**Transcript of Cyberseminar**

**HERC Health Economics Seminar**

**Mental Health Care during Periodic Health Exams: How Do They Occur and How Long Do They Last?**

**Presenter: Ming Tai-Seale, PhD, MPH**

**March 19, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**herc@va.gov**.*

Moderator: Good afternoon, or good morning everybody, depending on where you may be in country. I am very pleased today to present... to introduce actually, Dr. Ming Tai-Seale who is a senior investigator at the Palo Alto Medical Foundation Research Institute. Her research focuses on the economics of chronic conditions, including mental disorders in primary care. She has contributed to the understanding of time allocation decision making in biomedical and mental health care in primary care practices. Her research has been funded by a number of agencies, including the National Institutes of Health, AHRQ, the VA, PCORI; and private foundations such as the Gordon and Betty Moore Foundation. 

She is a member of the AHRQ MCC Research Network, the Commonwealth Fund, PCMH Evaluator Collaborative and the steering committee of the aging research network of the HMO Research Network. She has won the article of the year award from Academy Health, is an editorial board member of Health Services Research, and a past chair of the Health Economics Interest Group of Academy Health. She has been serving as a grant proposal reviewer for a number of federal agencies including NIH and ARQ, and is a member of the standing review committee for PCORIs communication and dissemination study section. 

In addition to contributing original research articles to peer review journals, her research has been discussed in hearings of the U.S. Senate, and in the popular press such as the New York Times, the Washington Post, O Magazine, Good Housekeeping, and the Ladies’ Home Journal. We are very pleased to have Dr. Ming Tai-Seale present to us today regarding her research on mental health discussions during health exams; and with that, I will turn it over to her. 

Dr. Ming Tai-Seale: Thank you very much. First, I want to thank Dr. Jean Yoon for inviting me to do this presentation. I have wanted to participate in the HERC webinar for a while, so it is great to get started. So, thank you very much. 

This is a work in progress, so your comments and questions are appreciated, so hopefully we will save time towards the latter part of the webinar for Q and A. Without further ado, I will just start the webinar. 

Again, I am going to talk about mental health care during periodic health exams. How often, how do they occur, how often do they occur, and how long do they last. I would like to acknowledge my research team; it is a multi disciplinary, multi-institutional collaboration with funding from NIMH and NCI. 

In terms of introduction, you probably all know that the majority of patients with mental health concerns turn to their primary care physicians for guidance and help. The focus of this study is on annual physicals, or periodic health exams, which are intended to provide patients with comprehensive preventive care diagnostic and treatment services. We thought, might annual physicals, or the periodic health exams, offer patients with mental health needs an opportunity to receive mental health services. If they do, how often do they receive such services, and for how much time within the context of the face-to-face visit in the office.

We also ask a few more questions. One is how did physicians communication styles and patient activation level relate to the length of the mental health discussion during the office visit, or during the PHE, the periodic health exam. We also asked, how did the level of mental health meet the patient’s level of mental health needs affect the length of... the computer just changed on me... 

Moderator: Yeah, we got the same thing here, so I am just going to pull this back up... it will take just a second for it to load back up here. There we go. 

Dr. Ming Tai-Seale: Okay, thank you. Yeah, so we also ask if the level of needs affect the length of the mental health discussions. The last question is if mental health discussion occurred, what did it look like. 

Moderator: Ming, we did just get a request in if you could speak up a little bit. Some people are having trouble hearing. 

Dr. Ming Tai-Seale: Oh sure, of course. I will try to project more. So, this study is a part of a larger study... it’s kind of a spin-off study, that was led by Dr. Jennifer Elston Lafata, she’s at the Virginia Commonwealth University. That study was funded by NCI and was called the preventive health discussion studies, and patients were drawn from a sample of five hundred patients who participated in that study. They were patients of an integrated delivery system in Detroit. 

The data collection took place between February 2007 to June of 2009 and included patients from fifty to eighty years of age. They enrolled in the health plan and they scheduled a routine annual preventive check up with a participating primary care physician, and they would do a colorectal cancer screening at the time of the check up. 

A brief telephone survey at the time of recruitment into the study included a PHQ2 screening, which is the two-item personal health questionnaire. It is basically a depression screener and also included in the surveys were questions on the socio-demographic characteristics. The physical, or the PHE, was observed and audio recorded by a research assistant. 

The data for this study, the NIH funded study, or the mental health discussion study, is a subset of the NCI study. We had two hundred-sixty-one patients. Criteria included that they have to score two or higher on the PHQ2, filled or were prescribed psychotropic medication in the twelve months before the observed visit, or had a mental health diagnosis in the EMR, or had visited a behavior health center in the twelve months before the PHE.

We also pulled data from the EHR on the patient covering twelve months before the visit and twelve months after the observed visit. We also obtained the characteristics of participating primary care physicians off the web site of the health plan. 

We used a mixed method approach, including qualitative coding of the audio recordings and transcripts, particularly focusing on the nature of discussions or topics that took place during the visit. Then we also quantitatively coded the time spent on each topic that defined as the amount of time between the start and end of all instances of conversation over a topic. With a descriptive analyses, and then we also used a zero inflated negative binomial model to look at the length of time using an account model, the negative binomial approach to look at the length of time spent on mental health discussion, while simultaneously accounting for the probability of not having a mental health discussion, so the zero inflated part. Then we tried to triangulate between a qualitative and a quantitative result. 

This is an illustration of how we code a visit. This is an example of a visit that you can see. In this visit, the doctor and patient discuss the five topics. They talk about the study, the dark square shows the time the doctor was talking, and the empty square shows the time the patient was talking. You can see the second topic in this visit was about a patient’s hip pain, the third was about the patient’s depression, the fourth was around backache, and then the patient’s discomfort in her gum. From the beginning of the visit, until the end of the visit, and this was described in a study published in Health Services Research in 2007. 

You can see that they went in and out of topics. Each block of conversation, like here, I hope you can see my cursor, but if you look at the first block of white and black and white and black and white axis, that’s the first instance of the topic of depression, and you can see there were three instances of depression talk during that whole visit. 

Moderator: Ming, if you need a cursor on screen, up at the top there is that arrow pointing in the lower right... if you click in that... yeah, just like that. 

Dr. Ming Tai-Seale: Wonderful, thank you. Yeah... thank you very much. So, here, this is the first instance, this is the second instance, and this is the third instance of the topic of depression. 

In terms of descriptive statistics, what we see is... here in this column, we show the characteristics of all the  patients, and then over here are the visits in which mental health discussions did not happen, and then this is the column for visits in which mental health discussions did happen. 

As you may recall, inclusion criteria were for patients with some mental health needs. What we see here in the first row is out of the two hundred and sixty-one patients, each patient contributed one visit to the study, only 37.2% of those visits had a mental health discussion, so it wasn’t a hundred percent. About sixty-three percent of those visits did not have a mental health discussion. 

I want to call your attention to the mean PHQ2 score. Those with mental health discussion were one-point-five, without mental health discussion it was zero-point-nine. We control for Charleston Index Score and the physician’s verbal dominance, that’s a measure that we use... that, has been used in the literature by Debbie Roter at Hopkins, to measure verbal dominance. They use the number of words spoken by physician over the number of words spoken by patient to get the verbal dominance. 

The way we defined verbal dominance in this study, is in order to avoid, or at least try to address the endogeneity issue, we used the verbal dominance in other visits delivered by the same physician and used that as an instrument for verbal dominance... more of a communication pattern of the physicians in the index of study with the patient. We used time spent by the physician talking, over the time spent by the patients talking during the visit, to get at the verbal dominance. You can see for visits in which there was not a mental health discussion, physicians spend three point five time more talking than patients. For the “with mental health discussions,” the verbal dominance went down to two point seven times. 

Continue on patient activation, we measured that with a proxy to capture if patients came to the visit with a list of issues that they wanted to talk to their physicians as a measure of patient activation. You can see, that between the two sub samples, there were no statistically significant differences. 

We also controlled for whether the patient was in an ongoing mental health episode of care, and if they were taking medications without a hiatus of eight weeks in between either a visit to behavior health or medication use. You can see that the patients in the sample with mental health discussions, there was a significant difference between these two sub samples of whether they were in an ongoing episode of mental health discussion. 

Another variable we accounted for in the model is the average number of evidence based of services delivered. Because in PHE, there is a large number of services that were supposed to be delivered, like a cancer screening for example, so we are trying to see if there is a crowd out. Whether physicians doing more of the evidence based services, excluding mental health, excluding depression screenings, may be significantly associated with whether we would have served a mental health discussion or not. Descriptively speaking it seems the visits with mental health discussion actually had, on average, a higher number of evidence-based services delivered. 

The last one we controlled for here is the number of patient visits on the day of the observed visit the physician had. We were thinking maybe the physician who had a busier day, whether or not that may affect the probability of them having a discussion about mental health. Here it is kind of contrary to what we may think about in terms of crowding out. The physicians saw more patients on average... some fifteen-point-seven visits, versus about fourteen visits, than one with higher number of visits, actually had a higher number... probability of having a mental health discussion here. 

This is the topic distribution and time on the topic. As you can see... just as a reminder, remember in the graph we showed that in the visit there were five topics, and here this is just an overview about the types of domains in which topics were coded. 

The first domain is a biomedical domain, so if the patient talked about their diabetes or hypertension, those topics will be coded into biomedical domain. Health behaviors, if they discussed smoking, alcohol, if they discussed preventive care that would be health behavior. Mental health is the third domain, if they talked about depression, anxiety, feeling sad or worries, or bereavement or grieving, or stress, those will be coded in the mental health domain. The psychosocial, about let’s say vacations, or job changes or moves, so those would be in the psycho-social domain. Then patient-physician relationships and then we have one on visit flow management. It includes agenda setting, mid-course, just checking on understanding, then in the end wrapping up the study, checking for understanding. That is more about small talks, like pleasantries, about the weather, or the color of the blouse the physician is wearing, things like that. 

Out of the two hundred-sixty visits, there were forty-eight hundred topics and we can see that the time... the average time spent on the topic, this is the unit or seconds, on biomedical topics was sixty-seven seconds, the median was forty-three seconds. On health behavior, slightly lower mean and slightly lower medium, but for mental health a longer mean, a longer medium as well, so on and so forth. So for mental health we saw that the maximum was much longer than the others.

A reminder of the research questions... one is about how much time and did the relationship between how much time with physician communication style measure by verbal dominance; patient activation measure, by whether the patient came in with a list to talk to the physician about. This was observed by the research assistants who were present in the room doing the audio recording and working off a checklist that we developed together. The third one was the patient’s level of mental health needs. 

Again, the empirical model is a zero-inflated negative binomial; here are the right hand side variables that I mentioned earlier. 

Here are the main results on the main co variates, and you can see here, this is the zero inflated part, so this is the probability of not having a mental health discussion, and this column is accounts part, that’s the time spent on discussing mental health. We can see that physician’s verbal dominance, the more dominant verbally, the higher the probability of the visit not having a mental health discussion. It is statistically significant at a point-zero-five level. Once they had a discussion, physician’s verbal dominance was not a statistically significant factor in the amount of time they spent on mental health. 

It seems here, patient activation was not a statistically significant variable. Patient’s mental health needs measured by PHQ2 was a significant variable. You can see that the higher the PHQ2 values, the lower the probability of the visit not having a mental health discussion, which intuitively makes sense. In terms of the time spent on mental health discussion, intuitively it also makes sense that the higher the need, the higher the PHQ2 value; so the more the time... the longer the time spent on that. Then, the mental health needs measured in terms of having had an anxiety attack in the last four weeks, it was a significant factor in the accounts part of the model. More time was spent on the mental health discussion. 

On the remaining co variates, we have quite a few significant variables here as well. We can see that if patients were in an ongoing episode of care for mental health, the probability of not having a mental health discussion was lower and the amount of time spent would be longer. We do not see evidence of crowd out of delivering other evidence-based services. There was no significant association here. This is really interesting in terms of how busy was the physician; the busier the physician, the lower the probability of not having a mental health discussion. This is consistent to where the descriptive analysis earlier, however, the busier the physician, the shorter the time spent on the mental health discussion. I thought this was a very interesting finding. 

The Charleson index is not a significant predictor. Patient age... it seems older patients... even though this is already fifty to eighty age range, older patients tend to have a higher probability of not having a mental health discussion, which is unfortunate. Older patients also had a shorter time on mental health discussions if they had one. Male patients were more likely to not have a discussion and they also tend to have shorter time on mental health, if they had one. Non-white patients are far more likely to not have a discussion, and also to have shorter times. Patients with less education are a lot more likely to not have mental health discussions, and also have a lot shorter time spent on mental health if indeed they did have a discussion. 

Now I want to spend a little bit of time looking at what is behind the numbers. This is a quote from an epidemiologist who said, “Statistics are people with their tears wiped away.” Let’s just take a look at when mental health discussion occurred and what did it look like. 

This is something that sort of emerged from our analysis of the qualitative part of the data, from listening to the audio, from analyzing the transcripts, that we thought, you know, for some patients, their mental health concerns may be the true reasons to schedule an annual physical. There are some indicators, one is mental health was the first topic that got raised in the visit. Some patients asked for anti depressants at the get-go. Some patients cried at the beginning of a visit, and another patient said, the doctor didn’t close the door, finish closing the door and the patient started to cry and said, I knew as soon as I saw you, I would start to cry. 

So it seems that for some patients, they would make an appointment and call it a check up, or an annual physical, but they really... their true intention for making that appointment was really to talk to their primary care about their mental health needs. 

Going to the verbal dominance, what we did is we basically looked at the lowest ten percentile in verb dominance. The median verbal dominance score and the highest... the top tenth percentile of the verbal dominance scores of physicians; and just to look at a few examples; and then we break it down to visits with mental health discussions apart from the visits without a mental health discussion.

You can see, here is an example of a discussion in a visit where the physician’s verbal dominance in other visits, not in this particular visit, but in other visits, that were particularly high. The patient here... The patient’s PHQ2 score was four. That’s a pretty high... that’s a pretty definitive indicator for patients that have major depressive disorder. The mental health discussion occurred in a litany, so when the doctor was talking about a list of things, and just simply mentioned... for example, like the dot, dot, dot here could be okay, you’re taking your thyroid medicine and the ADHD and this is the extent of the mental health discussion. This physician dictated in front of the patient towards the end of the visit, so this is a visit in which verbal dominance was very high, and the patient’s need for mental health care or services was very high. But what was delivered, was simply about a passing mention of ADHD without really doing any formal assessment. 

This is another visit, but without any mental health discussion. This patient’s PHQ2 was three; and here is a statement made by this physician, sort of mid way through the visit. She said, I think we have covered everything, is there anything you wanted to talk about. I did a lot of talking. So, the patient didn’t really step up to say yeah, I wanted to talk about this and that. One thing about patients with depression or... unless it is about anxiety, and some patients may have felt a pressure to talk, usually patients with depression are more reserved and withholding information. So, if the physician was talking a lot, it’s not very likely that the patients will be assertive and bring up this topic to discuss. 

Now let’s look at a couple of visits in the median range of verbal dominance. This visit, the patient’s PHQ2 scare was six, which is as high as it goes in terms of PHQ2 score. The patient cries because her son is dead. The physician showed repeated empathy; and investigates her current mental health. The patient already had an anxiety diagnosis, so the physician encouraged the patient to seek more counseling. 

In this visit, in which mental health was not discussed, the PHQ2 score was three, the patient was quite assertive and active. The physician asked the patient if the patient had any concerns in the middle of the visit. So, even though the patient was assertive and active, it was more about biomedical issues, not about mental health issues, so they did not really have a mental health discussion. 

Now let’s look at a pair of visits in which the physician’s verbal dominance was low. This suggests the patient did most or a lot of talking in other visits with this physician. In the visit without mental health discussion, PHQ2 was three; the physician missed a lot of opportunities to explore the patient’s mental health. The patient repeatedly stated that she and her husband were going through a hard time, but the physician did not really take the cue, so the patient did a lot of talking and floated a lot of balloons, gave a lot of cues, presented a lot of opportunities for empathy. We coded, I think in that visit, there were like six opportunities for empathy and the physician missed many of them. 

In this visit that there was a mental health discussion, this was an amazing visit. The patient has a PHQ2 score of six and this physician has consistently low verbal dominance, meaning the physician let her patient talk, in other visits that she had with other patients. What we see in this visit, the physician explored... she took the cue. This is a different physician. She took the empathetic... the empathic opportunities the patient presented. The physician asked several PHQ9 questions like sleep, interest in doing things, including I believe the suicide question as well, so this physician did a great job and towards the end, the physician diagnosed depression and the physician did a very good job; talked about the pros and cons of psychotropic medications. She prescribed Effexor and talked to the patient about Effexor, may have a beneficial effect on menopausal symptoms as well, so this visit was just very remarkable. The physician basically let the patient empty her cup, and did a very thorough job in recognizing empathic opportunity in exploring and doing a thorough assessment, making the diagnosis, prescribing, and also she recommended the patient go back to Al Anon if she wanted to talk to a counselor, the physician would encourage her to do that. This was what I think I would call a perfect visit in which the patient’s bio-social-psycho needs were addressed. 

This is an example of some patient’s mental health needs being short... met with short shift... a very short discussion... point-six minutes with a patient who’s mental health, the PHQ2 score was six. This is something I call out because it is not an isolated incident. The patient was under the care of a behavior health specialist, and what the PCP says, so are you still seeing Dr... (giving the name of the psychiatrist), and the patient said yeah, and that was pretty much it. There was no formal assessment of mental health, and there was not much about what are you... what is Dr.... working with you on? So, when we talk to our psychiatrist friend on this project, she said what works best is that if they can co-manage the patient with the primary care physician. The referral or the co management would do much better if PCP still owns the patient’s mental health needs, and bring in the psychiatrist as a consultant for med management. But the patient needs to know that they are co-managing and the psychiatrists are able to do a much better job when the PCP can provide more extensive information about the patient and provide continuity of care for the patient.  

This is an example of a visit in which the patient has given a lot of cues through psychosocial discussions. In the mental health discussion the patient talked about her sister having recently had a lung cancer diagnosis, and she’s about to go see her, and the doctor switched the topic to a biomedical discussion and changed the topic here, and the doctor changed topic here back to biomedical, and you can see here, the doctor did go to... actually, the patient switched the topic from psychosocial to the mental health discussion here, and then the doctor switched the topic again back to biomedical topic. So, there was a lot of back and forth. You can almost see it as if the doctor was avoiding talking about mental health and just spending a lot of time about biomedical issues. You can see here, finally the doctor brought the topic back to mental health, but it was somewhat dismissive of the patient’s concern. We can see that the patient started to cry at this point... twenty-five minutes into the discussion the patient said... the patient basically said, I’m really worried when I see her, if I see a downturn, I don’t know if I’ll be able to handle it, I think I need some medicine. And the doctor basically said, it’s not as if you’re having depression. For people having depression, they will be snappy, they would not be able to sleep, and they would not be able to do this and that. Even though the patient actually told the doctor, she did not sleep well. And the doctor didn’t really ask the patient how well... was she irritable, was she prone to anger. So the doctor seemed to have jumped to the conclusion that the patient was not in a major depressive episode without really doing a thorough assessment. If you see here, the time spent on mental health was seven minutes and seventeen seconds, biomedical was twenty minutes. 

I would like to quote here on Dr. Russell Harris from UNC. He said, when we are spending time doing things that do not potentially benefit people and skipping things that may be of benefit, that's a sign not only of waste but of misplaced priorities.

I just want to look back to think about annual physical. This is a fairly controversial topic, actually. I think the discussions for many years; probably over twenty years about should we do physicals, should we do annual physicals. Many of the things offered or provided in annual physicals actually do not have very strong evidence, but it is a time-honored tradition. Patients seem to want it. Maybe that was not based on evidence that annual physicals are... All the things done usually during annual physicals are effective, or have high eminence level. But based on observation, some patients schedule annual physical, or the PHE really, because they want to have their mental health needs addressed. When physicians are preoccupied with adhering to the guidelines about what should happen in the regular annual physical, some patient’s potentially urgent mental health needs are unmet. 

In terms of one of the main findings about verbal dominance of physicians, that being more verbally dominant were negatively associated with patients having a mental health discussion during the visit and also... That is something I think has implications about quality improvement, or continuing medical education. Unfortunately, we still find disparities due to age, gender, education and race both in terms of having a discussion, and in terms of how much time was spent. If we think about time spent on discussing mental health as a positive thing, what we found is these older patients, male patients, patients with less education and nonwhite patients tend to have a shorter time spent on mental health discussion. 

This is an article... one of many articles in New York Times about the controversies around should we have physicals. This was published almost two years ago and it got a lot of comments. What I wanted to say just to build off that nowadays, no one would think about managing patient’s hypertension. If a patient has high blood pressure, if a clinician needs to manage the hypertension, they would not just ask the patient, so how is your blood pressure. They would put a cuff on it and they would measure it to see how a patient’s blood pressure is doing. But what we often see in terms of mental health is, so okay, you have ADHD, oh so you don’t have depression, you don’t have anxiety, so an assessment of mental health is still an exception rather than the norm, so we ask, got mental? We need to really raise awareness for that. 

I would like to acknowledge my very esteemed research team, here’s Dr. Jennifer Elston Lafata, Richard Frankel, Lisa MacLean, Lisa Diamond, Tom McGuire, Laura Hatfield, Caroline Wilson, Ashley Stone, this is me, and Cheryl Stults. I want to thank them for their great contributions. I want to thank you for sitting through; this is like a forty-minute long lecture. Again, this is work in progress, your questions and comments are welcome and feel free to e-mail me if you have questions. So Heidi, back to you. 

Moderator: We have received a couple of questions here, Risha, do you want to read those.

Risha: Sure, thank you Heidi and thank you Dr. Tai-Seale, this presentation is really interesting, and we have a couple of questions. 

The first one actually relates to the data that you presented in slide eleven, if we can go back there for a moment. Perhaps the person requesting this had the wrong slide. It is the table that is looking at the number of patients that have... I think it is this one actually... so, it says... the question is that it does not appear that the all patients column is a weighted average of the without mental health and with mental health columns. For example, an anxiety attack in the past four weeks... maybe we have a different table we need to look at... here we go... this is it. So, the question is, this does not look like a weighted average, is the person misinterpreting the table? 

Dr. Ming Tai-Seale: Oh, okay good question. I think what we have here is eight-point-eight percent of all the patients reported having had an anxiety attack in the past four weeks. In all of the visits without a mental health discussion, thirty-nine percent of them had an anxiety attack; and the sixty-one percent of them... of these thirty-seven percent of visits, sixty-one percent of them, the patient had an anxiety attack. 

Risha: Hmm... Okay, got that. Thank you. Another question, were the physicians in the study aware of the patient’s PHQ scores?

Dr. Ming Tai-Seale: No. 

Risha: They were not.

Dr. Ming Tai-Seale: No, they were not. This was a research data, this was a part of the survey before the visit, and they were not available to the clinicians. Now, in the EMR at the delivery organization PHQ2 and PHQ9 were built in. They were in a drop down menu, so if the physician wanted to use this, they would be able to access the actual language of the instrument and unfortunately, out of the whole two hundred and sixty-one patients, the use of the PHQ2 or 9 was very, very intricate. I think we had like eight visits in which those were used. 

Risha: Were physicians assessing depression in some other way, not using the PHQ tool? 

Dr. Ming Tai-Seale: Well yes, some were asking a variation of the questions, like in the PHQ2 or none. They would ask about how you eat, sleep, appetite.

Risha: In that case, if there were some questions on the PHQ tool, but that were not specifically asked in the context of mental health, for example, do you feel your mental health is affecting your appetite, versus how are you eating? 

Dr. Ming Tai-Seale: Yeah, that is a very good question. If it is how are you eating... if it is in the context of a discussion of let’s say, diet, if the patient has diabetes and the patient did not provide empathic opportunities, then that question will be coded as a part of the diet or diabetes topic. But if the physician asked about how are you eating, how is your appetite in the context of a discussion about mental health, then we would code it as a mental health discussion. So, the context matters a great deal in our coding. 

Risha: Okay, thanks for the clarification. I have one question about the models that were used. You had a slide, somewhere around slide fourteen talking about the probability of occurrence and then the number of seconds spent on each topic. I am just wondering if you could walk me through, were you using a logistic model for evaluating whether a topic was discussed, and then switching to an account model for the number of seconds; or was it... what was the statistical approach? 

Dr. Ming Tai-Seale: This is called a zero-inflated binomial model. We used data... data can actually simultaneously estimate this, so it is basically one command in data that it does account part, which is the binomial part. It gets to the number of seconds spent on mental health discussion. Then it inflates the zeroes. With the notion that the visit, without a discussion, which is true of about sixty-two percent of the visits. There were sixty-two zeroes when it gets to the probability of whether or not they had a mental health discussion. There were a lot of zeroes, so it’s basically... if you write it out, it’s basically the account part for the number of seconds spent on mental health discussion, and then you inflate the zero part, which is the probability of having a mental health discussion. It’s like a two-part model estimated simultaneously, so what we have is the accounts part, and then we have the probability part. 

Risha: Right, thank you. And we have another question about physicians in this work, so the person who is asking says physicians don’t seem comfortable discussing or treating mental health, so what sort of additional training do you think is needed for those people? 

Dr. Ming Tai-Seale: Oh boy, that is the million-dollar question. There has been... this question has been asked many times and answers ranged from doing a more robust curriculum on mental health issues during medical school, during residency. Some people even went to the extreme of everybody do a much more robust rotation in psychiatry and motivational interviewing so that they can be much more aware of the bio-psycho-social aspects of health; to doing CME, continuing medical education. But CME models haven’t been very successful. Pulling physicians out for a day, or a half a day, or a few hours to teach them about depression assessment and treatment has very little... it doesn’t really stick. It may have a modest impact, and is often short lived. The collaborative care model is among the ones that have been shown to have truly cost-effective outcomes on doing primary care integration with mental health services. Which means primary care physicians are still in the loop of treating patient’s mental health needs, but they would be assisted by a specially trained care manager. The care manager can be a nurse with special training in mental health, or it could be a licensed social worker; or some places could use a clinical psychologist. But really a care manager who can spend the time and who has the training about doing assessments, like putting the cuff on the patient to do the blood pressure measurements, doing PHQ9 as a vital sign every time the patient is touched. Then, to be supervised regularly by a specialist, often by a psychiatrist, like they will have case reviews. Then, patients who are not responding to treatment, who are not remitting that they will have treatment intensification, they will follow the target treatment protocols so the psychiatrist would make recommendations to the primary care physician through the care manager to address, adjust, add or supplement or change, or add another psychotropic med. That model seems to be with the strongest evidence. 

I’m sorry, that’s kind of a very long winded answer to your question, but it’s a great question. 

Risha: Sort of to piggyback on that, did you have an ability to assess physician characteristics that were associated with higher verbal dominance scores or lower likelihood of ascertaining mental health status? 

Dr. Ming Tai-Seale: Oh, that’s a great question. You know we should. We really should look at it. now, the thing is, we have a relatively small sample. We had two hundred and sixty-one visits, basically. We can’t have a very extensive model with a lot of right hand side variables, but I think physician verbal dominance is a fascinating characteristic, so that’s a great question, I think we should look into it. Thank you. 

Risha: Okay, just a couple of other new questions in the five minutes we have left, one participants is wondering how many patients currently on an anti depressant were assessed for symptom severity or frequency at the clinic visit? Was SI assessed, and I am afraid I do not know what SI stands for, so if the respondent could actually clarify that, unless you know. 

Dr. Ming Tai-Seale: Oh, maybe suicidal intention or suicide index? I am only guessing. 

Risha: Sound reasonable... yes, suicidal ideation. 

Dr. Ming Tai-Seale: Oh, suicidal ideation, yes... yeah, some physicians did assess suicidal ideation; but it was a small number. In terms of patients who were on psychotropic medications, it was almost... it was a perfect co linear way of being an ongoing mental health episode of care, so we use ongoing episode of mental health care instead of the psychotropic medication. 

Risha: The same participant is wondering about the relationship between medication change or augmentation and the length of time discussing mental health during the visit. 

Dr. Ming Tai-Seale: Sorry, could you repeat that question? 

Risha: Was there a relationship between medication change, or augmentation in that amount of time that was spend discussing mental health. 

Dr. Ming Tai-Seale: Oh, that is a very good question. We did not see a lot of change in augmentation, so we could not really do... I was very interested in treatment intensification, but we didn’t have the sample size to do that, unfortunately. Hopefully, we will be able to do that in the future when we have a larger sample size. 

Risha: Yeah, I guess it gets very hard when you are doing such rich data collection to be able to have extremely large sample sizes at the same time. 

Dr. Ming Tai-Seale: Yeah, and recruitment was actually quite difficult. 

Risha: I guess to that extent, do you think that there is any sort of Hawthorn effect that’s occurring with these physicians in that if they know they are being evaluated they potentially, actually increase their query of mental health compared to what might occur in normal clinical practice? 

Dr. Ming Tai-Seale: That is a very fair question and that question is [inaud.] question. when we look at studies that involve direct observation methods, there is a literature that suggests that participants often tune out the recording device, or the person who is in the room, so by and large, I don’t think it’s a huge problem. Given that this is a sample of patients who, by definition, had mental health needs we were hoping we would see a higher percentage of those visits having mental health discussions. so even with the potential Hawthorn effect, what we saw was a thirty-seven percent of visits having such discussions, and some of the missed opportunities, or the dismissive comments in the face of crying adults would be an indication of acute distress, there still was not a very thoroughness of investigation or assurance. So, I’m not too concerned about Hawthorn effect, but that being said, some physicians did try to make conversation with the RA in the room. When we saw that, we were like oh, okay, here is an example of where the physician did not completely tune out the RA even though they have been basically advised to not pay attention to the RA in the room and just let RA be a fly on the wall. So it’s a very fair question and I think it is something that we continue to monitor. And we actually coded for whether the patient or the physician tried to acknowledge the presence of the RA to see if there was a higher number, but there was no higher number. 

Risha: Thank you, so I think we are out of time here, but there is one last question that I would like... given its relevance to the last one we just discussed. What were the physicians told about the purpose of this study? 

Dr. Ming Tai-Seale: That is a very good question. The physicians were told about the purpose of this study to see how they communicate with patients during periodic health exams. 

Risha: Okay. Great, well, I think we are out of time, but clearly, there was a lot of interest in this presentation. I personally found this work to be fascinating and I look forward to tracking more of it as you continue along this research line. So, thank you so much Dr. Tai-Seale, we very much enjoyed having you discuss your research with us. 

Dr. Ming Tai-Seale: Oh, thank you, it is my pleasure. 

Moderator: Yes, fantastic, thank you so much. For the audience, I did put a feedback form on the screen if you could all take just a few moments to fill that out before you leave today’s session, we would very much appreciate hearing your comments about today’s session. Thank you everyone for joining us for today’s HSR&D cyber seminar, and we hope to see you at a future session. Thank you. 

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