First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.
Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.
I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.
That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:
I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:
The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?
There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.
In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the
This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!
