Future Psychiatrists Learn Why Integrated Care Is Critical

There is “a huge opportunity in psychiatry to make contributions to reducing costs while improving the health of our patients by integrating primary care and mental health care,” said Roger Kathol, M.D., president of the consulting firm Cartesian Solutions and an adjunct professor of internal medicine and psychiatry at the University of Minnesota.

Kathol, who is board certified in both disciplines, spoke to a group of eager listeners—medical students attending the APA Institute on Psychiatric Services in San Francisco last October.

The session was organized by medical students Steven Chan and Aislinn Bird for PsychSign, an organization of medical students interested in psychiatry as a career. Chan and Bird both attend the University of California, Irvine, School of Medicine.

“Concurrent mental and nonpsychiatric illnesses interact to worsen clinical outcomes,” Kathol pointed out. “Segregating treatment ignores the negative effects of that interaction.”

Among patients with serious mental illness, 75 percent have at least one physical disorder and 50 percent have at least two, he said. These complex patients make up 2 percent to 5 percent of the U.S. population, but they account for 50 percent to 70 percent of health resources. Even so, their medical costs are relatively small compared with the disability, nonproductivity, and social-service costs that accrue if any of their illnesses go untreated.

Making a dent in these costs isn’t easy in a fragmented and segregated health care landscape, Kathol noted. Only about 41 percent of people with mental illness are treated, with approximately half of that group receiving that treatment in primary care settings.

“Psychiatrists should be involved in the care of these complex patients because they are in a special position to understand the interactions of diseases, treatments, and side effects,” he emphasized.

He cited studies showing that integrated depression treatment saved about $2.9 million per year for care of 100,000 patients. A program at Johns Hopkins designed to prevent delirium, for example, saved the hospital and payers $16.5 million in inpatient costs across 30,000 admissions.

Looking ahead, Kathol said that the highly touted idea of co-located primary and mental health care was “hugely important” but not the only answer.

Ideally, the psychiatrist should be part of a team, working with the primary care physician, not merely by having an office down the hall, but by sharing information about patients, diagnoses, treatments, and potential drug interactions, he said. The goal should be treating patients so that they get healthy, not merely “better.”

“We have also worked with social workers, psychologists, and nurse practitioners who can help get patients psychiatrically well, and thus affect their physical health,” he said. The problem with this ideal, Kathol added, is that the health system doesn’t pay for it, although that may change once last year’s health care reform law becomes fully implemented in a few years.