1 The Challenge of Integrating The Challenge of Integrating Psychiatry Psychiatry (Behavioral Medicine) (Behavioral Medicine) into into Primary Care Primary Care Thomas N. Wise, M.D. Thomas N. Wise, M.D. Professor of Psychiatry Professor of Psychiatry Johns Hopkins School of Medicine Johns Hopkins School of Medicine George Washington University George Washington University Chairman, Department of Psychiatry Chairman, Department of Psychiatry Inova Fairfax Hospital Inova Fairfax Hospital A Global Problem: But Today a Focus on A Global Problem: But Today a Focus on the U.S. the U.S.
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The Challenge of Integrating The Challenge of Integrating PsychiatryPsychiatry
(Behavioral Medicine)(Behavioral Medicine)into into
Primary CarePrimary Care
Thomas N. Wise, M.D.Thomas N. Wise, M.D.Professor of PsychiatryProfessor of Psychiatry
Johns Hopkins School of MedicineJohns Hopkins School of MedicineGeorge Washington UniversityGeorge Washington University
Chairman, Department of PsychiatryChairman, Department of Psychiatry
Inova Fairfax HospitalInova Fairfax Hospital
A Global Problem: But Today a Focus on the U.S.A Global Problem: But Today a Focus on the U.S.
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Psychiatry in the Past
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Outpatient TherapyOften Separated
With no communication
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Current Sites for CareCurrent Sites for Care(separate and not equal)(separate and not equal)
The Isolated Psychiatrist….The Isolated Psychiatrist…. The Anxious PatientThe Anxious PatientIn Primary CareIn Primary Care
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Other Sites for Care(2)Other Sites for Care(2)
The New Asylum: The Street The Clinic for Some Panic Disorders
Current Model:Current Model: Separate and Not Equal Care Separate and Not Equal Care
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Your Tests are Normal!Your Tests are Normal!Get Some Exercise…Get Some Exercise…Call your Insurance if Call your Insurance if You need a therapyYou need a therapy
1-800 Mental Health1-800 Mental Health
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Is This a Problem?Is This a Problem?
You Bet It Is!!!!You Bet It Is!!!!
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Here’s the Problem!!Here’s the Problem!!(Prevalence Rates…all probably higher in fact)(Prevalence Rates…all probably higher in fact)
DisorderDisorder Community(%)Community(%) Primary Care(%)Primary Care(%) General General Hospital(%)Hospital(%)
Major DepressionMajor Depression 2-62-6 5-145-14 >15>15
Somatization Somatization DisorderDisorder
0.1-0.50.1-0.5 2.8-5.02.8-5.0 2-92-9
PanicPanic 0.50.5 1111 No dataNo data
Academy of Psychosom Med,1997
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We Cannot PartitionWe Cannot PartitionMedical Care from Medical Care from Psychiatric CarePsychiatric Care
Many Patients with Many Patients with Medical Problems HaveMedical Problems Have
Psychiatric DisordersPsychiatric Disorders
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Prevalence of Prevalence of Anxiety DisordersAnxiety Disorders Among Persons with Chronic Medical Among Persons with Chronic Medical Conditions in the General PopulationConditions in the General Population
Medical ConditionMedical Condition Current % Current % SESE Lifetime % Lifetime % SESE
No Medical ConditionNo Medical Condition
ArthritisArthritis
DiabetesDiabetes
Heart DiseaseHeart Disease
Chronic Lung DiseaseChronic Lung Disease
High Blood PressureHigh Blood Pressure
6.0 6.0 ±± 0.60.6
11.9 11.9 ±± 2.62.6bb
15.8 15.8 ±± 6.16.1
21.0 21.0 ±± 5.75.7cc
10.0 10.0 ±± 2.52.5
12.1 12.1 ±± 3.03.0bb
12.412.4 ±± 1.01.0
20.7 20.7 ±± 3.33.3bb
27.1 27.1 ±± 7.07.0bb
28.328.3 ±± 5.85.8cc
21.021.0 ±± 4.14.1bb
16.116.1 ±± 2.92.9
bb p< .05 p< .05cc p< .01 p< .01
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The Essential Dialectic:The Essential Dialectic:WhoWho is the Patient? is the Patient?
vs. vs. WhatWhat do they have? do they have?
The Primary Care PhysicianThe Primary Care Physician
Knows This Better Than Anyone Knows This Better Than Anyone (Hopefully?)(Hopefully?)
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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
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Most Common Symptoms Without Clear Etiology
Kroenke,Am J Med 86:262,1989
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Depression is under-diagnosedDepression is under-diagnosed
But Before We get too Far…There is But Before We get too Far…There is another issue (unhappy docs)another issue (unhappy docs)
Working Conditions in Primary CareWorking Conditions in Primary Care 422 physicians (FP and IM) in 119 Clinics treating 422 physicians (FP and IM) in 119 Clinics treating
1795 patients with DM,CVD, or HBP1795 patients with DM,CVD, or HBP ResultsResults
• 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 administratorsLow trust with administrators• Burnout 26.5%Burnout 26.5%
Study Sites:Study Sites:• ¼ academic; 1/2 primary care (not multispecialty) and 42% ¼ academic; 1/2 primary care (not multispecialty) and 42%
financed by HMOsfinanced by HMOs• 20% indigent care;25% commercial20% indigent care;25% commercial
HOT OFF THE PRESSHOT OFF THE PRESS Linzer et al: Annals Internal Med:151,28-36,2009
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What are the What are the Barriers?Barriers?
PrimaryPrimaryCareCare PsychiatryPsychiatry
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Patient IssuesPatient Issues
Shame Shame Psychological distress is a character flaw or weaknessPsychological distress is a character flaw or weakness They will think I am crazy and lock me upThey will think I am crazy and lock me up
Limited ability to use emotional language and limited Limited ability to use emotional language and limited emotional awarenessemotional awareness
AlexithymiaAlexithymia This is not “in my head” it is physicalThis 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 didn’t work beforeHopelessness-it didn’t work before I called 15 psychiatrists and none took my insuranceI called 15 psychiatrists and none took my insurance My friends said the psychiatrist was “nuts”My friends said the psychiatrist was “nuts”
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Physician IssuesPhysician Issues Lack of Lack of knowledge baseknowledge base
Medical school rotation with only chronically mentally Medical school rotation with only chronically mentally ill inpatients ill inpatients
Lack of timeLack of time to see patients =pressure to see to see patients =pressure to see volume of patientsvolume of patients
Group practicesGroup practices don’t allow real long term don’t allow real long term perspectiveperspective
Personal uneasiness with psychiatric issuesPersonal uneasiness with psychiatric issues Past bad experiencesPast bad experiences
““Sending someone to a psychiatrist or therapist is like Sending someone to a psychiatrist or therapist is like sending them into a “black hole” (quoted from a fine sending them into a “black hole” (quoted from a fine internist)internist)
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Systemic IssuesSystemic Issues
Parity an illusionParity an illusion Shortage of psychiatristsShortage of psychiatrists and other mental health and other mental health
professionals with sufficient trainingprofessionals with sufficient trainingMental health carveMental health carve outsouts prevent truly integrated care prevent truly integrated care Usually for profit; no advantage to help primary care Usually for profit; no advantage to help primary care
savings; savings; Primary care physicians often have to refer to Primary care physicians often have to refer to
someone they don’t knowsomeone they don’t know Very limited care with medication separated from any Very limited care with medication separated from any
verbal therapyverbal therapy For some For some co-paysco-pays are too much are too much
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Systemic Issues(cont)Systemic Issues(cont)Lack of Shared CommunicationLack of Shared Communication
Electronic Records-Electronic Records- Cost to most MDsCost to most MDs HIPPA issues of confidentialityHIPPA issues of confidentiality Usual Paper Charts WithoutUsual Paper Charts Without
Psychiatry Notes (variablePsychiatry Notes (variableIn hospital care but outpatientIn hospital care but outpatientUsually separate to none!!!Usually separate to none!!!
A Call from PsychiatristA Call from PsychiatristMay Not be EnoughMay Not be Enough
A call can be forgottenA call can be forgottenPrimary Care ChartPrimary Care ChartIs the Patient Base forIs the Patient Base forDataData
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Current Buzz WordCurrent Buzz WordMedical HomeMedical Home
Is this another form of capitation?Is this another form of capitation?
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The Medical Home Concept?The Medical Home Concept?
I am Still in ChargeI am Still in Charge
Mental Mental HealthHealth
ServicesServices
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Medical HomeMedical Home(current buzz word)(current buzz word)
A concept with some demonstration projects A concept with some demonstration projects now being federally funded and by state fundsnow being federally funded and by state funds
A Method for Primary Care to Coordinate CareA Method for Primary Care to Coordinate Care Psychiatry is excludedPsychiatry is excluded from being the primary from being the primary
specialty in federal projects….specialty in federal projects…. Along with dermatology, radiology, chiropractic etc. Along with dermatology, radiology, chiropractic etc.
The Baucus SenateThe Baucus Senate bill does provide that the bill does provide that the chronically ill will be eligible for Medicaid chronically ill will be eligible for Medicaid treatmenttreatment
Psychiatrist Psychiatrist embeddedembedded into the system as consultant and into the system as consultant and supervisorsupervisor 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
ScreeningScreening for disorders often done for disorders often done DIAMOND project data ($$$)DIAMOND project data ($$$) PHQ??PHQ??
Use of Use of case managerscase managers Less complicated cases treated by non MDsLess complicated cases treated by non MDs Psychiatrist supervises and sees complex or resistant casesPsychiatrist supervises and sees complex or resistant cases
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Screening for Psychiatric IssuesScreening for Psychiatric Issues
Ease of use,scoring,patient acceptance Ease of use,scoring,patient acceptance Something like a psychiatric vital signSomething like a psychiatric vital sign PHQ-9PHQ-9 Two questionsTwo questions IssuesIssues
Do Primary Care Doctors use this?Do Primary Care Doctors use this? DIAMOND PROJECTDIAMOND PROJECT
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To SummarizeTo Summarize
Mental health disorders are major factors in our Mental health disorders are major factors in our health care systemhealth care system Excess utilization—cost factorExcess utilization—cost factor Improper treatment causes suffering, harm to future Improper treatment causes suffering, harm to future
generations , lost productivity generations , lost productivity
Reform demandsReform demands Models that offer true parityModels that offer true parity Remove partitions such as “carve outs” (we are not Remove partitions such as “carve outs” (we are not
separate and equal!!!!)separate and equal!!!!) Integrate care within primary care via diverse modelsIntegrate care within primary care via diverse models
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Primary Care IntegrationPrimary Care Integration
Education of both primary care providers but Education of both primary care providers but also mental health providers about needs and also mental health providers about needs and strategies within primary carestrategies within primary care
True integration doesn’t have to be in one True integration doesn’t have to be in one buildingbuilding Communication essentialCommunication essential; unified records or at least ; unified records or at least
sending recordssending records Cut out insurance barriers !!!!Cut out insurance barriers !!!!
Both direct and indirect input by specialist sectorBoth direct and indirect input by specialist sector
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Psychiatry also needs Integration Psychiatry also needs Integration with Primary Carewith Primary Care
There also needs to be a medical home within There also needs to be a medical home within psychiatrypsychiatry For the chronic patientFor the chronic patient Identified psychiatric patient who goes to a psychiatric Identified psychiatric patient who goes to a psychiatric
clinicclinic
The Chronic Mentally ill need primary careThe 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 Make sure we have medical assessment of such
patients and ongoing treatment optionspatients and ongoing treatment options True integration the other way.True integration the other way.
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Goals in the Best of WorldsGoals in the Best of Worlds
Medical HomeMedical HomeFor Certain
Psychiatric Patients(with Primary Care integration
To insure proper medicalCare for such patients)
Medical HomeMedical HomeFor Primary
Care(with collaboration with
Psychiatry that istruly effective)
We All Need to Lobby for Our PatientsWe All Need to Lobby for Our Patients
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