Psychiatry can play a leadership role in improving the quality and equity
of population-based mental health care through authentic partnerships with
community-based organizations, according to Kenneth B. Wells, M.D., M.P.H.
But the application of evidence-based strategies, especially in underserved
minority communities, and the development of such community collaborations are
fraught with systemwide barriers reflecting the decades-long emphasis of
American medicine on individual rather than population-based care.
Overcoming those barriers will require not only the commitment of
individual psychiatrists, but also a redirection of professional medical and
psychiatric identity toward the care of populations, said Wells, who received
APA's 2006 Research in Psychiatry Award at APA's 2006 annual meeting last
month in Toronto.
"We need to be thinking of what medicine and psychiatry are about and
develop a public-health perspective that is responsive to community mental
health priorities," he said. "That has really gotten lost in our
He is a senior scientist at RAND Corporation, a professor of health
services at the UCLA School of Public Health, and a professor of psychiatry
and behavioral sciences at the Geffen School of Medicine at UCLA. He is also
principal investigator for the NIMH-UCLA/RAND Center for Research on Quality
in Managed Care and the Robert Wood Johnson Foundation Community Partnership
Wells made his remarks in the lecture "The Search for Quality and
Equity in Mental Health Care for Psychiatric Disorders: A Story of
Opportunity, Evidence, and Partners." In the lecture, he outlined a
professional journey that began when he was co-chair of the psychiatry
curriculum for first-year medical students at UCLA.
In that role, he helped to develop a program for medical students on
awareness of race and cultural biases and founded a minority student research
program. He also helped to develop awareness programs for students around
religious tolerance and death and dying.
"The experience convinced me that psychiatry can play an essential
leadership role in medicine generally through its understanding of human
nature and behavior in the complex interactions that play out in the medical
world at critical periods in people's lives," he said. "It also
gave me a burning passion to understand what influences physician as well as
Later, he joined RAND, where he was lead author on a number of papers from
the landmark RAND Health Insurance Experiment. Since then, Wells has studied
the question of whether participatory research programs designed to engage
community stakeholders can increase the reach of evidence-based strategies in
In something of a departure for annual meeting lecturers, he was joined at
the podium by fellow researcher Loretta Jones, M.A., who discussed the
possibilities and pitfalls of community engagement and partnership. She is a
co-investigator with Wells of the NIMH-UCLA/RAND Center for Research on
Quality in Managed Care and has long been a community activist.
Together, they described the Witness for Wellness Program, a
community/academic collaboration focusing on raising awareness of depression
in the Los Angeles area. The partnership was based on a model used by Healthy
African-American Families, a community-based agency in south Los Angeles, and
the Partners in Care model developed at the UCLA/RAND NIMH Health Services
A number of papers describing preliminary findings from the collaboration
appeared in the January Ethnicity and Disease and are available
online in abstract form at<www.rand.org/health/feature/research/0603—wellness.html>.
"Based on our first three years with this initiative, our impression
is that depression is being discussed in the community, and community leaders
have emerged," Wells said. "Community members are very active in
working on all aspects of research, and our partnerships are expanding. There
are now 40 or 50 organizations involved, and I think that the partnership has
Yet the barriers facing widespread application of such community-based
partnerships are pervasive.
"Medicine faces a profound quality chasm and disparities of care,
including the care of psychiatric conditions, something we have seen in study
after study," Wells said. "For depression, we know that
evidence-based programs can support higher quality care while reducing
disparities— that's an important piece of information.
"But it's very challenging for psychiatry to consider these models,
especially when you think of rolling them out in practice," he said."
Our practices as clinicians are oriented to individual care, not
population-based care. Moreover, many clinicians are opting out of insurance,
which means there is a larger and larger gap since the public sector is
oriented toward [treatment of] severe mental illness."
There are few mechanisms for quality accountability in day-to-day clinical
practice, especially for psychotherapy. And Wells noted that psychiatry
residency programs have only just begun to require demonstration of competency
in evidence-based psychotherapies.
"Our information systems are scattered across different care sectors,
and the privacy regulations under HIPAA make quality monitoring very
challenging," he said. "Finally, we face knowledge gaps and social
stigma that lower the public demand for quality services. This is especially
true for minority communities that are already facing stigma."
But Wells suggested there is an emerging groundswell of interest in
community collaboration, evidenced by a new focus on the subject in the Robert
Wood Johnson Clinical Scholars Program at a number of leading academic
He also emphasized the vital importance of individual professional
responsibility. "One thing we have learned from pursuing an agenda like
this is that it really takes a village, and the village starts with