can identify mental health problems early in a clinic setting, then maybe we can intervene early before it becomes a big crisis,” said Dawan Utecht, director of Fresno County Behavioral Health Department. Besides providing initial funding for the program, county mental health social workers worked in Community Regional clinics to help connect patients to additional services.

Asking about mental health helps improve overall health

On a recent Thursday, Dr. Hersevoort was quizzing Dr. Kyle Heber, an internal medicine resident at UCSF Fresno, about his clinic patient.
“I have an (older) woman who overdosed on ibuprofen…She’s got mild obesity, hypertension,  hyperlipidemia and a (screening) score today of severe depression,” Dr. Heber reported, noting that her depression score had improved quite a bit from a previous exam.
Dr. Hersevoort started writing on his white board, asking if the patient who scored high for anxiety last clinic visit has been out of her house shopping or had friends in to visit – which would be a sign that she is improving. Had Dr. Heber asked about her sleeping habits? This is crucial, Dr. Hersevoort explained, because the stimulants prescribed for depression might be counter-productive if they interfere with sleep, and sleeplessness can worsen depression. He sent Dr. Heber back to ask more questions of his patient to help inform whether the fix would be a medication adjustment or more psycho-social support.

“Nine times out of 10, an hour sitting down talking to a trained psych official and a patient in crisis doesn’t need to go on a 5150 (involuntary) hold,” Dr. Hersevoort said. “And we’re seeing a lot of people with depression and diabetes in the ER. If we can manage those conditions together then they’d need a fraction of the intensive care.”
Dr. Heber said he’s “getting a lot of great techniques to get to the root of problems” with this training. He’s learning to take an extra few minutes to ask the questions that might indicate a psychiatric or psychological approach is needed, even when a patient doesn’t come in complaining about that initially.
Dr. Laura Pierce, a family and community medicine resident at UCSF Fresno, said she’s long had an interest in behavioral health but wanted to use a holistic approach to patients. The Integrated Mental Health Program helps her do that. “Lots of people are functioning but suffering,” she said. “If their PCP (primary care physician) can start them on a little (depression medication) they’re usually more willing to talk with a doctor and seek help for other health issues.”
That’s the main point of the program – to not only catch mental health problems early, but also to remove the mental health issues that interfere with wellness. “I moved from San Francisco especially to do this because it’s so innovative and so crucial,” said Dr. Hersevoort.

Regular screening improves depression, averts crisis ER visits

Because every patient gets screened at every clinic visit, the mental health team is able to track changes and is called in immediately to do triage if a significant change is seen. Dr. Karen Krause, a child psychiatrist with UCSF Fresno, sees all the pediatric patients who have mental health red flags on their screening. Severe cases of suicidal thoughts, schizophrenia or psychosis are referred to county mental health or Community’s Behavioral Health Center for more intense intervention.
“It’s like cancer screening,” Dr. Hersevoort said of the every visit screening model, “You can’t recommend pap smears and mammograms just 80% of the time and expect to catch all the cancers.”
In the first 18 months of the program, depression scores on patient screening questionnaires decreased by 62% and family medicine residents demonstrated a 66% improvement on exam scores in behavioral health knowledge. And by improving patients’ mental health, their compliance with chronic disease treatments and their overall health has improved, saving healthcare costs on emergency care and hospitalizations. Patients screened in the Integrated Mental Health Program also had 98% fewer emergency department visits.
Erin Kennedy reported this story. Reach her at