The Patient Protection and Affordable Care Act is designed to increase coverage for many individuals, and it explicitly includes a diagnosis of severe and persistent mental illness among the criteria for enrollment in “health homes” of patients who need a higher level of service and coordinated care. However, this progress on recognizing the need for psychiatric care is paralleled by the fact that it is still extremely difficult to access needed care: two-thirds of primary care physicians are unable to refer patients for specialty psychiatric care because of a lack of needed resources, including a severe shortage of child psychiatrists, while 96 percent of rural counties in the United States have an unmet need for mental health services.
Integrated care, which broadly refers to the integration of mental health care and primary care, has become a buzzword in the past few years. This model has been shown to improve access to mental health care (especially for underserved and minority populations) and to improve physical and mental health outcomes across a broad range of clinical measures (including systolic blood pressure measurements, depression scores, and glycosylated hemoglobin and LDL levels). It also reduces mental illness stigma, no-shows, and cost to the system, while improving patient satisfaction. Based on these developments, we are likely at the beginning of an era in which mental health treatment will be integrated with the rest of medicine.
As with any period of change, this era affords psychiatrists unparalleled opportunity to shape our own role in the new system. While the need for specialty psychiatric care in psychiatric settings will remain important, it is likely that the locus of much mental health treatment will shift to primary care settings. In these times, it is imperative that organized mental health advocacy focuses on taking a leadership role in shaping the future of mental health service delivery. In clinical settings, psychiatrists are certainly equipped, by virtue of training, to play a leadership role in guiding the development of integrated services. Primary care clinicians are clearly hungry for such guidance and are willing to work with psychiatrists.
Recent research by the Group for the Advancement of Psychiatry’s Mental Health Services Committee, of which I am a member, offers a framework for considering how psychiatrists’ traditional roles can be adapted for working in primary care settings. Roles key to this framework include the following:
Team member: Psychiatric training emphasizes working in interprofessional teams to enhance patient safety and improve care quality. This is also integral to working in primary care settings, where teamwork and collaboration with other specialties are essential. These skills can easily be adapted for working within health homes or integrated-care settings.
Information integrator: The detailed nature of psychiatric assessments frequently uncovers crucial health-related or psychosocial information that impacts treatment outcomes. Issues such as substance abuse, psychosocial stressors (for example, domestic violence or a history of childhood abuse), or medical problems like cancer, hypertension, or hypothyroidism are often discovered during psychiatric evaluations or when screening labs are ordered. Carefully synthesized by a psychiatrist, this information can meaningfully impact treatment. In addition, psychiatrists are often aware of, or connected to, mental health resources that primary care providers are not and can thus assist with care coordination and referrals.
Resource manager: Treating a previously undiagnosed psychiatric condition, such as depression, often results in functional recovery that impacts other health outcomes and reduces cost to the overall system. Untreated depression, for example, worsens outcomes for patients with pain, strokes, and myocardial infarction. Other ways in which psychiatrists can help manage resources include being aware of options for obtaining psychiatric medications at lower cost, prescription-assistance programs, understanding financing and regulation of psychiatric care, as well as information about the structure of public and private organizations that influence mental health care. This information can be valuable in guiding the primary care team in making referrals.
Patient care advocate: There is ample evidence that patients with mental illness often do not receive medical care of equal quality to care received by patients without such disorders. A psychiatrist working in an integrated-care setting is ideally placed to educate staff about mental illness, model appropriate interventions, and advocate for patients with mental illness, whose behavior may be perceived as obdurate, challenging, or refractory to treatment by the primary care team.
Psychiatrists working in integrated-care settings, as well as primary care physician colleagues, have reported high levels of satisfaction with this approach, and it is a model for the evolving system of integrated care. ■