1 The Challenge of Integrating Psychiatry (Behavioral Medicine) into Primary Care Thomas N. Wise, M.D. Professor of Psychiatry Johns Hopkins School of Medicine George Washington University Chairman, Department of Psychiatry Inova Fairfax Hospital A Global Problem: But Today a Focus on the U.S.

2 Psychiatry in the Past

3 Outpatient Therapy Often Separated With no communication

4 Current Sites for Care (separate and not equal) The Isolated Psychiatrist…. The Anxious Patient In Primary Care

5 Other Sites for Care(2) The New Asylum: The Street The Clinic for Some Panic Disorders

6 PrimaryCare MentalHealth Hospital And Some SpecialtyCare Current Model: Separate and Not Equal Care

7 Your Tests are Normal! Get Some Exercise… Call your Insurance if You need a therapy Mental Health

8 Is This a Problem? You Bet It Is!!!!

9 Heres the Problem!! (Prevalence Rates…all probably higher in fact) DisorderCommunity(%) Primary Care(%) General Hospital(%) Any psychiatric disorder Substance Abuse Delirium??15-30 Major Depression >15 Somatization Disorder Panic0.511 No data Academy of Psychosom Med,1997

10 Psychiatric Disorders are Common lifetime 12 month estimate

11 We Cannot Partition Medical Care from Psychiatric Care Many Patients with Medical Problems Have Psychiatric Disorders

12 Prevalence of Anxiety Disorders Among Persons with Chronic Medical Conditions in the General Population Medical Condition Current % SE Lifetime % SE No Medical Condition ArthritisDiabetes Heart Disease Chronic Lung Disease High Blood Pressure 6.0 ± ± 2.6 b 15.8 ± ± 5.7 c 10.0 ± ± 3.0 b 12.4± ± 3.3 b 27.1 ± 7.0 b 28.3± 5.8 c 21.0± 4.1 b 16.1±2.9 b p<.05 c p<.01

13 Current Models of Psychiatric Input in Primary Care (I am not using the word collaboration) ModelRecords Face to Face Assessment Communication (W ritten) (V oice) (E mail-secure) Where is Pt Seen Specialty Psychiatry Clinic SeparateYesW,V,EPsych Consulting Psychiatrist Variable if there is a written note YesW,V,E Psych usually TeleconsultationVariableVariableW,V,E Long Distance;Either in PC or Psych Staff Consultant Shared or separate VariableW,V,E In Clinic but can be separate Parallel Separate except for a note or phone call Face to Face VariableSeparate CollaborativeSharedSometimesW,V,ETogether

14 The Essential Dialectic: Who is the Patient? vs. What do they have? The Primary Care Physician Knows This Better Than Anyone (Hopefully?)

15 The patient presents their complaint with some preconceived idea (still disorganized) The physician responds with questions,exams and studies The complaint then is organized into a diagnostic entity

16 Most Common Symptoms Without Clear Etiology Kroenke,Am J Med 86:262,1989

17 Depression is under-diagnosed 1. Montano CB. J Clin Psychiatry. 1994;55(suppl):18-34; discussion Andersen SM, Harthorn BH. Med Care. 1989;27: Slide Modified: on: 4/8/2003 1:19:40 PM SL11 Rev: 2152 Review: by SHARIE SIPOWICZ 4/8/2003 1:19:10 PM SL11 Rev: 2152 Jackie Strasser 4/10/03 by LW 4/25/2003 5:21:19 PM SL11 Rev: 2161 Reviewer Memo: To the extent possible, we should utilize graphs/pie charts. This is an example of good content, that would give a more memorable message in a pie chart. (done) Source: Memo: rearranged references to be in order of the text Patients Suffering from Depression Do not seek treatment Seek treatment 66% 34% Diagnosed 50% Not diagnosed 50% Seek treatment from PCP 65% Seek treatment from mental health professional 35%

18 But Before We get too Far…There is another issue (unhappy docs) Working Conditions in Primary Care Working Conditions in Primary Care 422 physicians (FP and IM) in 119 Clinics treating 1795 patients with DM,CVD, or HBP 422 physicians (FP and IM) in 119 Clinics treating 1795 patients with DM,CVD, or HBP Results Results Time Pressure-53.1%Time Pressure-53.1% Work Pace is Chaotic 48.1%Work Pace is Chaotic 48.1% Low control over work 78.4%Low control over work 78.4% Low trust with administrators Low trust with administrators Burnout 26.5%Burnout 26.5% Study Sites: Study Sites: ¼ academic; 1/2 primary care (not multispecialty) and 42% financed by HMOs¼ academic; 1/2 primary care (not multispecialty) and 42% financed by HMOs 20% indigent care;25% commercial20% indigent care;25% commercial HOT OFF THE PRESS HOT OFF THE PRESS Linzer et al: Annals Internal Med:151,28-36,2009

19 Symptom Diagnostic Yield (%) Cost in $ per Organic Diagnosis Discovered Headache5$7778 Backache3$7263 Chest pain 6$4354 Dizziness9$2532 Abdominal Pain 11$1816 Fatigue9$1486 Numbness12$1364 Edema/Swelling15$793 Dyspnea29$720 DIAGNOSTIC YIELD OF FULL WORK UP FOR COMMON SYMPTOMATIC COMPLAINTS

20 BUT….. Under detection or misidentification is common in Primary Care Patients with Psychiatric Disorders

21 What to say or not to say to the Somatizing Patient Stone et al: BMJ 2002:325,

22 What are the Barriers? PrimaryCare Psychiatry

23 Patient Issues Shame Shame Psychological distress is a character flaw or weakness Psychological distress is a character flaw or weakness They will think I am crazy and lock me up They will think I am crazy and lock me up Limited ability to use emotional language and limited emotional awareness Limited ability to use emotional language and limited emotional awareness Alexithymia Alexithymia This is not in my head it is physical This is not in my head it is physical Headaches;fatigue;pain;etc (somatic symptoms) Headaches;fatigue;pain;etc (somatic symptoms) Cost-only the rich can see a shrink Cost-only the rich can see a shrink Hopelessness-it didnt work before Hopelessness-it didnt work before I called 15 psychiatrists and none took my insurance I called 15 psychiatrists and none took my insurance My friends said the psychiatrist was nuts My friends said the psychiatrist was nuts

24 Physician Issues Lack of knowledge base Lack of knowledge base Medical school rotation with only chronically mentally ill inpatients Medical school rotation with only chronically mentally ill inpatients Lack of time to see patients =pressure to see volume of patients Lack of time to see patients =pressure to see volume of patients Group practices dont allow real long term perspective Group practices dont allow real long term perspective Personal uneasiness with psychiatric issues Personal uneasiness with psychiatric issues Past bad experiences Past bad experiences Sending someone to a psychiatrist or therapist is like sending them into a black hole (quoted from a fine internist) Sending someone to a psychiatrist or therapist is like sending them into a black hole (quoted from a fine internist)

25 Training Primary Care Physicians Interviewing Style Interviewing Style Look patient in the eyes Look patient in the eyes Use open ended questions Use open ended questions Respond to emotional cues with supportive comments Respond to emotional cues with supportive comments Ask about health beliefs Ask about health beliefs Management skills Management skills Ventilation of affects Ventilation of affects Educate about psychological problems Educate about psychological problems Negotiate resistances to change Negotiate resistances to change What would you tell a friend with similar problems? What would you tell a friend with similar problems?

26 Systemic Issues Parity an illusion Parity an illusion Shortage of psychiatrists and other mental health professionals with sufficient training Shortage of psychiatrists and other mental health professionals with sufficient training Mental health carve outs prevent truly integrated care Usually for profit; no advantage to help primary care savings; Usually for profit; no advantage to help primary care savings; Primary care physicians often have to refer to someone they dont know Primary care physicians often have to refer to someone they dont know Very limited care with medication separated from any verbal therapy Very limited care with medication separated from any verbal therapy For some co-pays are too much For some co-pays are too much

27 Systemic Issues(cont) Lack of Shared Communication Electronic Records- Cost to most MDs Cost to most MDs HIPPA issues of confidentiality HIPPA issues of confidentiality Usual Paper Charts Without Psychiatry Notes (variable In hospital care but outpatient Usually separate to none!!! A Call from Psychiatrist May Not be Enough A call can be forgotten Primary Care Chart Is the Patient Base for Data

28 A Report from Psychiatry is Essential for Reasonable Care A Phone Care Is Usually Not Enough since The Patient Chart Is the Computer Chip of Primary Care

29 Current Buzz Word Medical Home Is this another form of capitation?

30 The Medical Home Concept? I am Still in Charge MentalHealthServices

31 Medical Home (current buzz word) A concept with some demonstration projects now being federally funded and by state funds A concept with some demonstration projects now being federally funded and by state funds A Method for Primary Care to Coordinate Care A Method for Primary Care to Coordinate Care Psychiatry is excluded from being the primary specialty in federal projects…. Psychiatry is excluded from being the primary specialty in federal projects…. Along with dermatology, radiology, chiropractic etc. Along with dermatology, radiology, chiropractic etc. The Baucus Senate bill does provide that the chronically ill will be eligible for Medicaid treatment The Baucus Senate bill does provide that the chronically ill will be eligible for Medicaid treatment

32 Collaborative Care (Katon) Psychiatrist embedded into the system as consultant and supervisor Psychiatrist embedded into the system as consultant and supervisor In a closed model HMO it works but…. In a closed model HMO it works but…. Our usual care is the separate office Our usual care is the separate office Screening for disorders often done Screening for disorders often done DIAMOND project data ($$$) DIAMOND project data ($$$) PHQ?? PHQ?? Use of case managers Use of case managers Less complicated cases treated by non MDs Less complicated cases treated by non MDs Psychiatrist supervises and sees complex or resistant cases Psychiatrist supervises and sees complex or resistant cases

33 Screening for Psychiatric Issues Ease of use,scoring,patient acceptance Ease of use,scoring,patient acceptance Something like a psychiatric vital sign Something like a psychiatric vital sign PHQ-9 PHQ-9 Two questions Two questions Issues Issues Do Primary Care Doctors use this? Do Primary Care Doctors use this? DIAMOND PROJECT DIAMOND PROJECT

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35 Does It Work? Meta-analysis (Gilbody et al) Meta-analysis (Gilbody et al) 37 randomized trials 37 randomized trials Clear clinical benefits at 6 months with longer benefits at long as 5 years. Clear clinical benefits at 6 months with longer benefits at long as 5 years.

36 To Summarize Mental health disorders are major factors in our health care system Mental health disorders are major factors in our health care system Excess utilizationcost factor Excess utilizationcost factor Improper treatment causes suffering, harm to future generations, lost productivity Improper treatment causes suffering, harm to future generations, lost productivity Reform demands Reform demands Models that offer true parity Models that offer true parity Remove partitions such as carve outs (we are not separate and equal!!!!) Remove partitions such as carve outs (we are not separate and equal!!!!) Integrate care within primary care via diverse models Integrate care within primary care via diverse models

37 Primary Care Integration Education of both primary care providers but also mental health providers about needs and strategies within primary care Education of both primary care providers but also mental health providers about needs and strategies within primary care True integration doesnt have to be in one building True integration doesnt have to be in one building Communication essential; unified records or at least sending records Communication essential; unified records or at least sending records Cut out insurance barriers !!!! Cut out insurance barriers !!!! Both direct and indirect input by specialist sector Both direct and indirect input by specialist sector

38 Psychiatry also needs Integration with Primary Care There also needs to be a medical home within psychiatry There also needs to be a medical home within psychiatry For the chronic patient For the chronic patient Identified psychiatric patient who goes to a psychiatric clinic Identified psychiatric patient who goes to a psychiatric clinic The Chronic Mentally ill need primary care The Chronic Mentally ill need primary care Manage obesity; cardiac disease etc.,smoking etc. Manage obesity; cardiac disease etc.,smoking etc. Make sure we have medical assessment of such patients and ongoing treatment options Make sure we have medical assessment of such patients and ongoing treatment options True integration the other way. True integration the other way.

39 Goals in the Best of Worlds Medical Home For Certain Psychiatric Patients (with Primary Care integration To insure proper medical Care for such patients) Medical Home For Primary Care (with collaboration with Psychiatry that is truly effective) We All Need to Lobby for Our Patients

40 Questions?