Psychiatric Consultant Helps Shape Care of Wide Range of Patients

My first exposure to primary care psychiatry came when I spent a month in residency rotating with the Rural and Remote Mental Health Service in South Australia. We provided psychiatric consultations via telemedicine and occasional visits to distant primary care sites. For someone concerned about the public-health impact of mental disorders, it was an exceptional experience—I was helping to shape the care delivered to hundreds of patients. My time in Australia introduced me to the importance of working with our primary care colleagues to help address the burden of mental disorders at large, and it helped me understand the value of leveraging psychiatric expertise through consultative models such as collaborative care.

I work as a consulting psychiatrist for two collaborative care programs: Washington’s Mental Health Integration Program (MHIP), which supports primary care–based mental health services in more than 100 safety-net clinics statewide; and the University of Washington’s Behavioral Health Integration Program (BHIP), which was launched a year ago and serves 11 university-affiliated primary care practices.

As a consulting psychiatrist for MHIP, I am not on site, and therefore most of my work is done remotely via telephone with care managers. Although I had previously worked for several years as a co-located psychiatrist in a family medicine clinic, I hadn’t provided indirect services through psychiatric case reviews. The patients in primary care are complex—medically, socially, and psychiatrically—and I had to learn the art of providing recommendations for patients I’d never met. It was challenging to develop a care plan based on another clinician’s observations complemented by standardized instruments such as the PHQ-9 or GAD-7, and I felt a tension between wanting complete information and the need to make timely recommendations. Now these tasks are easier, and I enjoy using our case consultations to build capacity by offering brief “just in time” training for care managers.

For BHIP, I spend one day a week in a primary care clinic where a social work care manager works full time. Being on site offers distinct advantages, the most notable being the ease of talking directly with primary care providers (PCPs) about their patients. The benefits are bidirectional, as PCPs can contribute a deep understanding of patients they have been following for many years, and they can take away new approaches to common clinical challenges. I do see patients in person for consultation, which may lead to a change in the patient’s treatment plan, but often our visit serves to reassure the patient or PCP and support patients’ acceptance of their diagnosis or treatment.

A year ago, colleagues and I discussed our roles as MHIP psychiatrists in a workshop at the Academy of Psychosomatic Medicine. We took some heat over a perception that our consultations overemphasized psychotropic medications, and I regret we didn’t better convey the breadth of our work. Although I regularly advise on the use of psychotropic medication, the psychosocial interventions the care managers deliver are an enormous agent of change for patients, most of whom have never experienced such an intervention and would not have access to it otherwise. In consultations, I routinely discuss the care manager’s work with psychosocial interventions and consider how to better reach, engage, activate, and empower patients.

I recently saw a patient in consultation for BHIP and asked about her experience working with our care manager. She explained how greatly she appreciated the visits because she has learned so much about herself. As I spoke with this woman, who has been untreated yet symptomatic for more than 10 years, her hopefulness about improving her life was palpable. She had met with the care manager only twice, but she already understood the potential that collaborative care could offer her.

Although many patients do well with evidence-based interventions implemented in primary care, collaborative care isn’t right for everyone. Some patients need more specialized help, and we either facilitate their connection with a specialist or help them with engagement and acceptance as they learn about their diagnosis. The spectrum of patients we encounter in primary care is much broader than the range of patients treated by psychiatrists in specialty care—not surprisingly, since they see only the 10 percent of patients who are able to overcome the substantial barriers that exist to getting specialty mental health care.

Working in primary care offers a wonderful opportunity for a psychiatrist to shape the care of a variety of patients, and I’ve found that collaborative care is a particularly efficient, effective, and rewarding way to do so. ■