Integrating Psychiatric Care Into Primary Care Practices

Depressive disorders and anxiety disorders are common, disabling conditions, and the number of people reporting depressive and anxiety symptoms skyrocketed as a result of the pandemic. However, there is a major shortage of psychiatrists, and this shortage is not going away in the near future.

Some psychiatric illnesses exhibit severe symptoms requiring complex treatments. Individuals suffering from these disorders are usually best evaluated and treated by psychiatrists and their teams. Examples include psychotic illnesses, bipolar disorder, anorexia nervosa, and severe depression. Once patients are stable, follow-up care can sometimes be transferred to their primary care physicians. But what about the large number of patients with less severe, but still function-impairing, symptoms of depression and anxiety disorders?

A paper in JAMA Psychiatry by Carlo, Barnett, and Unützer discusses mental health care in the era of COVID-19. The article concludes with this sentence: “With more than 2 decades of evidence supporting its use across diverse populations and diagnoses, [the collaborative care model] should form the backbone of our mental health care response to this pandemic and the challenges that lie beyond it.”

In the collaborative care model, specially trained behavioral health care managers — often clinical social workers or psychiatric nurse practitioners — are part of primary care teams. These individuals assist primary care doctors in evaluating patients for symptoms of depression or anxiety with standard assessment instruments and consult with designated psychiatrists to devise treatment plans for patients with significant symptoms. The onsite mental health team communicates regularly with the consulting psychiatrists to review diagnoses and treatment plans. Ideally, psychiatrists would personally evaluate each patient, but there aren’t enough psychiatrists for the large number of psychiatrically ill patients. Many patients have psychiatric conditions that can be treated with talk therapy by the onsite mental health professional and/or pharmacotherapy by the primary care doctor with supervision and advice from psychiatrists during regular phone or video meetings.

Does this model work? As the paper by Carlo and colleagues reviews, there have been a large number of studies demonstrating that these approaches are effective. Such a model requires specific funding mechanisms and over the last few years, these have been developed and are being implemented. Adopting these funding mechanisms requires changes in approach by health care systems, but such adjustments are doable.

Pandemic-related depressive and anxiety symptoms are disproportionately affecting minority populations. In a 2015 study published in the journal Medical Care, Kurt Angstman and colleagues demonstrated that collaborative care models were effective in reducing disparities between minority patients and non-Hispanic white patients with depression. Using data from a large primary care practice, they found that minority patients with major depressive disorder or dysthymia who chose to participate in a collaborative care model were more likely to remain engaged in care for their depression at the end of six months than patients who chose “usual care” (62 percent vs. 14 percent). They also had better clinical outcomes, with 50 percent (vs. 10 percent in the usual care group) achieving remission (i.e., having very few symptoms as determined by scores on a standardized questionnaire) and only 26 percent (vs. 63 percent) experiencing persistent depressive symptoms. There was no significant difference in six-month outcomes between minority and non-Hispanic white patients in the collaborative care model group. Minority patients had worse clinical outcomes than non-Hispanic white patients in the “usual care” group.

Although the great majority of psychiatrists were trained in traditional models of providing one-on-one care, societal needs are such that more and more psychiatrists will be asked to participate in collaborative care models. It is likely that many psychiatrists will divide their time between collaborative care and more traditional models. Some may specialize in caring for patients who do not respond to initial treatments. It will be interesting to see if collaborative care models indeed become “the backbone of our mental health care response to this pandemic and the challenges that lie beyond it.”

This column was written by Eugene Rubin MD, Ph.D., and Charles Zorumski, MD.