Unacceptably high mortality and morbidity among people with serious mental illness have prompted a call to action for behavioral health providers from all disciplines. Included among these providers are physicians and other prescribers, who have an important part to play in the integration movement.
Implementing integration has involved training large numbers of peer health coaches, social workers and paraprofessional case managers to identify and support self-management of physical health risks. In earlier issues of this newsletter, ICL has described dissemination of its Diabetes Self-Management and Healthy Living toolkits to support transformation of the behavioral health workforce across New York City to better take into account physical health. However, very few physicians were able to participate in these trainings, and the material did not specifically address the learning needs of people with a high level of medical training.
For physicians, integrating primary and behavioral healthcare has involved an expansion of scope of practice and development of engagement and motivational enhancement skills, as it has for other behavioral health providers. However, the new scope and skills are quite specific and require more training than most physicians have accessed at this time. Dr. Lori Raney, an expert on this kind of integration, has contributed very important curricula specifically designed to prepare primary care providers and psychiatrists to work in integrated settings. Supporting physician access to these trainings should be a priority for behavioral health agencies. She and others have also worked to support and legitimize the shift in scope that many physicians have had to undertake in order to provide the best care for people with complex health needs.
This article focuses on physicians, but many of the ideas are applicable to other prescribers, including advance practice nurses and physician assistants.
Psychiatrists in Primary Care Settings:
The Collaborative Care Model
Providing behavioral health care in primary care settings is called “forward co-location,” and the best-known model is collaborative care. In this model, primary care clinics screen people for mental illness, most commonly depression or anxiety. Those who screen positive can choose psychotropic medication prescribed by the primary care provider (PCP) and/or brief, evidence-based psychotherapeutic interventions provided by an on-site behavioral health clinician. Both types of staff are supported by a consultant psychiatrist who is available to answer questions and who may also meet with patients to help direct care. The status of the mental health symptoms are tracked regularly, with timely treatment adjustment for those who are not responding. More than 80 randomized controlled trials have been conducted on collaborative care, demonstrating improved depression and anxiety outcomes (http://aims.uw.edu/collaborative-care/evidence-base).
The advent of this model has created a new role for psychiatrists and a new type of relationship between PCPs and psychiatrists. The practice of primary care has always involved management of people with mental illnesses, since over 50% of people have a diagnosable mental illness at some point in their lifetimes (http://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_Estimates.pdf). In addition, as many as 70% of visits to primary care sites “stem from psychosocial issues” (http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf). However, the great demands on PCPs’ time have meant that, in most cases, only people whose chief complaint is a psychiatric symptom have received treatment. Many PCP’s have voiced frustration at being unable to find a psychiatrist for people who have more complex psychiatric needs. Therefore, greater access to psychiatry has been welcomed by PCPs who have been able to participate in the collaborative care model, and generally the feedback has been very positive. It may require PCPs to develop more skill in psychiatric diagnosis and the use of psychotropic medications, but does not require a major shift in scope of practice.
However, this model requires a certain type of psychiatrist: one who is willing to “share care” with another prescriber, in a role halfway between a supervisory and consultant role. On top of the uncertainty that comes with consulting on cases with limited information, liability is less well defined. Few psychiatry residents have participated in this model in training. The closest experience for many would be the consultation-liaison experience, in which residents typically consult on inpatients on medical/surgical units, rather than consulting on people receiving continuous outpatient care over time. Greater exposure to the collaborative care model would prepare more psychiatrists to take on this important role and expand access to behavioral health care.
Primary Care Providers in Behavioral Health Settings: Reverse Co-location
“Reverse co-location” puts primary care in the behavioral health settings where people with serious mental illness are already engaged in care. Behavioral health counselors can have very close relationships with individuals, often seeing them more frequently than any other provider. For individuals whose traumatic experiences have made trusting new providers difficult, being able to access primary care in a place where they already feel safe can facilitate management of health risks. While the literature on reverse co-location is currently at a younger stage than for forward co-location, there are nevertheless some promising research findings. In particular, Benjamin Druss’s group has demonstrated improved primary care linkage, rates of diagnosis of medical conditions, and quality of medical treatment for people with mental illness.
Finding PCPs who are willing and able to work in behavioral health settings, including clinics, rehabilitation programs and outreach teams, is not an easy task. As it is, there is a dearth of PCPs to serve the general population. A PCP who takes on this new role needs to be highly collaborative, flexible and open to creating a new model, not to mention having a commitment to working with people who have high behavioral health needs. Whereas PCPs are generally accustomed to working in group or private practices where they are team leaders, this new role makes them consultants and minority members of a multidisciplinary team that is usually led by non-physicians. And since reverse co-location is still being developed, with federal (SAMHSA) and other grants supporting innovations in this area, the pioneer PCPs doing this work need to be willing to try out different workflows with their colleagues, provide constructive feedback, and continue to develop new ways of working together to improve outcomes. Given the promising results demonstrated by the Druss group, behavioral health agencies and departments would do well to support family medicine and internal medicine trainees to engage in experiences that develop their interest and skill in reverse co-location.
Psychiatry’s Role in Management of Physical Health Conditions
For psychiatrists working in behavioral health settings, the main shift in scope has been to include not only cardiometabolic monitoring but also management of basic cardiometabolic conditions as part of routine patient care. Many psychiatric medications, including second generation, or “atypical” antipsychotics, have metabolic side effects including increasing weight, glucose levels and cholesterol levels, all of which are risk factors for heart attacks and stroke. Screening guidelines were introduced over a decade ago by the American Diabetes Association and American Psychiatric Association for people on atypical antipsychotics. These guidelines include regular measurement of weight, waist circumference, blood pressure, fasting glucose and fasting lipid profile at baseline and at intervals after starting an antipsychotic medication. The development of standards for non-fasting glucose and cholesterol measurement have made good screening more accessible for people whose psychiatric symptoms have made fasting for bloodwork difficult. Many psychiatric offices now have scales, tape measures and blood pressure cuffs available to make routine measurement possible, and some practices have nursing or medical technician support as well.
For people who develop metabolic side effects with a medication that has been effective for psychiatric symptoms, the risks of switching medications need to be weighed against the metabolic risks. Behavior changes to reduce risk should be discussed. Medication side effects are only one of the reasons why obesity, diabetes and high cholesterol are prevalent among people with serious mental illness. Symptoms of mental illness such as avolition and low energy lead to reduced physical activity. Tobacco or substance use can also affect health (e.g., alcohol causing weight gain) and worsen self-care.
When medication changes and/or behavior changes are not adequate to address metabolic risk, medications that reduce weight, blood pressure, glucose levels and cholesterol levels may be needed. Sometimes psychiatrists may prescribe these medications when access to primary care is difficult. For example, metformin can be used to reduce weight in people with schizophrenia and obesity, even if they do not have diabetes. Metformin is generally well-tolerated and has few risks. Psychiatrists can also prescribe amlodipine for hypertension, statins for elevated cholesterol levels, or aspirin to prevent heart attack if high risk, as the risk-benefit ratio for these medications is usually favorable. However, since this practice was not part of most psychiatrists’ residency training, and since major associations and regulatory bodies have not yet made a clear position statement on the issue, many psychiatrists are still reticent to prescribe these medications and manage basic cardiometabolic conditions.
What may be required is an integrated care model that is a reverse version of the collaborative care model, in which psychiatrists could manage a basic set of physical health conditions for people with serious mental illness, using the support of a primary care provider who is available for doctor-to-doctor consultation but also to examine people in person if needed. This would require development of another primary care role, which has not yet been investigated to any great extent.
Towards a More Continuous Continuum of Care
The health care system is moving toward a continuum of care that includes quality psychiatric care for people in the general population on one end, and quality primary care for people with the highest level of behavioral health needs on the other. This transition will require a greater supply of different types of psychiatrists and primary care providers to work in different roles. Expansion of scope of practice, and regulatory support of this expansion, will be needed to allow integration to flourish. Training physicians to work in these different roles should begin in residency or even before, with continuing medical education helping physicians in practice to keep up with changing models of integration. Ultimately, this increased flexibility in physician roles is needed to achieve better outcomes for the people we serve.