Approaches to Collaborative Care and Primary Care Psychiatry

Overview

Historical trends in the research, education, and clinical practice of psychiatry over the last century mirrored concerns and developments in the more general US health care system that called for system redesign to provide safe, personal, cost-effective, high-quality health care. This included innovative approaches to the psychiatric care of patients in the general medical setting, where most patients still prefer to receive care, and the only available resource for many. Advances in psychopharmacology greatly facilitated the development of such models, which were designed to address quality, cost-containment, and allocation of limited resources. Psychiatric consultation and care provided to medically ill patients was primarily hospital-based, but ever-shorter inpatient stays predominantly relocated these services to outpatient settings. This paralleled the trend for shorter inpatient psychiatric hospitalizations (without increased community mental health resources), which left primary care providers (PCPs) to treat more acute psychiatric illness in their outpatient practices. Innovative psychiatrists heeded the mandate to collaborate with their medical colleagues to develop and implement pragmatic, cost-effective, outpatient models of high-quality psychiatric care that could be delivered in the primary care setting.

The realization of limited health care resources and rapid escalation of health care expense also forced a change in focus from patient- to population-based care. Although inherently painful in our individualistic society, this transition exposed the tremendous fiscal burden of psychiatric morbidity. The psychiatrically-disordered population experiences increased physical health care utilization, work absenteeism, unemployment, subjective disability, and mortality rates. Though more difficult to demonstrate, there is also a cost-offset of appropriate and timely psychiatric treatment.

Changes in health care reimbursement resulted in conflicted PCP incentives. On the one hand, pre-paid, provider-risk plans (i.e., capitated programs), such as health maintenance organizations (HMOs), exposed the expensive use of general medical services by patients with untreated or poorly managed psychiatric illness. There was an incentive for the PCP to initiate treatment for the more common psychiatric problems seen in primary care. On the other hand, the PCP gate-keeper system, which evolved to manage the expense of specialty care, created a disincentive to recognize more serious mental illness (or any mental condition the PCP was not comfortable treating). Limited formularies, varying by plan, with onerous, time-consuming prior authorization requirements, further complicated and deterred treatment initiation. Managed care organizations (MCOs) often carved-out substance use and mental health (collectively called behavioral health [BH]) benefits management to managed BH organizations (MBHOs), some with limited referral networks not inclusive of the PCP's psychiatric colleagues. This was not only a major referral disincentive but also complicated future communication and collaboration between BH and physical health providers. While many MBHOs have spearheaded initiatives to promote primary care treatment of common psychiatric problems, most do not credential or contract with non-psychiatric physicians, so this essentially cost-shifts expense from the MBHO to the [medical] MCO.

Passage of the 2010 health care reform legislation (Patient Protection and Affordable Care Act [PPACA]) has pushed the envelope to create more inclusive, accessible, coordinated, and integrated care systems, and to achieve the “triple aim” (i.e., improved quality, improved outcomes, reduced total health care cost). These initiatives include the patient-centered medical home, the health home, accountable care organizations, and integrated programs for the “dual eligible” populations (i.e., those eligible for both Medicare and Medicaid, either the elderly and indigent, or the disabled and poor). To be successful, there is an important and recognized role for consultant psychiatrists in each of these initiatives. Medical and health homes share some features, but have notable differences, which are summarized in Table 59-1 . Health homes specifically focus on care for patients with certain chronic conditions, recognizing that care for patients with multiple chronic illnesses is seven times as costly as the care of patients with only one such condition. Serious mental illness is one of the identified chronic conditions because 68% of affected adults have other medical conditions, and they die, on average, 25 years earlier than the general population primarily from preventable medical issues. Collaborative care for this population has been shown to improve outcomes for both physical and psychiatric conditions. Health homes are required to offer six core services, listed in Box 59-1 , designed to integrate physical health care, BH care, and social services.

Epidemiology

The Epidemiologic Catchment Area (ECA) Study, conducted in the early 1980s, attempted to quantify the prevalence of psychiatric problems in community residents of the US. Within a 6-month span, roughly 7% sought help for a BH problem. More than 60% never saw a BH professional, but sought care in a medical setting (e.g., emergency department [ED], PCP's office). Even among those who met full criteria for a diagnosable psychiatric disorder, 75% were seen only in the general medical (rather than BH) setting. Psychiatric distress therefore was exceedingly common among primary care populations. About half of general medical outpatients had some psychiatric symptoms. The use of structured diagnostic interviews detected a prevalence of 25% to 35% for diagnosable psychiatric conditions in this patient population. However, roughly 10% of primary care patients had significant psychiatric distress without meeting diagnostic criteria for a psychiatric disorder. The majority of diagnosable disorders were mood disorders (80%), depression being the most prevalent (60%) and anxiety was a distant second (20%). The more severe disorders (e.g., psychotic disorders) were more likely to be treated by BH professionals.

The National Comorbidity Survey (NCS), conducted between 1990 and 1992), demonstrated a 50% life-time prevalence of one or more psychiatric disorders in US adults, with a 30% 1-year prevalence of at least one disorder. Alcohol dependence and major depression were the most common disorders.

A rigorous replication of the NCS (NCS-R), in 2001–2002, also measured severity, clinical significance, overall disability, and role impairment. The NCS-R found the risk of major depression was relatively low until early adolescence, when it begins to rise in a linear fashion. The slope of that line has increased (i.e., becoming steeper) for each successive birth cohort since World War II. The life-time prevalence of significant depression was 16.2%; the 12-month prevalence was 6.6%. Two findings, however, were of particular interest. First, 55.1% of depressed community respondents seeking care received that care in the BH sector. The other significant finding, attributable to advances in pharmacotherapy and educational efforts, was that 90% of respondents treated for depression in any medical setting received psychotropic medication. While this suggested improved community depression treatment, that was tempered by the finding that only 21.6% of patients received what recent, evidence-based guidelines (American Psychiatric Association [APA], Agency for Healthcare Research and Quality [AHRQ]) considered minimally adequate treatment (64.3% treated by BH providers, and 41.3% of those treated by general medical providers), and almost half (42.7%) of patients with depression still received no treatment.

Older studies documented PCPs' failure to diagnose over half of the full criteria mental disorders of their patients, but later studies demonstrated that PCPs recognized their more seriously depressed or anxious patients. These studies also demonstrate that higher-functioning, less severely symptomatic primary care patients have relatively good outcomes, even with short courses of relatively low doses of medications. This highlights the diagnostic difficulty for PCPs. Primary care patients are different from those who seek specialty care (i.e., the population in whom most psychiatric research is done). Primary care patients may seek treatment earlier in the course of their illness, since they have an established relationship with their PCP that is not dependent on their having a psychiatric disorder. They frequently present with somatic complaints, rather than psychiatric symptoms. Since the soma is the rightful domain of the PCP, this further obscures the diagnosis. Primary care patients often present with acute psychiatric symptoms that clear quickly (i.e., before therapeutic medication levels are reached), suggesting they might benefit as much from watchful waiting and the empathic support of their PCP. There is a high noise-to-signal ratio in psychiatrically-distressed primary care patients: that is, as many as one-third of these significantly distressed patients have sub-syndromal disorders not meeting criteria for diagnosable mental disorders. This diagnostic ambiguity, coupled with relatively good outcomes after brief trials of sub-therapeutic medication doses, is cause to reconsider the significance of the PCP's “failure” to diagnose. Much primary care patient angst resolves spontaneously, either with resolution of an initiating event, expressed caregiver concern, or the placebo effect of a few days of medication. It may be attributable to an adjustment disorder.

The Goals of Collaboration

Now that effective, evidence-based treatments exist, access and quality of care remain significant issues, best addressed through the collaboration of psychiatry and primary care. The four major goals of collaboration are to improve access, treatment, outcomes, and communication.