Background

For many individuals with serious mental illness diagnoses, mental health (MH) clinics serve as their primary healthcare contact; thus, there is growing interest in “reverse integration,” or delivery of primary care (PC) services in MH clinics. Providing contraception in MH clinics is a potentially impactful example. To inform such efforts, we assessed patient and provider attitudes on contraceptive counseling and provision in public MH clinics.

Methods

Applying a reproductive justice framework and principles of community-partnered participatory research, we partnered with leadership of a large, urban, safety net MH system to conduct qualitative interviews with 36 MH providers (psychiatrists, therapists, case managers, and nurses) and 22 reproductive-aged cisgender women patients (predominantly Black or Latina). Interviews focused on experiences and preferences of addressing contraception during routine MH care. Providers also responded to a vignette of a sexually active patient who desires to avoid pregnancy and is not using contraception. We used rapid qualitative analysis to summarize interview transcripts and identified themes using matrix analysis.

Results

Patients described limited experiences discussing contraception with MH providers, but many expressed a desire for discussion, citing relevance to MH and wanting information about contraceptive options or potential interactions with psychotropic medications. Those who had discussed contraception described these conversations as appreciated or “normal.” Asked whether they would prefer to receive contraceptive services from their MH or PC clinic, some favored PC, citing the relevant medical knowledge and scope of practice of PC providers. Others favored MH, citing a closer relationship and the MH provider’s intimate knowledge of the individual’s MH symptoms and medications. Providers varied in their experiences with and comfort discussing contraception. Some brought it up routinely; many never discussed it or brought it up only when concerned. In response to the vignette, most providers said they would educate the patient on her pregnancy risk and refer her elsewhere (e.g., PC or free clinic) for contraception; some would discuss specific contraceptive options. Providers shared concerns about pressuring the patient or that the patient might be uncomfortable or unreceptive. Providers who expressed discomfort around discussing contraception often cited scope of practice or lack of knowledge, training, or experience. Several male providers expressed gender-related discomfort.

Conclusions

Patients expressed a desire to discuss contraception with MH providers; providers, however, varied in degree of comfort and competence in contraceptive counseling. MH providers would benefit from training in contraceptive options, side effects and patient-centered contraceptive counseling approaches to mobilize their trusted relationships with patients to bridge gaps in access to contraceptive services.