Initiatives in Behavioral Health

Associate Dean for Student Affairs Matthew Duncan, MD, a Dartmouth medical school alumnus, and Julia Berkowitz ’20 partner on a program to address the mental health needs of medical students. Photo by Mark Washburn

No one should have to wait weeks for help for a mental health issue, and no one should be afraid to ask for the help they need. At the Geisel School of Medicine and in Dartmouth-Hitchcock clinics, new initiatives are improving access to mental health care for medical students and patients—quickly, confidentially, and without judgment.

Healthy Students, Healthy physicians

Attending medical school is notoriously stressful. Nationally, nearly a third of medical students report symptoms of depression and related mental illness, and one in ten have considered suicide, according to a 2016 study published in the Journal of the American Medical Association. The picture is equally grim for physicians, who have a suicide rate twice that of the general population. 

“We have a professional responsibility to care for
ourselves and our colleagues,” explains Matthew Duncan, MD, associate dean for student affairs at the Geisel School of Medicine and an assistant professor of psychiatry. Several studies have linked physician depression and burnout with medical errors and lowerquality patient care.  

Duncan is leading a multi-faceted initiative at Geisel to address the mental health needs of its medical students. This includes improving confidential screening for mental health; strengthening the school’s wellness and resiliency programming; providing mental health clinical services that are tailored to medical students’ unique schedules; and promoting a culture that encourages seeking help for mental health issues. Enhancing these efforts are recent changes to the MD curriculum and advising program that will create a more efficient and supportive learning environment—while at the same time fulfilling the ever expanding spectrum of knowledge, skills, and professional competencies that medical students today must master before graduating.  

“I feel grateful that Geisel is tackling these issues head on,” says medical student Julia Berkowitz ’20, who is working with Duncan to develop measurement tools to assess the program. Berkowitz learned how to create, test, validate, and implement program assessment tools when she was an S.M. Tenney Medical Student Fellow at The Dartmouth Institute for Health Policy and Clinical Practice at Geisel in 2017-18. Now, as the recipient of another Geisel fellowship, the Olive M. and Joesph F. Swigart Ethics Fellowship, she is applying those skills to initiatives that will benefit her fellow students. Both fellowships were funded through the generosity of donors. 

“If we can share the information we gather in a sensitive and confidential way, students will see that they are not alone.”

“One of the big questions with any initiative is how do we know that it is working and effective,” says Duncan. “That’s why the data and measurement piece is so important and complex. We don’t have the resources at this point to hire people to do this. It was really a gift when Julia, on her own, decided that this would be a good focus for her ethics fellowship.”

Berkowitz believes her work could ultimately help reduce the stigma medical students feel around their own mental health: “If we can share the information we gather in a sensitive and confidential way, students will see that they are not alone.” And that can be the first step in asking for help.

Bringing Mental Health Care into the Mainstream

New to the Upper Valley, a man with bipolar disorder found himself in trouble. He’d been managing his disease successfully for decades with lithium, but the drug had begun to damage his kidneys. Shortly after his nephrologist took him off lithium, the patient became suicidal. The first appointment he could get with a psychiatrist was months away. In deep distress, the man turned to his Dartmouth-Hitchcock primary care provider (PCP) for help. 

At Dartmouth-Hitchcock (D-H), most adult patients who present a mental health issue during a visit with their PCP have access to immediate counseling through Integrated Behavioral Health. Formally introduced at D-H Nashua in 2017 and now available at D-H clinics in Lebanon, Manchester, Concord, and Keene, this model of collaborative care embeds a licensed clinical social worker or licensed clinical mental health counselor within a primary care practice. These mental health providers can conduct same-day assessments, establish treatment plans, serve as a liaison between patients and community organizations, check in on patients after the initial visit, and offer short-term therapy. Cases are reviewed weekly by a supervising psychiatrist, and e-consults—an electronic communication system—allow PCPs to get guidance from a psychiatrist usually within 10 hours, and always within 24 hours.

Developed by a cross-disciplinary team of D-H caregivers, this collaborative care model was adapted from other models used throughout the country to meet the region’s needs. The program supports PCPs in their ability to treat a wide range of mental health issues, from depression and anxiety to substance use disorders. 

Matthew Duncan, MD, a staff psychiatrist at D-H, assistant professor at the Geisel School of Medicine, and a Dartmouth medical school alumnus, was one of the clinicians who helped bring collaborative care to D-H. He says, “These are common medical conditions and it’s a really positive evolution that mental health has moved into the mainstream of medicine.”

Patients are screened for mental health issues through a pre-visit questionnaire, a tool that can help start conversations about mental health needs and initiate early interventions.

Jonathan Thyng, MD, medical director at D-H Nashua and clinical assistant professor at Geisel, says, “The screening has been the biggest eye-opener. By asking people about depression, anxiety, and substance use, you get answers you wouldn’t anticipate—and we can help prevent these issues from getting worse.”

State funding and the commitment of D-H leadership have facilitated the expansion of Integrated Behavioral Health. But, notes Duncan, “Reimbursement models are in the earliest stages of development, so sustaining the program requires the institution to invest at a loss to do the right thing clinically.”

Even so, collaborative care has demonstrated success in improving outcomes and lowering health care costs, and D-H is working on adapting its adult model for pediatrics. “People are used to coming to their primary care doctors with all sorts of issues,” says Thyng. “With demand for mental health care far exceeding the supply of specialists who can provide it, this model helps patients receive expert care in the medical home they know and trust.”

By Jennifer Durgin and Lauren Seidman