Integrated Care: Working at the Interface of Primary Care and Behavioral Health

This excellent, very practical book reads as though you’re sitting in an APA symposium (actually two symposia: one on integrating behavioral health into primary care and one on integrating health care into community mental health centers). Even though the editor does not introduce each chapter writer or tell us why we should listen to them (relationships are not important in this book), it’s clear that each of them is an expert and has practical, first-hand experience to share with us. Each chapter has a unique voice and something special to offer.

This book gets down to business. It focuses on specific treatment targets (reducing depressive and anxiety symptoms in primary care patients and increasing life span in community mental health center patients), evidence-based approaches and outcome tracking, specificity in the interventions, how to get staff trained and working as a team, and how to get paid for these efforts. There’s no emotional inspiration or philosophical handwringing here. They accept the world as they find it without judgments (profound shortages of psychiatrists, patients refusing behavioral health referrals, complex and conflicting funding systems, widespread patient noncompliance, and even psychiatrist resistance) and draw up plans for achieving their goals.

The first six chapters describe in detail, from several points of view, the collaborative care model they are promoting (surprisingly, even including legal liability where we’re guided through the possible legal views of treatment without a doctor-patient relationship). In this model, a psychiatrist works for 2 hours a week, with ad hoc telephone availability, along with a full-time behavioral health provider embedded in a busy primary care practice serving 2,000 patients, very rarely meeting any of them, focusing instead on managing screening tool scores and appointment compliance.

Unfortunately, the clearer this vision of the future is made the more horrified I became. This is a dystopian vision for me. Their key concepts are “Emperor’s New Clothes” in my view: treat to target means put a Band-Aid on the presenting complaint (or the screening tool depression or anxiety score) without ever finding out what’s really wrong. Step care means failing at each level of inadequate care until you get the care you really needed in the first place. And population-based care seems to be data driven to the extreme. Gone are the cornerstones of my personal success—individualized personal understandings, relationship-based care, Jerome Frank’s triad of a trusting relationship, a shared story, and a shared plan, and Carl Roger’s triad of empathy, authenticity, and genuine affection. Gone is the idea that outcomes depend more on who the psychiatrist is than on what technique we’re using. (To be fair, they anticipate my outrage and warn you that people like me have to be kept from talking to patients too much or we’ll destroy the model.) They cite lots of research-based success for the model, but what are they really measuring? I wonder how many battered women leave their husbands in this model or how many acting-out teenagers tell you they’re being sexually molested and start to heal with this model. That’s how I’d measure success.

Read the book and decide for yourself if this is the kind of job you’d like or the way you’d want to be treated. I became a psychiatrist instead of a family doctor because we were still talking to patients.

Chapters 7–10 address the early deaths of people with serious mental illnesses treated in community health centers. They beat us down with all the bleak correlates that impact our patients (and then jump to the common assumption that reducing correlates will keep people alive longer). There is less confidence in these chapters as even the early Substance Abuse and Mental Health Services Administration pilot programs have struggled with creating integrated data bases, effective approaches, or sustainable finances.

My favorite chapter in this book was the last one, probably because it’s directly addressed to me: a community psychiatrist reluctant to practice primary care. Using a case example, they guide us step-by-step through how we can get off our behinds and actively treat the primary risk factors, including giving us specific medication guidelines. I’ll be copying that chapter to keep on my desk and give to my colleagues here.

All in all, whether you’re enthusiastic about practicing integrated care or reluctantly lifting your head out of the sand wondering what’s coming to a health home near you, this book is worth a read.