A Path for Psychiatry to Thrive
Abstract
Exciting changes have the potential to reshape the tools used to treat mental illness, promote mental health, and bring this country’s too-long fragmented and specialist-centered mental health system closer to delivering on the goals of improving population health, expanding access, and engaging with structural and social determinants. Innovative practices such as task sharing, cross-sector integration, and participatory methods are ready to be mainstreamed into psychiatric professional identity and practice. Local governments have started to adopt these new strategies, perhaps the most prominent recent example being ThriveNYC, a comprehensive attempt to drive mental health improvement. By enabling and partnering with other practitioners in these ways, psychiatrists can reach more people in more places, giving psychiatry an opportunity to evolve and flourish. As psychiatrists, we and our leadership should seize that opportunity and help lead this progress.
Our mental health system is not working and has not worked for some time. People needing care, especially evidence-based care, too often do not get it. Treatment gaps tend to be worse for people of color; challenges to maintain diversity in the clinician workforce and the role of racism in disparities in care and exposure to risks remain seldom-discussed topics in the field (1). Navigating care can be daunting, especially within a system designed to accommodate practitioners’ schedules and work styles more than to serve patients’ schedules and sensibilities. On top of that, even getting an appointment with a psychiatrist (or other provider) is also a small part of promoting mental health or recovering from mental illness.
Although mental illness and substance misuse have outsized contributions to overall health and disability, affect most families, and are key to many social outcomes many people care about—homelessness (2), jail recidivism (3), sustained employment (4), overall health (5), socioemotional development (6), school success (7), community and social ties (8)—psychiatrists are not adequately reaching those issues, places, and people. Ending treatment gaps and connecting mental health treatment to social and structural determinants will require new practices.
Progress in advancing integrated primary care, parity of mental health care benefits, responsive first-episode care, and investments in child mental health has made it possible to reach more people, sooner. But this progress is still the exception—not the rule—and even these examples are relatively modest steps toward reengineering a response that meets the burden of treating mental illness and promoting mental health and that acknowledges the relevance of this burden to public health.
Additional progress means putting the work into more hands in more settings outside of the conventional mental health system and democratizing knowledge. It means acting across sectors and building the capacities of places other than mental health provider offices to promote mental health or provide treatment. It means taking these other places seriously as partners in developing solutions through methods such as learning collaboratives and collective impact. It means looking across the general population for a picture of existing priority gaps and assuming accountability for closing them.
One key to accomplishing these steps is increasing evidence of the potential value that results when psychiatrists support the skills and knowledge of others. A central component of the collaborative care model, which shows that most depression treatment should happen in primary care, is positioning the psychiatrist as a consultant, not a provider, for that care. But this principle can be extended much further, and with great effect.
A growing evidence base on task shifting, or task sharing, drawn largely from lower-resourced countries but increasingly appearing in research from the United States, shows how a substantial number of tasks of effective treatment, prevention, and early intervention can be readily and effectively managed by nonclinicians, such as teachers, clergy, parents, community health workers, and other health extenders (9). These tasks can encompass a range of adaptable skills, such as relapse prevention, screening and monitoring, proattachment parent coaching, and counseling protocols informed by cognitive-behavioral therapy. The growing applications of task sharing highlight the undertapped potential for clinicians to be part of scaling, prevention, and promotion by collaborating with those outside the mental health system.
To succeed, these approaches need strong clinician partners to work with nonclinicians. Psychiatrists should help fill that need. The comprehensiveness of psychiatric training, clinical experience, and skills can be a transformative anchor for this vision to not only improve communities but also to improve and enliven the practice of psychiatry in the process.
Applying psychiatric expertise to aid the work of others encourages needed fresh thinking about psychiatric practice. This includes questioning the increasingly critiqued utility of the prevailing psychiatric categorical diagnostic nosology (10), better translating research into working models of best practice (11), and looking critically and innovatively at opportunities for digital apps and Web-based tools to offer solutions to scaling and enhancing treatment and self-care. Wider use of quality improvement and practices informed by implementation science are also needed within psychiatry and are particularly valuable for these partnerships to succeed.
The work and knowledge to advance mental health must be more broadly shared. That means including other places, sectors, people, and government agencies—especially city and local agencies, which are underexplored and underresourced drivers of a more expansive approach to mental health. Local governments are customarily better prepared than state and federal governments to act and communicate across sectors, to know and work with their neighborhoods, to convene stakeholders, to implement new approaches, and to meet concrete needs. Partnerships with city government agencies enable an often discussed but challenging approach—“mental health in all policies” (12).
Psychiatry risks being increasingly isolated from the mental health system as these new directions are pursued. But these directions actually open the door to exciting and expanded roles for psychiatrists to lead task-shared collaborations. To fulfill these roles, psychiatrists will need psychiatric clinical, research, and training leadership to mobilize around them. They will also need advocacy, including for reimbursement, such as for payment approaches tied to outcomes rather than utilization. These are significant challenges to be sure, but taking them on would better match psychiatric needs to the practices psychiatrists know will improve mental health.
Is all this realistic? ThriveNYC is an attempt by the New York City government to pursue an in-all-policies public health approach to mental health. The plan aims to extend mental health care—and prevention and promotion—into places that conventional approaches have had trouble reaching, adopt novel treatment methods, and position clinicians closer to areas such as primary care offices, police cars, senior centers, and homeless shelters. It prepares more than a dozen city agencies to respond to mental health challenges, supports both health systems and community-based organizations (CBOs) to close gaps through learning and collective impact collaboratives, and offers all city residents free short-term counseling and systems navigation 24/7 by phone, text, or chat.
Although these initiatives were designed to have a worthwhile impact on their own, they were intentionally chosen to also set into motion key paths of innovation described by six principles for change. Those principles were derived from research and input from expert groups, hundreds of organizations, town halls, and community focus groups in New York City (13).
Task sharing is a component of many of these initiatives. Although end results are not yet available, given the recent launch of most of these initiatives, implementation lessons are emerging about versatile adaptation and feasibility proof of concept to inform wider adoption. For example, Connections to Care (C2C) seeds partnerships between CBOs (e.g., day care centers, shelters, job training programs) and behavioral health providers. The latter serve as coach and trainer to the CBO in the use of a range of task-shared skills, such as motivational interviewing and use of symptom scales, as well as a source for formal care when needed.
The implementation learning curve and the needs of both partners are under evaluation by RAND, and initial-phase qualitative findings have been published (14). Implementation led to the development of scaling mechanisms, including city agency contracting and technical assistance capabilities, and to an implementation toolkit to instruct others how to form such partnerships. As a proof of concept, as of the end of March 2019, 15 C2C pairs had trained 1,638 CBO staff in task-shared skills that reached 30,690 clients who demonstrated high rates of need (21% had depression [measured by the nine-item Patient Health Questionnaire, delivered by CBO staff]; 29% had experienced trauma [measured by PTSD Checklist]) and engagement (the most recent quarter [June 2019] referral-kept rate was 75%). These data support C2C’s premise that CBOs can engage patients who are not reached by conventional treatment and connect them to more formal care.
Similarly, the Early Child Mental Health Network teaches trauma-informed proattachment socioemotional skills to high-need public day care caregivers and parents. As of June 2019, this team had provided on-site coaching to 4,631 early care staff and parents. Quality signal tracking of a subset of children screened for behavioral needs in those classrooms, using the validated Devereaux Early Childhood Assessment, showed that 48% had improved to exhibiting typical behavior levels during the past school year. Operational feasibility and associated data on cost per child reached provided support for this model to emerge as the consensus recommendation by an expert and stakeholder review process across New York State to identify new payment approaches that would have the greatest impact on children in their first 1,000 days of life (15).
These are a few of ThriveNYC’s efforts that capture the versatility of task sharing. Applying psychiatric knowledge and practice in these ways expands the possible roles, impacts, and opportunities for psychiatry: to build capacity of others, to link treatment more closely to population well-being, to reach more people in ways that matter to them, to diversify the knowledge base, and to optimize who benefits from psychiatric care. The reach of (what will always be) too few clinicians can be extended through these kinds of collaborations between psychiatrists and communities.
ThriveNYC implemented these methods in multiple settings. Realizing the potential of these initial efforts in progressing from templates for change to widely adopted methods requires engagement by leadership in psychiatry. It is possible to build a mental health system based on these foundations. Psychiatry should take part in leading that change and thrive in the work of transforming mental health in our communities.
References
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2018 NYSCAA Poverty Symposium. Albany, NY, Schuyler Center for Analysis and Advocacy, 2018. https://www.scaany.org/wp-content/uploads/2018/05/NYSSCAA-2018-Poverty-Symposium-presentation-NY-1st-1K-Day-on-Medicaid-Initative.pdf
Information & Authors
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Received: 21 February 2019
Revision received: 20 August 2019
Accepted: 29 August 2019
Published online: 29 October 2019
Published in print: August 01, 2020
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The author reports no financial relationships with commercial interests.
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