Learning to Share

One of the core principles underlying effective integrated behavioral health care programs is a concept called “task shifting” or “task sharing.” The World Health Organization (WHO, 2008) has described task shifting as the rational redistribution of tasks among health care teams. When feasible, health care tasks are shifted from higher-trained health care professionals to less highly trained workers to maximize the efficient use of the existing workforce.

At a recent Summit on Innovation in Global Health, I encountered powerful examples of how this approach can be effectively employed in mental health from low- and middle-income countries such as India and Chile. In these settings, task sharing allows psychiatrists to support large populations of patients who would otherwise have little access to specialty mental health care.

The principles of task sharing are relevant not only in low-income countries; they may also be helpful in rural or otherwise underserved settings in the United States, where there may never be enough mental health specialists. In such settings, treatments that might otherwise be provided by a psychiatrist (for example, medication management for depression or anxiety disorders) may instead be provided by a primary care physician or a nurse practitioner who has regular consultation with a designated consulting psychiatrist. Similarly, master’s-level counselors and even trained lay individuals such as community health workers can provide education, support, and brief structured psychotherapies with support from a mental health specialist.

Stein and Test demonstrated the value of effective task sharing in the care of patients with severe and persistent mental illnesses in the 1970s when they studied the effectiveness of assertive community treatment (ACT) programs, now the gold standard for good community mental health care. Effective ACT teams have members who respect, trust, and complement each other in their skills and can accomplish things that no one team member could easily accomplish alone. The research evidence for collaborations of psychiatrists and primary care physicians goes back to the early 1990s when Wayne Katon, M.D., and colleagues first studied this approach in a randomized, controlled trial. Since then, more than 70 studies have proven that effective collaborations of psychiatrists with primary care providers and other health care professionals can result in better outcomes for patients with common mental health problems, such as mood or anxiety disorders, who are often seen in primary care and school-based health settings.

Such programs not only help us reach more people in need of mental health care but provide us with an opportunity to provide truly patient-centered care. If we work closely with a patient’s primary care provider, we can address both the physical and behavioral health needs of our patients in one place. Mental and physical health are inextricably linked, and it makes sense to have general medical providers and psychiatrists working closely together.

A recent follow-up of participants in the IMPACT study, the largest study of collaborative care to date, reported in the January Psychosomatic Medicine that over an eight-year period, patients without preexisting heart disease who received collaborative care were half as likely to have serious cardiovascular events or deaths than those who received care as usual.

We can see examples of effective task sharing in sports, music, and other fields of medicine (for example, surgery, which often requires highly sophisticated collaboration of complementary team members). On a sports team, each member has a clearly defined role and skill, but an effective team is much more than the sum of its parts. In an orchestra, a violinist must master her own instrument, but she also has to learn to play well with others to create truly beautiful music. To be an effective consultant on a collaborative care team, psychiatrists have to be solid and comfortable with their own skill set. They also have to learn to work with and trust other team members who complement their strengths. As the most highly trained mental health professional on a collaborative care team, psychiatrists should also provide leadership to make sure the team is adequately trained, resourced, and supported to be effective.

When we learn to share effectively, we reach more patients than we could on our own and we provide better care. Going back to the music analogy, when we learn to play together, we have an opportunity to produce beautiful music and enjoy the process of making music together.

The concept of task sharing is simple, but in my experience, this kind of sharing or collaboration is not a natural state for most health care providers, psychiatrists included. In other words, we may have to learn to share. For psychiatrists, such learning should start in residency and fellowship training, and recent articles by several early career psychiatrists (see end of column for references) have explored ways to learn such skills early on. Mid-career psychiatrists interested in sharing their knowledge and expertise as part of a collaborative care team are increasingly finding opportunities to learn and share these skills at APA’s annual meeting, APA’s Institute on Psychiatric Services, and the Academy of Psychosomatic Medicine’s annual meeting. ■