Psychiatrists Find Home In Primary Care Clinics

Two years ago, one-fourth of Houston's Harris County Hospital District's patient visits included a psychiatric diagnosis, a daunting figure that left the system's primary care physicians frustrated.

“We'd have patients with diabetes or high blood pressure who wouldn't take their medications or couldn't get them filled or were too depressed or anxious about side effects,” said Thomas Gavagan M.D., M.P.H., the system's vice chair for community health and assistant chief of staff at the community health program in the Department of Family and Community Medicine at the Baylor College of Medicine. “All this led to primary care not being very effective.”

The psychosocial burden on patients was not trivial. The Harris County system is one of the largest health care providers in the country for persons on public assistance, recording 1.2 million patient visits a year. Despite the 25 percent prevalence of psychiatric diagnoses in its patients, those who needed to see a psychiatrist had to wait six to eight months for an appointment at the system's main facility, Ben Taub Hospital.

“The district couldn't afford to hire another 20 or 30 psychiatrists, so we had to reorganize,” said Britta Ostermeyer, M.D., director of the psychiatric outpatient clinic at Ben Taub and an assistant professor of psychiatry at Baylor College of Medicine.

Their solution, part of a wider trend in patient care, meant putting their psychiatrists and mental health professionals into primary care clinics.

The Community Behavioral Health Program began as a test at three sites in 2004, the latest example of integrated or collaborative care, a practice model that has slowly gained acceptance over the last decade. Collaborative care involves systematic care management—usually by a nurse, social worker, or other non-M.D.—linked to consultation with the primary care provider and a psychiatrist or other specialist.

“Under the new system, a psychiatrist may see scheduled patients but is also available to consult with the primary care doctors, either in or out of the examining room, while the patient is still there,” said Ostermeyer.

The hospital district and the Hogg Foundation of Austin gave $1 million in July 2005, to expand the program to the three hospitals, 11 primary care clinics, seven school-based clinics, and several other partner sites that compose the system.

Today, the system's nine psychiatrists work at the primary care sites, backed up by social workers who conduct individual or group therapy three to five days a week at each site. Substance-abuse counselors also spend three to five days each week at the primary care locations.

Once patients are stabilized, the primary physicians can supervise their mental health care. More severe cases are treated in the hospital or directly by the psychiatrists.

“The program mirrors the way that cardiologists and other specialists work,” said Ostermeyer. “They assess and stabilize patients then return them to the care of their primary doctors, who can write cardiac prescriptions as needed.”

The waiting period has dropped from six to eight months down to four weeks, said Ostermeyer.

Patients in crisis can be seen the same day by psychiatrists or by a social worker in their absence. The program helps reduce stigma and overcomes barriers to psychiatric care because patients visit the same site for both psychiatric and primary care.

“The integration of psychiatry into the team makes a more powerful primary care unit that can take care of most problems in a cost-effective way,” said Gavagan. “We used to spend a lot of time addressing the tip of the iceberg. We just treated the physical symptoms—headache, palpitations— or ordered a bunch of tests. But we have limited resources for the number of patients we see, so resources have to be directed more effectively.”

Psychiatry Now `Carved-In'

The psychiatrists also run an educational program for the system's primary care physicians. They lecture on major psychiatric issues like bipolar disorder, depression, psychosis, child psychiatry, and medications. Where psychiatry was once carved out of primary care, now it is “carved in,” said Gavagan. “The physical and psychosocial sides are connected.”

Psychiatrists also have set up a mental health curriculum for the primary physicians' office staffs, and for residents, as well.

“The psychiatry residents get exposure to the integrated model of care, while primary care residents have a chance to work with psychiatrists and get more practical exposure to psychiatry,” said Ostermeyer.“ It's a great experience for them.”

Such models of care are becoming more common, said Nicholas Kates, M.D., a professor of psychiatry and family medicine at McMaster University in Hamilton, Ontario. They were a more prominent part of psychiatric care in Great Britain for a long time and have been part of major initiatives in Canada. In the United States, increasing academic research has led the way in studying the effectiveness of these models.

Clinical Trials Study Integrated Care

More than 20 clinical trials over the last two decades have examined the effects of integrating care, moving from “screen and refer” to“ screen and treat.”

The IMPACT study of 1,800 elderly patients reported in 2003 that nurses, supervised by psychiatrists, improved patient outcomes by about one-third, said study leader Wayne Katon, M.D. a professor and vice chair of psychiatry and behavioral science at the University of Washington Medical School in Seattle. The PATHWAYS trial of patients with depression and diabetes found that treating depression, which is twice as frequent among patients with diabetes, improved both depression scores and diabetes outcomes.

“And it may save medical costs, as well,” said Katon.

Nationally, sources like the Hartford, the Robert Wood Johnson and MacArthur foundations, the National Institute of Mental Health, and Department of Veterans Affairs have funded studies and demonstration and dissemination projects in integrated care that are leading to wide-ranging changes in practice, said Katon.

If perhaps 25 percent of patients seen in primary care have a mental health diagnosis, an additional 20 percent have problems following their regimens because of behavioral problems, said Katon. “So half of what doctors do is mental health work. Without integration we won't be able to provide support to patients with mental illness.”

“Many mental disorders must be understood as chronic illnesses, so perhaps care should be shared within primary care among physicians and other professionals,” said Kates. Kates's clinical work includes a large practice involving 145 family physicians in Hamilton, such that 60 percent to 70 percent of the city's population now has access to mental health services in primary care offices.

Collaborative care involves more than putting a specialist in a primary care setting, cautioned Henry Chung, M.D., a clinical associate professor of psychiatry and assistant vice president for student health at New York University.

“It's not as easy as you think,” said Chung, in an interview.“ You can't just plop a psychiatrist into a primary care setting.”

Access to specialty support in the same primary care setting is the key, he said, but the culture of psychiatric care may have to adjust as well.

For instance, in a similar program, Chung and colleagues scheduled appointments twice as frequently, every half hour, to mesh more closely with the pace of primary care doctors, who see patients every 15 minutes. Psychiatrists also wore white coats to match the primary care doctors, overcoming patient resistance to “seeing a psychiatrist” and lessening stigma.

“Integrated care is a very exciting idea,” Katon said.“ As psychiatrists we can do more in a primary care setting than when we hang up a shingle.”

A discussion of collaborative psychiatric care, “Transforming Mental Health Care at the Interface With General Medicine,” is posted at<http://ps.psychiatryonline.org/cgi/content/full/57/1/37>.▪

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