Three Decades of Working in Integrated Care

At a recent meeting in the United Kingdom, Wayne Katon, M.D., was introduced as the “grandfather of collaborative care.” He was the first to adapt the chronic care model to depression and other common mental disorders, and he continues to be on the forefront of researching new ways to integrate behavioral and physical health care. Wayne has been a wonderful mentor, colleague, and friend to many of us, and as we continue this new column on integrated care in Psychiatric News, I have asked him to share his perspective on 30 years of work in the field.

I began working as a consultation psychiatrist in primary care in 1979 during my chief residency year. One of my initial surprises was the high prevalence of mental illness among patients, later documented to be 20 percent to 25 percent in mixed-income populations and as high as 50 percent in low-income populations. The majority of these patients presented with somatic complaints or worsening of a chronic illness such as diabetes, rather than with psychological complaints. I often evaluated patients who had never seen a mental health professional or had resisted referral to specialty mental health care either for financial reasons or stigma. I realized that psychiatrists could have a much greater public-health impact working with primary care physicians, who typically have a panel of 1,500 patients, rather than treating patients in a specialist’s office where only 30 to 35 patients are seen each week.

In my early experience in primary care, I hoped that educating family doctors about diagnosis and treatment of common mental illnesses would improve both recognition and outcomes of these illnesses. Accurate recognition in primary care of common mental disorders such as depression improved from about 25 percent in the early 1980s to 60 percent in later decades. However, persistent gaps in quality of care for depression in primary care continued to be documented. In most systems of care, once accurate diagnosis occurred, patients weren’t adequately educated about their illness and had few follow-up contacts with their physician, leading to poor treatment adherence and outcomes.

At the same time that my research group was developing research ideas about improving quality of care and outcomes for patients with depression and anxiety in primary care, several national leaders emerged in Seattle to emphasize the large gaps in quality of care for all chronic illnesses. Ed Wagner and Michael Von Korff from Group Health Cooperative began publishing papers on the deficits in quality of care for chronic illnesses, developing influential ideas about changing the primary care system to improve these deficits, and building a chronic illness model that shaped our thinking about how to improve depression care. A key part of this model is how to activate and educate patients to participate in their own care and how to provide improved education, greater frequency of contacts, and flexible ways to deliver patient care—such as use of telephone or secure messaging—while improving adherence and medication management.

The first trials of collaborative depression care began in 1995 and 1996. We developed and tested two initial models in patients diagnosed with depression and started on an antidepressant. In the first trial, a psychiatrist was integrated into primary care and provided two to three visits to help the patient and primary care physician improve patient education about the patient’s illness and pharmacologic management. In the second, a mental health professional supervised by a psychiatrist provided brief cognitive-behavioral treatment and enhanced pharmacologic management. Both trials provided enhanced educational materials to the patient to improve depression self-management, ongoing measurement of depression symptoms, monitoring of adherence to and side effects from medication, and proactive tracking to ensure patients did not miss visits and to facilitate return visits.

These initial trials showed that collaborative care could improve the rate of significant clinical depression response from approximately 40 percent to 70 percent. Today, there are more than 80 trials of collaborative depression care that have been completed in multiple countries, and the model has shown robust evidence of effectiveness.

Because many patients with depression have comorbid chronic medical conditions—and epidemiologic studies have shown that depression is associated with poor adherence to medical regimens, increased complications of medical illness, and increased mortality—we recently developed and tested a multi-condition collaborative care approach. The goal is improving both medical and depression disease control for patients with comorbid depression and poorly controlled diabetes and/or heart disease and includes training and supervision of a medical nurse by a psychiatrist and primary care provider. This model of care improved the quality of both mental and physical health care; improved depression, glucose, blood pressure, and LDL cholesterol outcomes; and reduced costs (see teamcarehealth.org). We are currently involved in a large Center for Medicare and Medicaid Innovation project that is adapting this model of care to several thousand patients in eight health care systems.

Today, I still spend one half day each week consulting in primary care, with the first hour supervising a collaborative depression care manager and the next three hours providing psychiatric consultations. I still value this experience of working with family physicians and the ability to improve the quality of mental health care in a large population of patients. ■