Psychiatrist Urges Public-Health Focus To Eliminate Barriers to Care

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 field.”

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 Initiative.

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 patient behavior.”

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 underserved communities.

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 Research Center.

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 become authentic.”

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 institutions.

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 you.” ▪