Caring for patients with depression takes work—often too much work
for primary care doctors to handle alone, although they may shoulder that
burden because there are too few mental health clinicians around to help.
Beginning a couple of decades ago, physicians and health service
researchers began looking for ways to make depression care in the primary
setting more effective, especially given the overwhelming need and the
insufficient resources available to cope with it. One choice was co-location,
having psychiatrists set up shop in the same clinics as primary care doctors.
A referral could be handled by walking down the hall—if the psychiatrist
were not already overbooked. Co-location alone was not the answer, many now
Another model, which grew into programs like IMPACT or RESPECT, was
developed based on a closer interaction of primary care clinics with mental
health providers. In IMPACT, the psychiatrist stays in the background, serving
mainly as a consultant or reference source, backing up a care manager and the
primary physician who handle diagnosis and care.
IMPACT has produced many offspring, but not all are identical twins. As
with evolution, variation arises depending on local conditions and interests,
driven as much by necessity as by choice.
The Dartmouth-Hitchcock Medical Center in New Hampshire is putting together
its version now, one that combines the psychiatrist's presence in the primary
clinic with an extended role as a consultant to the primary team, along with
some limited clinical activity.
The system is expected to be in operation by late summer, although
educational programs for the doctors and other staff at the family practice
group have already begun.
"We began as part of a year-long, strategic planning process for the
whole medical center, looking not at just caring for the individual patient
but for the population in the region," said William Torrey, M.D., an
associate professor of psychiatry at Dartmouth Medical School.
The Department of Psychiatry at Dartmouth-Hitchcock worked closely with its
primary care community in designing a collaborative-care program adapted from
IMPACT. They sought to build care around a medical-home model by linking a
psychiatrist directly with teams in pediatrics, family practice, and general
internal medicine in outlying towns as well as at the main medical center.
"Our aim is to build a system based on what had been shown to
work," including IMPACT, he said.
The medical center agreed to hire a full-time psychiatrist who devotes one
day a week to leading the collaborative process for the whole system.
Christine Finn, M.D., directorof the Crises and Consultation Service, moved
from Massachusetts General Hospital to Dartmouth in January to organize and
manage the program. She has extensive consultative experience in emergency
"Our first goal is to provide more specific support to primary care
physicians by being present in person at least once a week at general internal
medicine or family practice sites," said Finn in an interview."
That personal connection, knowing that they're there, may be the most
Plans currently cover the main medical center and sites in three other
towns within driving distance of the main campus. Different psychiatrists will
be attached to each clinic, adding up to the one new full-time equivalent
Along with the primary care provider and the psychiatrist, the depression
care manager will serve as the team's third member.
The care managers will serve as the pivots for the system. They will meet
in the office with the patient, offer education on depression, follow up by
phone, monitor medication adherence and side effects, troubleshoot any
problems, and coordinate care with the primary physician. Care managers will
use the PHQ-9 for both diagnosis and for measuring patient progress. All three
team members will consult on referrals for additional therapy when needed.
Care managers may be licensed clinicians and may offer some therapy, but
Torrey is wary of filling their time with therapy if it would crowd out their
care managerial duties.
At Dartmouth, the psychiatrist may also provide some short-term care in
some circumstances, but will not take on many patients for long-term
"The psychiatrists will see patients and be available for short-term
management but will also attend team meetings and be available for informal
consults," she said. These embedded psychiatrists will also provide
easier access to expertise for the primary physicians and for the care
managers, helping them choose the right therapy and the right therapist for a
The psychiatrists also will offer formal didactic talks on topics of
interest, like suicidality, or informal conferences over lunch at which the
primary clinicians present cases for discussion.
"Care for patients with conditions other than depression will remain
the shared responsibility of the primary care physician and psychiatric
resources now available at the medical center or in the community," said
Finn. "The new program will ... be best able to determine the type of
psychiatric care that would be of benefit if they are being referred
These varying roles can provide the primary practice with a better
understanding of depression, its management, and its measurement to improve
clinical decision making, say its advocates.
Funding the program still presents problems, said Torrey. Insurance will
pay for some direct evaluations but not the system's consultative functions.
They will be covered by the medical center for the moment.
"Insurance doesn't pay adequately for behavioral health care, so you
can't do it unless you subsidize it," said Torrey in an interview."
It's hard to grow if you're going to lose more money by growing. At the
same time, there is great demand relative to supply."
Linking psychiatry closer with general medical care may be good for both
patients and psychiatrists, commented Thomas Wise, M.D., chair of the
Department of Psychiatry at Inova Fairfax Hospital in Falls Church, Va.
"Psychiatry has something to offer primary care, so we have to
develop a model where we're included on the inside of the medical home,"
said Wise. ▪