Psychiatry and Primary Health Care: Beyond Integration, Toward Fusion?

Unique function of a psychiatrist in primary health care

As health care is redesigned and primary health care reemphasized, the move toward integrating behavioral health care with primary medical care appears to be accelerating across the country. It’s now broadly accepted that a number of models, such as the Collaborative Care model from Seattle and the related DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) program, have demonstrated the clinical value of integrating care delivery.^1,2 In addition, numerous other approaches utilize psychiatrists and other behavioral health professionals as providers, collaborators, consultants, and supervisors in collaboration with a primary medical care team.³

This is all well and good. Yet, when a psychiatric colleague posed the following question in an informal email to a group of psychiatrists (including me) working on integration, I came up short. Here’s the question: “Do we have the evidence to show that psychiatrists, including child and adolescent psychiatrists, lead to better outcomes than (primary medical) teams that have access to other mental health professionals, but not directly to psychiatrists?”

I wasn’t alone in not being able to bring to mind clear evidence of the specific value of psychiatry in primary health care beyond the limited role found in collaborative care studies. One of our colleagues reported that he spent 20 minutes doing a PubMed search for studies and could find nothing; I didn’t have any better luck.

Also see:

6 Unique Functions of Psychiatrists in Primary Care

Because I make my living, in part, by working as a psychiatrist in a Federally Qualified Health Center (FQHC) in Pittsburgh, where we pride ourselves on providing whole person, whole life primary health care, the question stuck with me. As I thought about it, it occurred to me that what psychiatry can do for primary medical care may be limited relative to the contribution other mental health providers can make-BUT (this is a big but) for 2 important considerations.

First, it’s important to consider the unique functions of a psychiatrist in primary care (see Figure).

No other behavioral health profession can provide the same competencies. Efforts to determine the effectiveness of team-based mental health care that do not note the presence or absence of these competencies in the team are not really evaluations of what a psychiatrist can contribute. Without these competencies, a primary health care team will be unable to address the full extent of psychiatric challenges that are likely to be present in a population of patients seeking primary health care.

The many patients with psychiatric challenges whom a primary health care team is unable to fully care for are likely to leave the practice. As a result, the outcomes that “psychiatrically light” primary medical care teams attain are going to be based on a sample of patients with lesser morbidities than a team in which a psychiatrist is more fully able to exercise his or her unique competencies.

Do psychiatrists add value?

The answer to my colleague’s question is that we can’t tell whether psychiatrists add value to primary health care teams because we have yet to test primary health care teams in which psychiatrists are full members. Right now, the question is, What do we want primary care to do? Do we want it to be “primary medical care” with limited psychiatric capacity, mostly provided by non-psychiatric mental health providers, caring for patients with limited psychiatric needs, or do we want it to be primary health care where medical and psychiatric care are fused and the needs of people with complex psychiatric illness can be addressed? If we want the latter, more studies are needed of primary health care teams that fully incorporate the competencies of psychiatry and the kinds of patients for which psychiatrists are needed.

Recognizing that psychiatry has unique competencies that are of value to a primary health care approach, rather than just a narrower primary medical care approach, leads to the second issue I want to address. I am concerned that psychiatry may not be fully appreciating the opportunity health care redesign has placed in front of the profession. So far, we have tended to approach the issue as integrating behavioral health with primary medical care. I no longer think of it this way. I want to draw out the critical distinction I made between integrating behavioral health services with primary medical care and (the terms I now use) fusing primary psychiatric care and primary medical care into primary health care.

The distinction between “primary medical care” (what we now call “primary care”) and “primary health care” is of central importance. Primary care is defined as first-contact, accessible, continued, comprehensive, and coordinated care.

• First-contact care is care accessible at the time of need

• Ongoing care focuses on the long-term health of a person rather than the short duration of the disease

• Comprehensive care provides a range of services appropriate to the common problems in the respective population

• Coordination is the role by which primary care acts to coordinate other specialists that the patient may need.

What’s notable about this is that in the US, primary care is focused on medical concerns and has, at best, extremely limited behavioral health capacity, let alone psychiatric capacity-it is hardly comprehensive. In real life, current primary medical care falls far short of addressing the array of psychiatric challenges facing the country. Our behavioral health services, on the other hand, are not easily accessible, ongoing, comprehensive, or coordinated.

Primary health care

We desperately need a primary care approach to psychiatric disorders. We need to push beyond bolstering primary medical care with some integrated behavioral health care activities. As a nation, we can create something unique, namely, “primary health care”-where medical, behavioral, and social interventions are fused to meet the health needs of all people in an accessible, continuous, comprehensive, and coordinated manner.

Persons seeking such care will be served by their “primary health care home,” aka “medical home.” I alluded to this earlier when I noted that the FQHC where I work prides itself on providing whole person, whole life primary health care, which is also whole community, family oriented, and community based. We strive to be a “primary health care home.”

Psychiatric concerns requiring active psychiatric engagement are common enough in all populations to require that psychiatry be fully embedded in all primary health care practices. When I suggested that psychiatry may make a relatively limited contribution to primary medical care, I meant exactly that-a limited contribution to primary medical care. But the anticipated contribution to primary health care would be enormous. In fact, primary health care is only possible if psychiatry’s competencies are fully integrated.

Of course, the critical shortage of psychiatrists able, ready, and willing to work in primary health care is a very serious impediment to psychiatrists assuming a central role, especially because the psychiatric component of the primary health care team is only now being invented. One of the main benefits of the Impact model, which uses non-physician mental health professionals working in primary medical care practices with support from a consulting psychiatrist, is that it addresses the shortage of available psychiatrists by introducing only limited psychiatric capacity to the primary medical care team. Refitting psychiatrists for this more discrete role requires significant time and money-witness the recent million dollar contract the American Psychiatric Association signed with the Centers for Medicare and Medicaid Services to do just that for 3500 psychiatrists.

The idea of getting psychiatrists a more extensive role in a newly designed primary health care team can seem daunting and perhaps unrealistic. However, 2 things may lead to this happening over time. First, in some segments of the evolving health care system, primary health care teams with psychiatry at their core are becoming a reality. Specifically, FQHCs-serving vulnerable populations with significant medical and, it turns out, psychiatric challenges-have been pioneering a primary health care approach for a number of years and have been increasing the extent psychiatry is involved. Psychiatrists who are able, ready, and willing to work on primary health care teams can find work doing exactly that. For example, at the FQHC I oversee a growing primary psychiatric care initiative, fused with primary medical care.

The other reason I believe we will continue to move toward primary health care is the ubiquity of important psychiatric challenges in the general population and their significant connection to medical problems over the life span. As more psychiatric services are offered in primary health care teams, more people will avail themselves of these services.

The clinical and cost benefits of primary health care teams that fuse primary psychiatric care with primary medical care will drive the evolving health care system and the future of psychiatry. To fully integrate the large number of people with psychiatric needs into accountable, ongoing, comprehensive, and coordinated primary health care, we need psychiatry to be fully engaged with the design, development, implementation, and practice of primary health care-we need to remember that the head and body are actually fused at the neck.

My colleague’s question about what value psychiatrists add to primary medical care teams is a very different question than asking what value they can offer to primary health care teams. While we don’t have good data to answer either question, we may want to consider carefully the question we want to answer.

Disclosures:

Dr. Thompson is Clinical Associate Professor of Psychiatry at the University of Pittsburgh in Pittsburgh, PA, and Medical Director of the Pennsylvania Psychiatric Leadership Council. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Advancing Integrated Mental Health Solutions Center. Collaborative Care. https://aims.uw.edu/collaborative-care. Accessed April 11, 2016.

2. 2010 APA Gold Award. A New Direction in Depression Treatment in Minnesota. DIAMOND Program, Institute for Clinical Systems Improvement, Bloomington, Minnesota; October 2010. https://www.icsi.org/_asset/1rq9xl/DIAMOND-Program-Wins-National-APA-Gold-Award.pdf. Accessed April 11, 2016.

3. Collins C, Hewson DL, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care: 2010. http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf. Accessed April 11, 2016.