Integrated Care Marginalizing Psychiatrists or Optimizing Access to Psychiatric Treatment?

So I ran across this interesting article in the June 2013 issue of Clinical Psychiatry News about collaborative care, which showed improved response for patients suffering from late-life depression [1]. The results of a records review of Patient Health Questionnaire (PHQ)-9 of 186 older adults enrolled in the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) collaborative care project, started in March of 2008, were presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting.

After six months of treatment, mean PHQ-9 scores were significantly lower for the 93 patients in the DIAMOND group than for the 93 patients in the usual care group. Antidepressant medication use was similar in both groups. The findings also showed antidepressant use was not increased using the collaborative-care model. This is a concern I’ve heard raised by some psychiatrists. Another is that psychiatrists will ultimately be further marginalized than we already are, a point raised at the November 2012 annual meeting of the Academy of Psychosomatic Medicine (APM) meeting in Atlanta, Georgia. I posted about this, which you can review at link, Clinical Excellence in Psychiatry and Integrated Care: Can We Have Both? – The Practical Psychosomaticist.

According to the Worcester article, “Collaborative-care models that bring primary care providers and psychiatrists together to care for patients have been shown in numerous studies to be more effective than usual care for the management of depression.”

The model involves a primary care manager and a “liaison or consultative relationship with a psychiatrist…” Programs like DIAMOND provide consistent assessments and follow-up, using a population-based registry to track treatment response over time. I’m going to warn readers ahead of time that, although I’ve written in enthusiastic praise of integrate care models in the past, I’ve heard other physicians raise doubts about it that have made me think a little harder.

A legitimate question some psychiatrists have is how these collaborative-care models are going to be funded after the research programs which currently support them end their support. Others believe that psychiatrists are being marginalized to the point of near-extinction. However, a recent Journal of the American Medical Association (JAMA) interview with a major research leader in integrated care models, Wayne Katon, MD, may not support that concern [2]. Dr. Katon is a psychiatrist, I’ve heard him speak many times at Academy of Psychosomatic Medicine (APM) meetings, and I doubt he would engage in this field of research if he thought it would marginalize psychiatrists. In fact, in the JAMA article he says,Wayne Katon, MD

“We don’t want psychiatrists to be left behind in the changes that are rapidly going on. Many psychiatrists are involved in efforts to integrate mental health services into primary care and medical specialty care as well as collaborative care and dissemination trials.” True, he doesn’t specify how psychiatrists will not be left behind.

Dr. Katon mentions the three main elements in collaborative care, which are “population-based care, measurement-based care, and integration of psychiatry expertise into primary care.”

A fair criticism, though, of measurement-based care as it occurs in primary care clinics is that the favored tool, the PHQ-9, may tend to overestimate the severity of depression, according to Zimmerman and colleagues [3].

Moreover, a recent U.S. survey shows depression is overdiagnosed and overtreated [4].  The study looked at whether patients identified by their clinicians also met the DSM-IV criteria for 12 month major depressive disorder. Out of over 5,600 patients with clinician-identified depression, only about 38% met diagnostic criteria for major depression. Study author Dr. Ramin Mojtabai of Johns Hopkins said, “This finding highlights the growing trends in prescription and use of psychiatric medications, and especially antidepressants, in the USA, even in the absence of a psychiatric diagnosis.”

It remains to be seen whether the physician shortage will lead to the dwindling number of primary care physicians to refer patients to psychiatrists sooner because of being overwhelmed by the increasing numbers of patients ushered in via the Affordable Care Act–and consequently expand the already large wait list to get into undermanned, overworked mental health clinics. Alternatively, what we could see are an overwhelming number of patients taking psychiatric drugs whether they need them or not.

Integrated care can be a double-edged sword and could mean greater access for patients with better treatment of psychiatric illness or greater marginalization of psychiatrists and overmedicalizing of sorrow, grief, and reactive, temporary sadness which could ultimately be a growth experience for many. I guess I don’t what to say…yet.

References:

1. Worcester, S. (2013). Collaborative care improved response in late-life depression. Clinical Psychiatry News, IMNG Medical Media. 41.

2. Kuehn, B. M. (2013). “Health reform, research pave way for collaborative care for mental illness.” JAMA 309(23): 2425-2426.

Wayne Katon, MD, professor of psychiatry at the University of Washington in Seattle, has worked to develop and test models for integrating mental health care into primary care practice for the past 30 years. For much of that time, dissemination of the model moved slowly, but this process has been rapidly accelerated by health reform and growing recognition of the benefits of integrated care. Katon discussed the future of the model with JAMA.

3. Zimmerman, M., et al. (2012). “How can we use depression severity to guide treatment selection when measures of depression categorize patients differently?” J Clin Psychiatry 73(10): 1287-1291.
OBJECTIVE: Treatment guidelines for depression suggest that severity should be taken into account when initiating treatment. If clinicians are to consider illness severity in selecting among treatment options for depression, then it is important to have reliable, valid, and clinically useful methods of distinguishing between levels of depression severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared 3 self-report scales that assess the DSM-IV criteria for major depressive disorder on the basis of how these scales distribute patients into severity categories. METHOD: From June 2010 to November 2011, 245 depressed outpatients completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology (QIDS), and Patient Health Questionnaire (PHQ-9). The study was conducted at Rhode Island Hospital, Providence, Rhode Island. The patients were subdivided into severity categories according to the cutoff scores recommended by each scales’ developers. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS-17). RESULTS: The correlations between the HDRS-17 and the 3 self-report scales were nearly identical. Yet the scales significantly differed in their distribution of patients into severity categories. On the CUDOS and HDRS-17, moderate depression was the most frequent severity category, whereas on the PHQ-9 and QIDS, the majority of the patients were classified as severe. Significantly fewer patients were classified as severely depressed on the CUDOS compared to the PHQ-9 (McNemar = 153.8; P < .001) and QIDS (McNemar = 114.0; P < .001). CONCLUSIONS: If clinicians are to follow treatment guidelines’ recommendations to base initial treatment selection on the severity of depression, then it is important to have a consistent method of determining depression severity. The marked disparity between standardized scales in the classification of depressed outpatients into severity groups indicates that there is a problem with the use of such instruments to classify depression severity. Caution is warranted in the use of these scales to guide treatment selection until the thresholds to define severity ranges have been empirically established.

4. Rajaraman, M. (2013). U.S. survey shows depression overdiagnosed, overtreated. Clinical Psychiatry News, IMNG Medical Media. 41.

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