Chapter 3: Mental Health Care Model

INTRODUCTION

Let’s summarize where we have been and where this chapter is going. From Chapters 1 and 2, you learned that mental disorders often occur in patients presenting with the physical symptoms of chronic medical disorders and/or chronic medically unexplained symptoms (MUS). This means that, in any patient with severe, disabling physical symptoms, we must also actively inquire about the associated psychological symptoms that can lead us to a diagnosis of a comorbid mental disorder.

In this chapter, before presenting the specific mental disorders and their treatment, we introduce the Mental Health Care Model (MHCM), an overarching model for the treatment of the mental disorders we will consider. The MHCM identifies aspects of treatment that are common across all mental disorders. As we progress to later chapters, we will show how pharmacologic and other treatments of specific mental disorders are integrated into the MHCM. (While the MHCM actually applies to all health care interactions, we label it “mental” because these problems are far more complex and require this overarching framework.)

THE MENTAL HEALTH CARE MODEL

The MHCM has 5 dimensions addressing a wide range of often overlooked needs in treating patients with mental health disorders:

1. Establish communication and an effective clinician-patient relationship

2. Educate the patient

3. Obtain the patient’s commitment to treatment

4. Determine the patient’s goals

5. Negotiate a specific treatment plan

The pharmacologic and other treatments specific to each mental disorder that we present in Chapters 4, 5, 6 are integrated into the last dimension—negotiating a treatment plan. Treating mental disorders, however, is far more complex than simply prescribing medications. Rather, it also requires the other 4 measures we now discuss in detail.

The MHCM has a wide-ranging conceptual background in self-determination theory,^1,2 shared decision making,^3-7 motivational interviewing,^8-10 social cognitive theory,^11,12 and the chronic care model.^7,13,14 The overarching theoretical backdrop is the general systems-based biopsychosocial (BPS) model,^15,16 and the patient-centered approaches required to operationalize it.^17-19 The BPS model contrasts with the current biomedical/biotechnical model and its isolated focus on diseases. It integrates the patient’s psychological and social life to complement the biological or disease aspects of the biomedical model. Instead of describing the patient just in disease terms, the BPS model describes them from disease (biological), psychological, and social perspectives. One elicits this multifactorial database, using PCI rather than the isolated physician-centered interview used when focusing only on diseases.²⁰

The MHCM values patient autonomy^21,22 and emphasizes that while the clinician is the expert on disease and treatment, the patient is the expert on their life experience, needs, limitations, and priorities.^22,23 With the MHCM focus on self-management,⁷ fostering patients’ self-efficacy (confidence) is paramount.^11,12 Finally, the MHCM emphasizes a negotiated (rather ...