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Typically when people get sick or injured, they must seek help to get care. But a common symptom of depression and other mental disorders is social withdrawal—in other words, their sickness may prevent sufferers from seeking help. In the face of this contradiction, Neda Laiteerapong, MD, Associate Professor of Medicine and Psychiatry and director of primary care behavioral health integration at the University of Chicago, wondered if there could be another route for patients to access care.

“People with mental health problems are less likely to engage in many things in life, including the health care system,” she said. “I saw people who were suffering, and they were not calling the doctor or walking into a clinic to get care. There’s a belief that if people want help, they need to ask for help—but I thought that the health care system and clinicians could reach a hand out to patients who are suffering at home, and maybe some of those patients would meet that person’s hand and get pulled into the health care system.”

In 2018, funded by AHRQ, Laiteerapong began the first of what is now a growing series of studies using the electronic patient portal system to screen for mental health issues. In Patient Outcomes Reporting for Timely Assessments of Life with Depression: PORTAL-Depression, Laiteerapong and colleagues at the University of Chicago studied whether a short questionnaire administered over the patient portal could identify patients with symptoms of depression and help connect them to care.

They found that patients who filled out the survey at home had more symptoms of depression than those who came to the clinic for care, and that their symptoms were more severe—confirming Laiteerapong’s suspicion that more depressed patients may drop out of the health care system. Yet the process also opened a window of opportunity for intervention: inviting patients to self-report through the patient portal could increase the reach and frequency of depression screening and monitoring and identify people with symptoms of depression symptoms instead of waiting for them to seek care.

An active approach to caring for patients with indications of disease is already in place for patients with chronic diseases such as diabetes and hypertension, notes Laiteerapong. “For people with diabetes, if their A1C is elevated, the health care system will reach out to them and try to get them engaged in care, or for people with high blood pressure, the health care system will reach out and try to set up care management programs, but for mental health care, I wasn’t seeing people do this type of work. I was interested in understanding if it would change patient’s outcomes and behaviors,” she said.

“One benefit of portal depression screening and monitoring is that people can do it privately on their own time,” said Lisa Vinci, MD, Professor of Medicine and director of the primary care group at the University of Chicago, who partnered with Laiteerapong to implement patient portal screening for depression. “Primary care visits are very rushed because there’s just so many things that need to be covered—patient questions, vaccines, preventive health, and chronic diseases. Often it’s hard for medical assistants and doctors to find time to monitor depression,” she said.

The questionnaire for depression is just one of many tools Laiteerapong has pioneered to streamline and facilitate mental health care as part of the Primary Care-Behavioral Health Integration Program she began in 2014 at the University of Chicago, says Vinci. Offering guidelines and algorithms for diagnosing behavioral health conditions, prescribing drugs, and educating patients, these tools help enable primary care clinicians to offer frontline mental health care to patients in need.

“My ability to provide what my patients need or bring resources to them is completely different now than it was 10 years ago,” Vinci said. “Now all of us have a better understanding of the options and resources, and our competence and confidence is much higher than it was.”

Offering help for substance abuse

Since the initial success of PORTAL-Depression, Laiteerapong is extending the concept to other mental illnesses, starting with substance use disorder and post-traumatic stress disorder. Laiteerapong is serving as co-PI with Jessica Ridgway, MD, Associate Professor of Medicine and a specialist on HIV and infectious diseases, on an R01 awarded this year through the National Institute on Drug Abuse’s Racial Equity Initiative for Achieving Equity in Patient Outcome Reporting for Timely Assessments of Life with HIV and Substance Use (ePORTAL HIV-S), a project to identify substance use disorder in Black patients with HIV. They are among the inaugural cohort of awardees to the NIDA REI, a landmark program aimed at addressing racial and ethnic disparities within the field of addiction science.

“People with HIV in general in the US have higher rates of substance use disorder and higher rates of psychiatric illness than the general population,” Ridgway said. “Right now, we are not doing a good job of treating our patients with HIV for substance use disorder. We aren’t really screening them, and when they screen positive, we don’t do a great job of referring for resources or giving treatment.” Aware of Laiteerapong’s work to increase screening for depression in the primary care group using the portal, Ridgway approached Laiteerapong to collaborate on developing a similar tool for the HIV clinic.

In ePORTAL HIV-S, Ridgway and Laiteerapong aim to increase enrollment in the patient portal by current patients, including patients who have missed appointments, and use the portal to screen for substance use disorder at the South Side Health Home, a clinic funded by the Chicago Department of Public Health to provide HIV care on the south side of Chicago. After identifying patients with SUD, they will implement a collaborative care model of care, a team-based intervention in which an addiction psychiatrist, social worker, and case manager can advise the patient’s existing HIV provider on delivering treatment. “A lot of our patients don’t want to go to an outside resource for treatment—they feel comfortable here and with us,” Ridgway said. If the process proves effective, Ridgway and Laiteerapong will adapt and expand their work to other sites.

The project also dovetails with Ridgway’s longstanding interest in patient portals and clinical informatics. “I was in fellowship was when we switched over from the paper chart to the electronic chart,” she said. “My fellowship mentor did clinical informatics, and that got me really interested how medical records can be used to improve care and the data that we put into and get out of them. I like that we’re using the patient portal and electronic health record tools to gather patient-reported information. Because I help run the University of Chicago HIV clinical program, I’m really interested in improving the quality of care for our patients with HIV.”

More screening for PTSD

In parallel to ePORTAL HIV-S, Laiteerapong is partnering with Melissa Duplantis, chief behavioral health officer of Chicago Family Health Center, a federally qualified health center that serves patients on the south side of Chicago, on Patient Outcome Reporting for Timely Assessments of Life with Post-Traumatic Stress Disorder (PORTAL-PTSD), a project to screen for PTSD in patients in disenfranchised communities on the South Side of Chicago. Their partnership was developed through the Chicago Chronic Condition Equity Network (C3EN), a collaboration between the University of Chicago, Rush University, and community-based organizations to find real world, community-based solutions for chronic disease and funded through the National Institute on Minority Health and Health Disparities.

PORTAL-PTSD is part of Chicago Family Health Center’s growing initiative to increase behavioral health care on the south side, which began with Duplantis’s hiring in 2015 and has since expanded to include a team of providers, care coordinators, and patient navigators, as well as programming for substance use disorder.

“We were designated a trauma-informed center of care by Chicago Department of Public Health in 2020,” Duplantis said. “That was when we started to take a more comprehensive approach to trauma in the patient population. Now that we are officially funded for the PORTAL-PTSD study, we’re going to be ramping up our efforts at identifying patients with trauma across the health system and intervening with evidence-based care.”

In PORTAL-PTSD, anyone who has been a CFHC patient within the past 24-48 months will receive a 5-question validated screening questionnaire for PTSD through the patient portal. The same questionnaire will also be delivered to patients at the clinic. Patients who screen positive for PTSD will be connected to a behavioral health provider team for more detailed screening. Those who meet the diagnostic criteria for PTSD will be referred to an interdisciplinary team to get care. CFHC uses an integrated primary care behavioral health model, which incorporates a licensed behavioral health professional into the patient’s primary care team.

Duplantis anticipates that PORTAL-PTSD will increase care for people suffering from PTSD on the south side. “When you ask, you get answers,” she says. “I am really excited that PORTAL-PTSD will be doing universal population screening to catch trauma before a patient is even in the clinic, so we’re reaching out to look for those issues, not waiting for the patient to come to us for assessment. The south side of Chicago, particularly 60617, has a high incidence rate of severe mental illness—200% of what we expect from neighboring zip codes—and all of our communities on the south side have been victims of systemic trauma, systemic racism, and inequities including food insecurity and transportation deserts. When we do this population screening, we’re going to be capturing all that information and connecting those patients with care whether they’re in the clinic or not.”

Overall, the PORTAL projects offer a more anticipatory model for diagnosing mental health issues and delivering care that could both help more patients get care and address the shortage of specialized mental health providers.

“I’m hoping that we’re changing the conversation around whose responsibility mental health care is and this myth that patients who are at home suffering with mental health problems are not willing to get help. I’m hoping to do more studies like this across different mental health conditions to try to change the culture,” Laiteerapong said. “If we’re just putting out fires, we’re not preventing or reaching people early enough in their disease. Now we’re trying to do more mental and behavioral health care in the primary care clinic.”

Research reported in this article was supported by the National Institute on Drug Abuse Center, or other NIH offices of the National Institutes of Health under award number R01DA058965. 100% of e-PORTAL-HIV-S is federally funded. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.