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
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
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,
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.
Courtesy of Britta Ostermeyer, M.D.
Following a request from Brett Perkison, M.D. (left), a primary care
physician and medical director of the Strawberry Community Health Center,
psychiatrist Britta Ostermeyer, M.D. (right), discusses the patient's problems
and psychiatric treatment plan.
"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
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
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.
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
"It's not as easy as you think," said Chung, in an interview."
You can't just plop a psychiatrist into a primary care
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
"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>.▪