Advances in Collaborative Care

The number of patients needing psychiatric care far exceeds the supply of mental health providers. Meanwhile, mental and substance use disorders are among the top five conditions leading to disability, and in the United States, mental disorders are first on the list of costly conditions. In addition, the separation of our care delivery into general medical care alone and mental health care alone has failed to adequately address the needs of patients with comorbid conditions; costs for care remain high for this group, and the mortality rates of persons with a serious mental illness exceed by 25 years those with medical illnesses alone.

Clearly this is not a time to double-down on a fragmented mental health system; instead, it is time to reach across the health care silos and into the community if we are to have a chance at effectively and efficiently serving our patients. This issue of Focus brings together a range of professionals involved in some way in collaborative care delivery systems, either in primary care or in mental health care settings. The collaborative care field is a rapidly growing area with much to learn.

In the early days of collaborative care, the focus was on depression and anxiety. In this issue, we sought input on where the model has successfully expanded for other patient groups. Readers may be surprised to learn that patients with bipolar disorder see their primary care physician for psychiatric care at least as often as they see specialists. Cerimele and Kern (1) explain why many aspects of the primary care setting may be optimal for the care of patients with a bipolar disorder. Only one-quarter of child and adolescent patients with psychiatric illness receive services. Dillon-Naftolin and colleagues (2) provide us with the core principles, walk us through three models of integrated care with real-world examples, and describe some of the barriers and opportunities ahead in this important work. Mental health issues are common and costly in combination with general medical conditions. Chauhan and Niazi (3) highlight the outcomes of research into collaborative care for patients with complex needs. Finally, pain is the most common presenting symptom for medical outpatients, and with the country reacting to an opioid epidemic, Leasure and Leasure (4) review multiple ways in which the collaborative care setting may be ideal for alternative ways of addressing pain.

We also hope to balance updates on specific populations with practical information on tools of the trade. We have articles making the business case for collaborative care and describing the unique role of the psychiatrist doing systematic case reviews in primary care. In addition, telepsychiatry not only offers ways to see patients over a distance but also allows for indirect educational, coaching, and supervisory support to primary team members to increase capacity for them to delivery high-quality care to their patients. The article by Adaji and Fortney (5) is an excellent summary of the evidence, barriers, and practical considerations in this area. Evidence-based psychotherapy also is a critical tool in caring for our patients. Dr. Sawchuk and Craner (6) with years of experience embedding these treatments in primary care, review the evidence and approaches for these common problems, providing practical suggestions on methods and delivery.

Finally, integration is a two-way street. What are some ways for medical services to better address the 25-year shortened lifespan of people who have a serious mental illness? Ward and Druss (7) tell us where the evidence is and discuss practical ways to develop collaborative care by bringing medical attention to psychiatric settings for better patient outcomes.

We hope that this issue piques your interest and enthusiasm for a growing area in psychiatry. Rather than asking our patients to adjust to the silos of care delivery, should we not find ways to bring the best we have to them?