Fellowship Expands Behavioral Health Care Where Needed the Most

One way to increase access to effective mental health treatment in primary care is to leverage the expertise of limited mental health professionals through integrated care models. Another way is to increase the expertise of primary care providers in the provision of psychiatric care. This month, we learn about a new Primary Care Psychiatry Fellowship in California that has already made a big impact in increasing the knowledge and confidence of primary care providers treating patients with mental illness. —Jürgen Unützer, M.D., M.P.H.

Primary care providers (PCPs) outnumber psychiatrists nearly 7 to 1 in the United States. More than 70 percent of patients who receive psychiatric medications get their prescriptions from their PCPs, and approximately 30 percent of patients seen in primary care have psychiatric disorders. Mental health and substance use specialists are not readily available for consultation, and less than 50 percent of patients referred to mental health services ever see a mental health clinician. The primary care setting functions as the principal or de facto mental health delivery system in the United States.

Unfortunately, PCPs are often not appropriately or consistently trained to meet the behavioral health needs of the patients they see, which results in suboptimal prevention and treatment of behavioral health conditions and associated diminished longevity for those who suffer with mental illness.

The University of California, Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry Fellowship was designed to squarely address these concerns. The fellowship is a one-year, non-ACGME accredited certificate program for primary care trainees and providers (for example, internal medicine, family medicine, obstetrics/gynecology, emergency medicine, neurology, physician assistants, nurse practitioners) who wish to receive advanced training in the provision of psychiatric care in primary care settings. The curriculum targets the most frequently encountered mental health–related disorders and evidence-based treatments.

The fellowship consists of two in-person conferences, the first of which is a traditional CME conference in which fellows and other attendees learn the basics of “primary care psychiatry”—an overview of mood disorders, anxiety, psychosis, substance use, personality disorders, and pain. Our kick-off conference will be held in Las Vegas on January 26 and 27, 2018. The second conference focuses on high-yield exercises involving systems analysis to address barriers to implementation of knowledge and skills learned through the fellowship; practice of motivational interviewing and cognitive-behavioral therapies; and presentations by the fellows as “new trainers.”

Each month of the fellowship, learners participate in web-based didactics on topics that take them deeper into the engagement, diagnosis, and treatment of common psychiatric disorders. The fellows are also assigned mentors with whom they have monthly mentoring sessions, either in person or via computer or phone, intended to discuss the questions and challenges that fellows encounter as they implement the knowledge gained from the fellowship. Mentors are principally combined trained (internal medicine/psychiatry or family medicine/psychiatry) physicians who are well versed in the culture of primary care. Fellows have commented that it is this perspective of the combined-trained faculty that distinguish their training from other continuing medical education training. The final component of the fellowship—the TNT portion—focuses on developing skills to transmit newfound knowledge and attitudes to other providers and administrators in the fellows’ home institutions.

Preliminary data on PCPs who participated in the fellowship show increased knowledge, self-efficacy in mental health, and decreased stigmatization of patients with mental illness. Anecdotal comments by the fellows include feelings of decreased stress and increased enjoyment of treatment of patients with mental illness. One fellow felt less “physically tired” at the end of the day, and fellows agreed they felt more able to be present in the moment with patients because they felt more secure with their knowledge in primary care psychiatry.

As we enter our third year, we are hearing from not only individuals and entities from other states, but from other countries as well. It seems that the need for expanded awareness and treatment of mental health disorders in primary care is not exclusively a U.S. problem. We hope to expand the fellowship to provide scholarships, via grant funding, and to provide training to providers in underserved areas, particularly for bilingual and underrepresented minorities in medicine. Future directions also include developing similar TNT fellowships in preventive medicine for psychiatrists, opiate management, sleep medicine and telemedicine.

Just in the first two classes, we can predict positive impact on hundreds of thousands of patient lives. PCPs have an average panel size of 2,300. We’ve taught 84 fellows (not including more than 250 physicians who attended the stand-alone weekend CME conferences) who will go on to teach many more. That’s about 200,000 patients who are seeing providers who are appropriately trained to diagnose and treat mental health disorders. As we continue the fellowship and our fellows continue in their careers and teach other providers, we can expect that number to hit the millions. That’s real impact. ■