It’s time for afternoon clinic at Bread for the City. Salsa classes are finished in the waiting area, and patients are filling the chairs. I look through the glass door and see my one o’clock patient, Fatima. She has been a patient since 2009, but today was the first visit since the birth of her first  baby girl. I was excited to see them. I called her name, and she stood cradling her 2-month-old baby on her chest. I met her eyes, which were slowly filling with tears. She came back to the room, and says, “I just had to come and see you. I feel so sad, I did not know this was going to be so hard.” She proceeded to tell me how she is having a hard time caring for her baby. She can’t help but cry all day. She was afraid to be alone while  her boyfriend and mom were out working, so she came to Bread. We called her mother and boyfriend, and we made arrangements for them to care for the baby. The rest of the time we spent time talking and initiating her treatment for postpartum depression while our social services staff helped her access community resources for new Spanish speaking moms.

Running a little behind, I go to greet Maria. She walked in for a medication refill. She is a diabetic and reports that she has been out of medications for several months. After probing and trying to figure out why, she tells me she has felt so depressed she did not want to leave the house. Today was the first day she had been out in a while, and she was grateful to be seen. She has been suffering from depression for years after enduring and finally leaving an abusive marriage, but  she is not seeking help for that today; she just wanted to pick up her medications.

HeatherPrimary care is an important bridge between mental health assessment and treatment. More than 40% of patients with mental health problems seek initial care with their primary care provider. Many patients both new and old have diagnosed, non-diagnosed, treated, untreated, and partially treated mental health problems — the most common being anxiety, depression,  and post traumatic stress syndrome. As per the Health Report by the US Health and Human Services, from 2005 to 2010 adults living below the poverty line were 4 times more likely to be depressed when compared to those living 400% above the poverty line. We also know in primary care people with mental illnesses are five times more likely to have co-occurring medical conditions. And, for severe mental health problems, mortality is much higher than the general population largely due to treatable medical conditions, which are left undetected or untreated.

What do we do at Bread for medical patients with mental illness? Simply put, we develop relationships and we listen. Primary care is a place where conversations happen, trust is built over time. We know that treating their medical conditions can’t be independent of their mental health. We’re always getting to know our patients, assessing and reassessing their mental health status. Some patients come to us, like Fatima, seeking help, while others like Maria do not want help. However, with some patients like Maria, we know that if we cannot try to treat their depression then their diabetes may never be controlled. She may never walk into a psychiatrist’s office, but she will come to the clinic for her diabetes care.

And, yes, doing this work is not easy. It requires flexibility, patience and being present — having your doors, heart, and ears open. Working specifically with Latinos, speaking Spanish and understanding cultural differences in reference to mental health is essential. It takes time for histories of domestic abuse, substance abuse, and loss to emerge. Many people are lucky to have escaped or survived their past, but it does not leave them. Seeing a consistent, familiar face of someone who speaks their language can strengthen the relationship and ease the path toward healing. It also helps to have bilingual and culturally competent staff in our other departments at Bread, such as legal and social services staff who can help assess additional factors contributing to depression.

So at the end of the day, many patients are seen in our medical clinic. We understand the link between primary care and mental health and the population seeking care. So when patients come in, the answer is yes. We will help when you are ready. And yes, you can see your provider because we don’t want to miss a good day or a bad day.