Literature Collection

A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.

BACKGROUND: Collaborative models for depression have not been widely adopted throughout the USA, possibly because there are no successful roadmaps for implementing these types of models. OBJECTIVE: To provide such a roadmap through a case study of the institutionalization of a depression care management (DCM) initiative for adult depression in a large healthcare system serving over 300,000 adults with depression. DESIGN: A retrospective observational program evaluation. Program evaluation results are presented for those patients enrolled in the initiative from January 1, 2015, to December 31, 2018. PARTICIPANTS: Over a 4-year period, 17,052 patients were treated in the DCM program. In general, participants were women (76%), were Hispanic (47%), spoke English (84%), and were 51.1 ± 18.3 years old, the majority of whom were 30-64 years old (57%). INTERVENTION: The collaborative care portion of the DCM initiative (DCM program) was implemented by a collaborative care team containing a treatment specialist, an assessment specialist, administrative staff, a primary care physician, and a psychiatry physician. MAIN MEASURES: The main outcome measures were total score on the 9-item Patient Health Questionnaire (PHQ-9). Outcomes were improvement (defined as at least 50% reduction in symptoms) and remission (defined as a PHQ-9 less than 5) of depression symptoms. Follow-up of depression symptoms was also collected at 6 months following discharge. KEY RESULTS: The average course of treatment in 2018, after full implementation, was 4.6 ± 3.0 months; 62% of patients experienced improvement in symptoms, and 45% experienced remission of their depression at the time of discharge. These rates were maintained at the 6-month follow-up. CONCLUSIONS: Collaborative care for depression can be institutionalized in large healthcare systems and be sustained with a specific, detailed roadmap that includes workflows, training, treatment guidelines, and clear documentation standards that are linked to performance metrics. Extensive stakeholder engagement at every level is also critical for success.