In 1974 the music critic Jonathan Landau penned a classic article in which he stated, “I have seen the future of rock and roll and its name is Bruce Springsteen.” Landau was commenting on his impression of the debut album of the then-fledgling rock star. If you will permit my imaginative analogy, I believe that the same can be said about the collaborative care model with respect to the future of psychiatry. For this reason I invited Jürgen Unützer to co-author this column for Psychiatric News.
With the enactment of the Affordable Care Act, the rise of accountable care organizations and patient-centered medical homes, and the increased national attention on mental health, psychiatrists and primary care providers have an unprecedented opportunity to join together and work collaboratively on increasing the overall health of millions of Americans. APA recognizes this opportunity and has been actively involved in efforts to improve integration and collaboration with our primary care colleagues.
As one of the largest medical specialties, psychiatry is an important component of the physician workforce in the United States, but psychiatrists are distributed unequally around the country. More than half of the counties in the United States don’t have a single practicing psychiatrist. Only about 1 in 10 adults with a diagnosable mental disorder receives care from a psychiatrist in any given year and patients are much more likely to receive mental health treatment from their primary care provider than from a psychiatrist. It is well known and often said that 40 percent of primary care (adult and pediatric) involves dealing with psychiatric problems. Our colleagues in primary care are well aware of the substantial challenges related to treating the millions of patients who present with mental health problems in their offices every year and report serious limitations in the support they receive from psychiatrists and other mental health specialists.
Although we have effective pharmacological and psychosocial treatments for most common mental disorders, they are not widely accessible, and only a minority of patients receive them. Many patients are not on medications at therapeutic doses or for long enough to see positive effects, while others continue to use medications even if they are not effective. As few as 20 percent of patients started on antidepressant medications in primary care show substantial clinical improvements. The situation is not much better for those referred for psychotherapy. Many who are referred don’t go. Others may receive an insufficient number of visits or ineffective forms of therapy, leaving big opportunities to close the gaps between what we know and what we do.
One way to help close these gaps is for psychiatrists to work more closely with our colleagues in primary care using a collaborative care approach. Originally developed and tested by Dr. Wayne Katon and colleagues at the University of Washington in the early 1990s, collaborative care has been examined in the treatment of depression and anxiety disorders in more than 80 randomized, controlled trials and has consistently been found to be more effective than care as usual. In such programs, psychiatrists work closely with primary care physicians and mental health care managers (usually a licensed clinical social worker, nurse, psychologist, or therapist). Each team has a designated psychiatric consultant who provides systematic treatment recommendations on patients who are not improving as expected.
Effective collaborative care programs follow the established principles of chronic illness care including measurement-based care, treatment-to-target, and stepped care. Each patient’s progress is closely tracked using validated clinical rating scales (for example, PHQ-9 for depression), analogous to how patients with diabetes are monitored via regular HbA1c tests. Treatment is systematically adjusted if patients are not improving as expected. Such adjustments can often be made by the primary care treatment team, with input from the psychiatric consultant. This type of systematic treatment-to-target can overcome the clinical inertia that is often responsible for ineffective treatments of common mental disorders in primary care. The psychiatric consultant typically focuses in-person assessments on patients who present special diagnostic or therapeutic challenges. Patients who continue not to respond to treatment, who have an acute crisis, or who prefer to see a psychiatrist in traditional practice are referred to appropriate specialty mental health care.
In Washington state’s Mental Health Integration Program (MHIP), for example, which was designed to help low-income or safety-net populations gain access to quality mental health care, psychiatric consultants typically support primary care–based care managers with active caseloads of about 50 to 100 patients. For patients who suffer from anxiety, depression, or bipolar disorder, most of the consultation is done directly with the care manager who then passes on psychotherapy and/or psychotropic recommendations to the primary care physician. Patients who are not improving or those with more serious forms of mental illness can be prioritized for a face-to-face or televideo consultation with the psychiatric consultant who then provides advice on an appropriate treatment plan. Using this collaborative care approach, MHIP has served over 35,000 patients in more than 148 primary care clinics statewide with the support of five FTE psychiatric consultants, a reach that would be impossible in a more traditional practice model, especially in rural areas.
Collaborating with our colleagues in primary care can substantially improve access to mental health care and create a more patient-centered care experience for patients who often have both mental health and acute or chronic medical problems. Closer collaboration may also help our patients with more severe mental illnesses such as bipolar disorder or schizophrenia. These patients often receive most of their care in community mental health centers and other specialty mental health programs where a psychiatrist is often the only physician they will see. Research from the United States and several European countries has demonstrated that patients with such chronic and persistent mental disorders die 10 to 25 years earlier than those without mental disorders, most often not from their mental illness but from health risk factors such as smoking and obesity and from inadequately treated hypertension and diabetes, sometimes worsened by the antipsychotic medications we prescribe. This is a situation where we need help from our primary care colleagues.
When behavioral health problems are effectively treated with collaborative care, patients experience improved quality of life, better self-care, better adherence to medical and mental health treatments, and better overall health outcomes. Evidence on collaborative care also suggests that these programs not only improve care at the individual and population-based levels, but also they can lower total health care costs. In the language of health care reform, this is called achieving the “Triple Aim.” For psychiatrists who enjoy working in teams and working closely with their nonpsychiatric physician colleagues, collaborative care presents a wonderful opportunity to bring their expertise to help a larger population of patients. ■