Mental Health Care during 

Periodic Health Exams

How Do They Occur and How Long 

Do They Last 

VA HERC 2014 1 
Research Team

• Ming Tai-Seale, PhD 

– Palo Alto Medical 

Foundation Research 

Institute (PAMFRI)

• Thomas McGuire, PhD 

– Harvard Medical School

• Caroline Wilson, MSc

– PAMFRI

• Cheryl Stults, PhD

– PAMFRI

• Richard Frankel, PhD

– Indiana University

• Laura Hatfield, PhD

– Harvard Medical School

• Lisa Diamond, MD

– Memorial Sloan Kettering 

Cancer Center 

• Ashley Stone, MPH

– PAMFRI

• Lisa Maclean, MD

– Wayne State University 

School of Medicine

• Jennifer Elston Lafata, PhD

– Virginia Common Wealth 

University 

VA HERC 2014 2 
Acknowledgement 

NIMH R01 MH081098

NCI R01 CA112379

VA HERC 2014 3 
Introduction 

• The majority of patients with mental health 

(MH) concerns turn to their primary care 

physicians (PCPs) for guidance and help.

– Unutzer et al 2006

– Wang, et al 2006

• Annual physicals are intended to provide 

comprehensive preventive care, diagnostic, 

and treatment services. 

VA HERC 2014 4 
Research Questions

Might annual physicals offer patients an 

opportunity to receive mental health services?

• How often? For how much time?

• How did physician communication styles and 

patient activation relate to length of MH 

discussion? 

• How did the level of mental health needs affect 

the length of MH discussions? 

• If MH discussion occurred, what did it look like ? 

VA HERC 2014 5 
Preventive Health Discussion 

- PHD Study

• Patients were drawn from a sample of 500 patients 

who participated in a study on physician-patient 

communication

• An integrated delivery system in Detroit

• February 2007 to June 2009 

• Inclusion criteria: 

– 50 to 80 years of age

– enrolled in a health plan

– scheduled a routine annual preventative checkup with a 

participating PCP, and 

– due for a CRC screening at the time of the checkup (Shires 

et al 2012)

VA HERC 2014 6 
Data (PHD Study, Continued)

• A brief telephone survey at the time of 

recruitment into the study 

– PHQ2 screening, 

– socio-demographic characteristics. 

• The physical was observed and audiorecorded by a research assistant. 

VA HERC 2014 7 
Data for Mental Health Discussion 

(MHD) Study

• Subsample of 261 patients

• Patient inclusion criteria: 

– scored ≥2 on the PHQ2 

– filled or were prescribed a psychotropic medication in the 

12 months before the observed visit, or

– had a mental health Dx the EMR, or 

– visited a BH center in the 12 mos before the visit 

• EMR 12 mos before and 12 mos after the observed visit

• Characteristics of participating PCPs 

VA HERC 2014 8 
Methods

• Mixed Methods

– Qualitative

• Coding of audio recording and transcripts

– Nature of discussion: Topics

– Quantitative

• Coding of the time spent on each topic, defined as the 

amount of time between the start and end of all instances of 

the topic.(Tai-Seale, McGuire, and Zhang 2007)

• Descriptive 

• Zero-Inflated Negative Binomial Model

– Triangulation 

VA HERC 2014 9 
VA HERC 2014 10

Tai-Seale, McGuire, and Zhang, HSR, 2007
MHD Study Patients

 All patients W/o MH With MH

Sample 261 62.8% 37.2%

Mean pt age (SD) 59.5 (8.2) 60.0* 58.6

Pt Male 37.2% 74.2%** 25.8%

Pt non-white 34.9% 73.6%* 26.4%

Pt not high sch/GED or higher 4.6% 91.7%** 8.3%

An anxiety attack in past 4 wks 8.8% 39.1% 60.9%***

Mean PHQ2 (SD) 1.1 (1.5) 0.9 1.5***

Mean Charlson score (SD) 0.8 (1.4) 0.8 0.9

Mean MD verbal dominance (SD) 3.2 (2.2) 3.5*** 2.7

* p<0.10, ** p<0.05, ***p<0.01 VA HERC 2014 11
MHD Study Patients – con’t

 All patients W/o MH With MH

Pt activation 10.3% 51.9% 48.2%

Pt Ongoing MH Episode of Care 36.8% 55.2% 44.8%*

Mean N of evidence-based 

services Delivered (SD) 2.9 (1.5) 2.8 3.2*

Mean N of pt visits on the day (SD) 14.6 (4.7) 13.9 15.7***

VA HERC 2014 12

* p<0.10, ** p<0.05, ***p<0.01
Topic Domains N (%) Time Spent on Topic

Mean Median S.D. Min Max

Biomedical 2,995 (62%) 67.1 43 80.4 5 856

Health behavior 525 (11%) 56.0 30 67.5 5 543

Mental health 102 (2%) 146.3 63 211.7 2 1401

Psychosocial 561 (12%) 44.6 28 51.9 5 464

Pt-MD rltnship 67 (1%) 50.3 26 52.6 6 293

Visit flow mgmt 448 (9%) 52.9 23 99.2 5 814

Other 104 (2%) 54.5 32 62.4 5 480

Total 4,802

Topics Distribution & Time on Topic

VA HERC 2014 13
Research Questions

• For how much time?

• Relationships with

– physician communication styles 

– patient activation 

– level of mental health needs ? 

• If MH discussion occurred, what did it look 

like ? 

VA HERC 2014 14
Empirical Model

Zero-inflated negative binomial model

where ... =

- MD verbal dominance in other visits

- Patient activation (brought a list)

- MH needs (PHQ2 score, anxiety attack)

- Episode of MH care (ongoing vs. not)

- N of evidence-based services delivered in visit

- N of patient scheduled on the day of the visit

- Covariates (age, gender, edu, race, Charlson) 

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VA HERC 2014 16

Prob

(No MHD) 

Count 

(Time on 

MHD) 

MD Verbal Dominance 0.151 ** -0.084

Pt activation -0.695 -0.078

PHQ2 -0.284 *** 0.215 ***

Had an anxiety attack in last 4 weeks -0.805 1.014 **

N 242

* p<0.10, ** p<0.05, ***p<0.01

Results from Zero-Inflated Negative 

Binominal Model: Main covariates
VA HERC 2014 17

Prob

(No MHD) 

Count 

(Time on 

MHD) 

Pt Ongoing Episode of Care for MH -0.549 * 0.534 ***

N of evidence-based services 

delivered

-0.143 -0.030

N of pt visits on the day -0.090 *** -0.069 **

Charlson score -0.171 -0.025

Pt Age 0.036 * -0.034 **

Pt Male 0.837 *** -0.754 ***

Pt non-white 1.060 *** -0.793 ***

Pt not HS grad or higher 2.087 * -1.130 ***

N 242

* p<0.10, ** p<0.05, ***p<0.01

Results: Remaining Covariates
STATISTICS ARE PEOPLE WITH THEIR 

TEARS WIPED AWAY

What’s behind the numbers?

VA HERC 2014 18
Research Questions

• For how much time?

• Relationships with

– physician communication styles 

– patient activation 

– level of mental health needs ? 

• If MH discussion occurred, what did it look 

like ? 

VA HERC 2014 19
UC Davis 20
Emergent Qualitative Insight

• Mental health concerns may be the true 

reason for some patients to schedule an 

annual “physical”

– 1st topic

– Asking for antidepressants at the get go

– Crying at the beginning of the visit

– “And I knew as soon as I saw you I would start to 

cry.”

VA HERC 2014 21
Verbal Dominance - High 

• With MHD

– PHQ2=4 

– In a litany - “...and the ADHD” 

– Dictates in front of patient

• Without MHD

– PHQ2=3 

“I think we covered everything. Is there 

anything you wanted to talk about? 

I did a lot of talking.”

VA HERC 2014 22
Verbal Dominance - Median 

• With MHD

– PHQ2=6,

– Pt cries because her son is dead 

– MD shows repeated empathy, and investigates her current 

mental health. Already had an anxiety diagnosis, and 

encouraged her to seek more counseling. 

• Without MHD: 

– PHQ2=3 

– pt very assertive/active

– MD asks pt has any concerns, middle of visit

VA HERC 2014 23
Verbal Dominance - Low

• No MHD:

– PHQ2=3 

– MD missed many opportunities to explore 

– Pt repeatedly: “going through a hard time” 

• With MHD:

– PHQ2=6 

– explored empathic opportunities 

– asked several PHQ9 questions

– Diagnosed depression and prescribed Effexor

VA HERC 2014 24
Short Shrifts

• The shortest mental health discussions: 0.6 

minutes

– Patient’s PHQ2=6

– was under the care of behavioral health 

specialists. 

– PCP: “Are you still seeing Dr. xyz (name of the 

psychiatrist)?” 

– No formal assessment of MH. 

VA HERC 2014 25
VA HERC 2014 26

tears

Topic length: Mental health – 7:17 

Biomedical - 20:48 
Misplaced Priorities

When we're spending time doing things that 

don't potentially benefit people and skipping 

things that may be of benefit, that's a sign not 

only of waste but of misplaced priorities. 

Russell Harris, MD 

University of North Carolina

UC Davis 27
Discussion

• Annual Physical - A Time Honored Tradition

• Some patients’ potentially urgent mental 

health needs are unmet

• Verbal dominance negatively associated with 

mental health care in PHE

• Disparities due to age, gender, education, and 

race 

VA HERC 2014 28
Let’s (Not) Get 

Physicals

By ELISABETH ROSENTHAL

Published: June 2, 2012 

272 Comments

Got Mental?

VA HERC 2014 29
Jennifer Elston

Lafata, PhD

VCU Medical Center

UC Davis 30

Research 

Team

Richard Frankel, PhD

Regenstrief Institute

Lisa MacLean, MD

Wayne State School 

of Medicine

Lisa Diamond, MD

Memorial SloanKettering Cancer Center

Thomas McGuire, PhD

Harvard Medical School

(L to R)

Caroline Wilson, MSc

Ashley Stone, MPH

Ming Tai-Seale, PhD, MPH

Cheryl Stults, PhD

Laura Hatfield, PhD

Harvard Medical School
Thank You! 

Work-in-Progress

Question & Comments Are Appreciated

Tai-sealem@pamfri.org

VA HERC 2014 31
VA HERC 2014 32

Kroenke et al. 2003, Medical Care
High PHQ2 Short MHD

VisitID Visit 

Length 

Time 

MH 

Start

Part of 

Litany

PHQ2 MH 

topic 

length 

Physical 

exam 

length 

78006 36 14:36 Yes 4 6 s 407 s

97211 30 8:33 No 6 34 s 619 s

25767 31 3:07 No 6 74 s 511 s

40336 28 9:22 Yes 3 19 s 739 s

59755 15 11:28 No 4 24 s 186 s

77854 24 1:57 No 4 120 s 438 s

36367 35 11:45 No 3 88 s 756 s

63267 26 0:18 No 4 58 s 330 s

VA HERC 2014 33
Views from A Psychiatrist

• She would love all her primary care colleagues to inquire more 

deeply about the mental well-being of their patients with more 

than just, “are you still seeing your psychiatrist?” 

• Because: 

– The majority of those who commit suicide saw a PCP within 6 months 

of their death.

– When she gets phone calls from PCPs who do screen more extensively, 

they are better able to collaborate on the care of the patients they co- manage, 

• including instruction about medication titration and 

• support from the PCP for the patient to be more engaged with their mental 

health treatment. 

• She wasn’t necessarily surprised by the finding on co-location

– “Our building has Behavioral Health, people know where to go.”

• Do they go?

VA HERC 2014 34
“It’s not like you’re going through 

depression”

Patient 8: = but I wake up . . . maybe three hours into it and then I’m up for two 

 hours and I go back to sleep. And a lot of it is when things are on your

 mind = 

Doctor D: Yep. Yep. Mm-hmm ....

Patient 8: = it, yeah. And it’s, it’s depressing . . . . 

Doctor D: Because at this time, it’s not like you’re going through depression.

Patient 8: Yeah.

Doctor D: Okay? Medical depression is where it interferes with your day to day stuff, you’re

withdrawn, you don’t socialize, you’re snappy and stuff like that. You don’t have all

that. It’s mainly because of the stress and just adjustment ... And uh, maybe, I can give

you a few sleeping pills to take for the time being that would help.

Patient 8: [cries] . . . she doesn’t start her first treatment until Monday. And I think if I notice a big

difference, down difference with her, then I don’t know, it won’t be so easy to

handle . . . So maybe I’ll call

• Post-visit EMR data showed that patient received prescriptions for an antidepressant, a few 

months later. 

VA HERC 2014 35