Mainstreaming mental health: Inside Charlottesville’s Free Clinic’s study on integrated care

Director Erika Viccellio is excited that, after a five-year collaboration with the Women’s Initiative, the Charlottesville Free Clinic is now offering mental health services to its patients. Photo: Christian Hommel Director Erika Viccellio is excited that, after a five-year collaboration with the Women’s Initiative, the Charlottesville Free Clinic is now offering mental health services to its patients. Photo: Christian Hommel

John Davis never pictured himself going to the Charlottesville Free Clinic, much less to regularly meet with a therapist. Mental health patients have to conquer society’s stigma and the negative connotations surrounding treatment, and until Davis found himself uninsured and spilling his guts to the Charlottesville Free Clinic’s licensed social worker, he said he never would have considered seeing a counselor for any reason.

“I used to live in that stigma,” he said. “I used to think that if you looked for a mental health professional, it was a sign of weakness. It meant something was really wrong.”

But when Davis visited the clinic for a routine appointment and was handed a questionnaire regarding his own mental health, he said he wasn’t taken aback or offended. In fact, he ended up sitting down with the on-site therapist and has since attended regular counseling sessions with a new attitude toward mental health care.

The idea that mental and physical health are intrinsically linked isn’t new, but the two facets of human care still aren’t addressed in the same way. The Free Clinic is trying to change that with Integrated Care, the result of a five-year partnership with the Women’s Initiative and a three-year $105,000 grant from the Virginia Health Care Foundation. The program is a collaborative effort between Free Clinic physicians and a Women’s Initiative social worker to evaluate patients for both physical and emotional well being during yearly checkups.

In addition to checking blood pressure and other basics, physicians at the Free Clinic now go over a nine-question questionnaire filled out by the patient. The survey asks for a zero to three ranking—zero being not at all, three being nearly every day —on items like trouble concentrating, suicidal thoughts, loss of appetite, and loss of motivation. Doctors review the responses before meeting with a patient, and discuss them in relation to any physical ailments, like migraines. Patients are told, regardless of the numbers they circle, that a certified mental health specialist is available onsite.

“To sit down and chat with someone who’s a qualified listener?” Davis said. “It’s just fantastic. I wish I’d done this a long time ago.”

Davis said he had to overcome a feeling of embarrassment in the beginning, which he described as extremely humbling. But now that he’s benefitted from regular therapy sessions and eliminated his own stereotypes, he said he’s glad to see the world of mental health care is less stigmatized than it was 10 to 15 years ago.

Nurse practitioner Barrie Carveth said the preconceived notions surrounding mental illness have improved in the 28 years she’s been in the medical field, and the majority of her patients are open to the idea of filling out the questionnaire.

“For the most part, people are very receptive,” she said. “A lot of people are just relieved that there’s help.”

Carveth said the integrated care system has exposed her to a whole new reality about mental health.

Because severe mental health disorders like schizophrenia and psychosis have traditionally gotten more attention from doctors, Carveth said general, functional depression, which affects a substantially larger population, has long been overlooked.

“It’s been a real eye opener to see how many people suffer on some level,” she said. “So many just sort of live with it because they can’t afford therapy.”

Programs like the Free Clinic’s have brought more awareness to the different levels of mental health needs, Carveth said, and a telltale sign of mild depression is when a patient loses interest in physical health.

“If somebody is not taking their medicine, or clearly not taking care of themselves physically, we start to address if there’s something going on that’s making them unmotivated,” she said.

Liz Ramirez-Weaver, a licensed clinical social worker and the Free Clinic’s integrated care coordinator, said treating the underlying cause of a physical issue, not just the symptoms, is essential for both mental and physical health.

Diabetic patients, for example, have shown improvements in blood sugar levels when they adopt better ways to cope with stress.

“When they learn to use simple techniques to decrease stress levels and anxiety, like breathing deeply or going for a walk, we see overall blood sugar levels going down,” Ramirez-Weaver said. “It goes to show that we need to be treating the whole person.”

Ramirez-Weaver said she didn’t anticipate the number of people already using the services, but has been especially surprised by the diversity of her patients. About one in four Americans age 18 and older suffer from a diagnosable mental disorder each year, she said—roughly 57.7 million people, and from all walks of life. She described her patients as a “mixed bag,” and said there’s really no stereotype that comes to her.

“What’s interesting to me is, it’s never who people think. It can be anyone,” she said. “Giving everyone access is the beauty of this model. There are no barriers, and there’s no stigma.”

Ramirez-Weaver and her colleagues want to minimize the negative connotation around mental health care, and believe that combining it with routine physical health care will help. Patients may be embarrassed to be seen coming out of a therapist’s office, she said, but seeing a doctor for chronic migraines or a broken leg is expected, and not likely to be judged.

“We’re leveling the playing field for folks in this community by having it all under the same roof,” she said. “People can go without judgment and get the help that they need for their depression, anxiety, bipolar disorder, whatever it is that they’re feeling.”

Free Clinic Executive Director Erika Viccellio said integrated care is not a new concept, but understands why it’s not yet widely practiced.

“It’s logical, but it’s time consuming,” she said. “Unfortunately in the health care industry, people are squeezed. Everything happens a lot faster than it’s supposed to, and so a lot of times what’s addressed is the presenting concern.”

Other regional free clinics, including those in Richmond and Fredericksburg, have established their own versions of the integrated care system. Viccellio said she hopes that with enough data, more and more practices will catch on that, despite being time-consuming and logistically challenging, treating the mental and physical is essential in treating the whole patient—not just the symptoms.

“We’re going to treat the reason they’re here today, but we also want to look at how we can help this person to be well every day,” she said.