I was trained to do collaborative care in the Assertive Community Treatment (ACT) model of Test and Stein in 1987. For three years following residency, I did collaborative care with a case management team out of a community mental health center. We provided comprehensive medical and psychiatric care to every person on the team and that included determining medical needs and making referrals for testing and treatment if I felt the patient’s medical problems were not being addressed. In that model of care, the psychiatrist is a physician coordinating medical and psychiatric care for people with severe mental illnesses and significant medical comorbidity. All of the care comes from a personal relationship with each patient. The psychiatrist sees the patient frequently and knows them well. We were tremendously successful in helping people stay out of hospitals, helping them live independently, providing 24/7 crisis coverage, reducing the total amount of medications prescribed, and getting them medical care for significant problems that were misdiagnosed or that they had refused to get care for. As far as I know, the community psychiatry models are being taught in most residency programs and the number of these programs has increased significantly since I was trained.
The problem with current models of collaborative care is that the psychiatrist does not or provides minimal medical or psychiatric care. One central question is – what model are we talking about? The original model in a JAMA article points out that the psychiatrist does not see the patient at all but reviews rating scales. The new model from a group consulting to the American Psychiatric Association (APA), has put the psychiatrist in the role of seeing the occasional patient, probably similar to the link to the Sanchez and Adorno article. The remaining links are less specific.
The responsibilities outlined in both the AMA and APA models are not really psychiatry. Instead they can be seen as an extension of a process initiated 20 years ago by managed care companies to ration access to psychiatrists and psychiatric care. Everybody reading this knows what that means. We currently have no useful inpatient treatment besides crisis care based on “dangerousness” criteria. The largest psychiatric hospitals in the country are county jails. We have limited to no access to detox facilities despite being in the midst of an opiate epidemic. Access to psychiatrists is rationed and it is not uncommon to be told that a psychiatrist will be available for a 10-15 minute discussion of medications only. Psychotherapy that resembles the psychotherapy delivered in research studies is rarely if ever provided. In their place we have models where patients fill out a checklist and get placed on a medication as soon as possible. That is occurring in the context of clear evidence that in many cases antidepressants already exceed the actual diagnosis of major depression. It also occurs in the context that depression screening has no evidence basis and in most cases screening equates with diagnosis.
The current models of collaborative care can easily be done without a psychiatrist. I think that is really the point. Anybody can look at a PHQ-9 score and an antidepressant algorithm and put somebody on an antidepressant. It is ironic that when psychiatrists and other physicians are being told that it is important to go through maintenance of certification procedures in addition to continuing medical education that the federal government and professional organizations have recommended such a low standard. On the other hand it does seem like the logical conclusion of the marginalization of psychiatry and psychiatric services by the insurance industry and federal and local governments.
What is a proactive position for psychiatry? First, recognize that this model is not the model for providing psychiatric services. If anything it highlights the well known fact that there are two tiers of care for mental illnesses. Psychiatrists have adapted to managed care rationing by refusing to accept insurance and changing to a cash only basis. I recently saw this compared to how dental care is rationed and I think that is an accurate comparison. Excellent dental care is available but the odds are the patient will pay for it. Second, this form of rationing will probably continue the current managed care tradition of rationing psychiatric services. It will not lead to any improvement in the availability of inpatient services, detoxification services, or psychotherapy for people with severe mental illnesses. It will allow these companies to advertise collaborative care along with all of the other business services that are marketed as improvements to their patients. Third, there is the undeniable connection between PHQ-9 scores and medication exposure at a time when the FDA has issued a warning on a widely prescribed antidepressant. Fourth, with the widespread use of the PHQ-9 and availability of administrative data it is just a matter of time before somebody publishes papers based on the data showing a marked increase in the prevalence of depression. Some researchers and many clinicians equate a PHQ-9 score with a diagnosis of depression. Fifth, psychiatrists need to remain focused on providing a high standard of care to people with severe mental illness, neuropsychiatric problems, and people with significant medical comorbidity. There are many internists and family physicians who are very competent in prescribing antidepressants and using typical augmentation strategies. They are also using fewer benzodiazepines to treat anxiety disorders. That constitutes a first line of medical care from the primary care side for mental illness in this country.
Collaborative care should not be confused with psychiatric care and psychiatrists should not be confused about this being a new model for them to follow.
George Dawson, MD, DFAPA
Sharon Worcester. Future of psychiatry may depend on integrated care. Clinical Psychiatry News. April 2014. page 1.
The Model of Psychiatric Care for the Future
Collaborative Care – Even Worse Than I Imagined