Integrated Care Book Offers ‘How-To’ Advice for Psychiatrists

Integrated Care: Working at the Interface of Primary Care and Behavioral Health, a new book from American Psychiatric Publishing, brings together the two sides of the interface—with hands-on, how-to advice for psychiatrists serving as consultants to primary care as well as working to improve the health status of patients with serious mental illness in community mental health centers.

With as many as one-fourth of primary care patients having a mental illness, there is a sound clinical basis for integrated care. The new text reviews the evidence base and core principles that support integrated care models and key concepts such as population-based care, measurement-based care, and stepped care, emphasizing how health reform initiatives are stimulating rapid dissemination of these models.

Editor Lori Raney, M.D., a leader in integrated care, says the book had its genesis in an educational seminar on integrated care at the 2010 APA annual meeting. “I started taking notes thinking to myself about what a psychiatrist needs to know to begin doing integrated care,” she told Psychiatric News. “When I started this work, there was nothing else available.”

Four years later, the result is a 10-chapter book, divided into two sections: “Behavioral Health in Primary Care Settings,” and “Primary Care in Behavioral Health Settings.”

“The first half of the book is about bringing evidence-based mental health care into the primary care setting,” Raney said. “The second half is about closing the mortality gap [in which people with serious mental illness die significantly earlier than the general population] by bringing good medical care into the mental health setting.”

The book includes chapters on core principles, the collaborative care team in action, the role of the consulting psychiatrist, child and adolescent psychiatry in integrated settings, risk management and liability issues, training psychiatrists for integrated care, the case for primary care in public mental health settings, providing primary care in behavioral health settings, behavioral health homes, and management of leading risk factors for cardiovascular disease.

Each chapter is written by recognized leaders in the field: Jürgen Unützer, M.D., M.P.H., Anna Ratzliff, M.D., Barry Sarvet, M.D., Robert Hilt, M.D., Martha Ward, M.D., Benjamin Druss, M.D., John Kern, M.D., Joseph Parks, M.D., Erik Vanderlip, M.D., and Lydia Chwastiak, M.D., among others.

A unique contribution to the literature on integrated care is a chapter on child and adolescent psychiatry in integrated settings by Sarvet and Hilt. Raney explains that treating this population presents special challenges but is ripe for collaborative care because of the severe shortage of child and adolescent psychiatrists.

And in child and adolescent psychiatry, collaboration has also involved technology: existing models of collaborative care for children and teens often involve use of telemedicine in pediatric settings, Raney said.

She added that Sarvet and Hilt also included a section on adult psychiatrists providing mental health care to children and adolescents. “They specifically addressed the things an adult psychiatrist needs to know,” Raney said. “That’s important. We all need to become more like generalists to do this kind of work.”

Of interest to many psychiatrists will be the chapter on liability issues by Kristen Lambert, J.D., and D. Anton Bland, M.D. “Liability is one of the main reasons that psychiatrists say they are reluctant to do this kind of work,” Raney noted. “There is a misperception about the liability issues involved in doing even simple curbside consultations. But there is an entire field—consultation-liaison (CL) psychiatry—that has been doing these kinds of consults all along in the hospital setting.”

Raney said literature from the CL field has indicated that there is no legal liability unless the physician has what the courts have called a “duty to the patient,” which is usually established when there is a direct doctor-patient relationship. “If you are consulting with a primary care physician about a patient you don’t know and have never seen, you haven’t established a doctor-patient relationship,” she explained.

The concluding chapter on management of risk factors for cardiovascular disease, by Vanderlip and Chwastiak, describes the management of hypothetical patients with high blood pressure, abnormal lipid levels, and other common medical conditions relevant to cardiovascular disease. “The purpose is to show how psychiatrists doing integrated care work will have to become comfortable with knowing more about common medical problems,” Raney said.

The book is heavy on practical advice from psychiatrists and other clinicians. “We tried to provide direct quotes from physicians doing this work, as well as patients being treated in integrated care settings,” Raney said. “I wanted to give people a feeling for the real world of integrated, collaborative care.” ■

Purchasing information for Integrated Care: Working at the Interface of Primary Care and Behavioral Health can be accessed here. APA members are eligible for a discount.