One of the best ways in which American psychiatrists can extend mental
health care to more Americans is to work together with family doctors,
Canadian psychiatrist Joel Paris, M.D., argues in his new book,
Prescriptions for the Mind.FIG1
But what are the chances of such "collaborative care" between
psychiatrists and family doctors becoming a seismic
Actually quite good, according to U.S. psychiatrists who are pioneering and
promoting the practice.
The concept of collaborative care, which started about three decades ago in
England, was imported into the United States during the 1990s, notably by
Wayne Katon, M.D., and colleagues at the University of Washington. Today Katon
is a professor and vice chair of psychiatry at the university.
That collaborative care in the United States debuted in Washington was not
by chance, Jurgen Unutzer, M.D., also a professor and vice chair of psychiatry
at the University of Washington, told Psychiatric News.
"We are the only medical school with a psychiatry training program
for a five-state region that makes up a quarter of the land mass of the
continental United States.... The only care available to people in this region
by and large is primary care. There just aren't enough psychiatrists. So we
have to leverage what is a tremendously limited resource and assist our
colleagues in primary care in caring for patients with some common mental
Early on, Katon and his colleagues applied research principles to the
concept of collaborative care to learn whether integrating psychiatrists into
a primary care clinic could improve the outcomes of depressed patients. They
found that it could. They reported these seminal results in the April 5, 1995,
Journal of the American Medical Association.
Since then, they and other researchers have found that partnering between
psychiatrists and primary care doctors can help depressed patients
(Psychiatric News, June 3, 2005; January 20, 2006; April 7, 2006). To
date, there have been 37 trials, Katon said in an interview. "Overall,
the trials have shown a dramatic effectiveness of collaborative care, compared
with usual primary care."
And since then, Katon noted, "What people have begun to ask is, 'If
this works for depression, might it work for some other mental disorders?' So
trials have been launched to find out. For example, two trials have shown that
it is very effective for panic disorder. We have also begun testing the model
in patients with depression and medical comorbidities, particularly diabetes
and heart disease."
Partnering between psychiatrists and primary care doctors assumes various
profiles. For example, Britta Ostermeyer, M.D., an associate professor of
psychiatry at Baylor College of Medicine, and colleagues have established a
collaborative-care program between psychiatrists and primary care doctors at
Harris County Hospital in Houston to care for patients with depression or
anxiety disorders (Psychiatric News, March 17, 2006).
"We are furthering the scope of what the primary care physicians
do," she explained. "We want them to diagnose mental illnesses,
make referrals for those patients whom they cannot properly treat or address
themselves, and then when a psychiatrist stabilizes those patients and refers
them back, they continue the care. So that is one aspect. The other aspect is
that there are patients who do not need to be seen by a psychiatrist.... The
primary care doctor seeks a 'curbside' consultation with the psychiatrist and
then goes back and treats the patient."
Such collaboration, initially only research based, is becoming routine
clinical practice in several places. Count Ostermeyer's program among these,
along with the groundbreaking approach at the University of Washington where
psychiatrists practice within most of the university's large primary care
In California, the large HMO Kaiser Permanente has integrated psychiatric
staff into all of its primary care clinics. This means that collaboration
between psychiatrists and primary care doctors has become a standard benefit
for some 6 million Californians who receive health care through Kaiser. A
project at the Department of Veterans Affairs (VA) called the Tides and Waves
Project is expanding its partnering between psychiatrists and primary doctors
to VA outpatient clinics throughout the country.
Probably the most groundbreaking collaborative-care operation that is
moving beyond research into clinical practice is the Diamond Project in
Minnesota. It is run by the Institute for Clinical Systems Improvement, which
is working to get routine depression screening with the nine-item Patient
Health Questionnaire (PHQ-9) established in some 25 large primary-care groups
and in some 90 clinics in Minnesota. The institute is also working to get
eight health insurance companies to pay for such screening, as well as for the
services of psychiatrists, primary care doctors, and case managers who assist
in treating the screened patients found to be depressed.
And more is coming. "All sorts of places around the country are
looking into doing collaborative care by bringing primary care and psychiatry
together at one location," Ostermeyer observed.
In the rush to transform psychiatrists and primary care doctors into
confreres, experts agree that several hurdles need to be overcome.
"I think the biggest challenge is payment," Unutzer said,
adding that although some insurance companies are making it easy for primary
care clinics to adopt the collaborative-care model (Psychiatric News,
January 20, 2006), others are not.
A second obstacle is getting collaborative-care models past review sections
at the National Institute of Mental Health (NIMH) or the VA. "Most
people who sit on review sections at the NIMH or at the VA," Katon said,"
tend to be 'splitters' or 'lumpers.' Splitters are people who want you
to do something in a very narrow population very well. Lumpers are
people" who want you to do something for more people with the resources
A third barrier to be overcome is to "change the mentality of primary
care physicians, especially some of the older generation," Ostermeyer
noted. "Some are not comfortable prescribing psychiatric
"Effectiveness studies have shown that you can improve patient
outcomes dramatically by using algorithms to make sure that patients are
getting evidence-based care and then to refer them to specialty care if they
are not meeting certain criteria," said David Katzelnick, M.D., a
clinical professor of psychiatry at the University of Wisconsin. Yet he also
noted that getting such algorithms implemented in collaborative-care clinics
is tough. In other words, there are two separate challenges. One is convincing
primary care doctors that using algorithms is worthwhile. The other is
actually getting them to put algorithm information into patients' medical
records so that psychiatrists and other health care providers have access to
Nonetheless, partnering between psychiatrists and primary doctors has its
"Our patients are absolutely thrilled that they can walk into their
neighborhood primary-care center and get psychiatric care," Ostermeyer
attested. "It removes the stigma that surrounds walking into a
"Primary care patients really like getting results from the
PHQ-9," Katzelnick reported. "The PHQ-9 is also very helpful in
communicating with primary care clinicians and in advising them on depression
"For me, the main reward is that I feel that I am providing better
patient care," Unutzer remarked. "I am providing care to whole
patients, not just to their minds or emotions. For example, if a patient says,
'I hurt all over,' I can address the depression and then work with a primary
doctor to address the arthritis pain."
"Part of the gratification for me," Katon noted, "is that
we psychiatrists are able to treat a much wider portion of the population than
we would otherwise be able to treat."
The best in the psychiatry-primary care partnership may be yet to come.
"We are seeing a dramatic expansion of it now, and I think that is
going to continue because there is going to be more demand from regulators,
insurance, and the government to provide evidence-based care," Katon
"Certainly many large health care settings, like the VA and the large
HMOs, but also many federally qualified health centers that serve low-income,
uninsured, safety-net populations are moving toward integrating mental health
specialists into their clinics," Unutzer observed. "So I think we
will see more of this. I think we will start to train psychiatrists to work in
these kinds of settings. I also think we are going to see more of the
reverse—those of us who practice in mental health specialty settings are
going to find ways of inviting our colleagues in [primary care] medicine to
help care for our [seriously, persistently ill] patients."
"I hope that collaborative care will become the standard of care
within the United States and that reimbursement of clinicians will be
restructured to support it," Katzelnick asserted. "I think that is
starting to happen. The Diamond Project is an example.... If that goes well,
it will spread throughout Minnesota, and I know that Wisconsin is also looking
"I think there is a bright future for collaborative care because both
primary care and psychiatry realize that they need each other,"
Ostermeyer said. "For the new generation of primary care doctors, it
will be normal and natural for them to treat mental illness, just as they
treat cardiac conditions." ▪