Looking at Psychiatry Through a Population Lens

Over the past few years, we have seen increasing interest in a new area of psychiatry called “integrated care” or “collaborative care,” and today I have the privilege of writing the first in what will become a monthly Psychiatric News column that explores the joys, challenges, and limitations of practicing in this new model of care.

October marked an important milestone in American Health Care. Key provisions of the Affordable Care Act became effective that may eventually give as many as 62 million Americans new or more complete insurance coverage for mental health care. This is wonderful news for many of our patients, but it will also create challenges to our existing mental health system.

Early in my career, I had the opportunity to take additional training in public health and to learn about the challenges of caring for populations of patients rather than simply thinking about the people who find their way to our offices. Psychiatrists are an important part of our physician workforce, but research suggests that only 1 in 10 adults living with a mental disorder will see a psychiatrist in any given year. This is partly due to lack of access. More than half of the counties in the United States do not have a single practicing psychiatrist or psychologist, and the simple truth is that we will never have enough psychiatrists to meet the mental health needs of most Americans.

If every psychiatrist practicing in the United States spent 30 hours in direct patient care each week, and 3 percent of Americans needed mental health care at any given time (a conservative estimate), the average patient would get about five minutes with a psychiatrist each week. Those living in rural America would have about 90 seconds, barely enough time to say hello and goodbye. In residency, we learn how to do a 50-minute session, and in practice we may learn how to provide briefer, more focused visits (for example, 20-minute medication management or 30-minute brief psychotherapy sessions), but nothing has prepared us to meet the needs of the large populations of patients who need mental health care.

Meanwhile, patients need help, and they are most likely to get it in primary care. More than 25 million Americans leave a primary care provider’s office with a prescription for an antidepressant medication each year, and our primary care colleagues are well aware of the fact that they are stepping into the gap shouldering much of the burden of mental health care in this country. They also know that they don’t have the breadth of experience with psychotherapy and psychotropic medications to effectively treat all the patients they see, and they are looking to psychiatry for help.

For those of us who feel inclined to make a difference for the larger population of patients in need of mental health care, the answers lie in new ways to “leverage” our skills through partnerships with primary care providers, school-based health providers, and other health and mental health providers. Collaborative care programs in which psychiatrists work closely with primary care providers are a proven solution to this challenge. In such programs, psychiatrists support teams of primary care providers and mental health care managers (usually a licensed clinical social worker, nurse, psychologist, or therapist) in primary care. More than 80 randomized, controlled trials in the United States and abroad have demonstrated that collaborative care for common mental disorders such as depression or anxiety is not only convenient for patients, but also more effective than our current situation in which primary care physicians provide the brunt of mental health care and refer patients to mental health specialists when they can. Evidence-based collaborative care programs not only improve access to care and patient satisfaction, but they are more effective and more cost-effective than care as usual. This is called achieving the “Triple Aim,” a home run, in the language of health care reform.

Well-implemented collaborative care programs create opportunities for psychiatrists to help larger populations in need of mental health care. As consulting psychiatrists, we provide systematic treatment recommendations for patients who are not improving as expected and focus in-person contacts on those patients who present special diagnostic or therapeutic challenges. Patients who are not improving with this population-focused model of care or who prefer to see a psychiatrist in traditional psychiatric practice are referred for such specialty care, and in my experience we will always have our hands and our practices full trying to meet the needs of these patients.

I am not suggesting that integrated care should replace good psychiatric practice. Instead, I present it as an evidence-based solution for many of the patients who do not have access to such care today and to lessen the burden of existing community mental health centers that are already at capacity. In this new column, I look forward to presenting collaborative care programs in different settings and populations, profiling psychiatrists who work in such programs, and sharing insights into this emerging field. ■