A Solution to an Overloaded System?
Recently I have been eagerly reading about a few smart people who are studying new solutions to help psychiatrists with an endemic problem: we are an overworked speciality that is far outstripped by a growing demand for our services. It is a sobering thought, the vast, vast majority of folks with behavioural health care issues like mood disorders, anxiety, substance abuse, eating disorders, etc., never set foot in our offices, and their generalists (GPs) end up doing all the work. Sadly, a referral to a psychiatrist goes into the “black hole” and a GP and their patient never hear back for months and months. It is so very frustrating for both sides: psychiatrists are inundated and can burn out from overwork. GPs are baffled and jaded. This is the typical solution–limit access, keep psychiatrist caseload size small, protect the specialist from overload, and put the referrals on “the wait list” or state your caseload is “closed.” Obviously, waits in excess of six months are commonplace.
Yet, I am now very excited by novel thinkers attempting to remould the psychiatrist into a more accessible consultant. I think the best plan comes from a collaborative care model which places behavioural healthcare service in the primary care setting. The IMPACT study (and many others like it) showed that you could successfully care for 93-95% of a the patients in the primary care setting (with a few key modifications) without ever seeing a psychiatrist face-to-face. All the study groups shared eight core components in common. They relied on informal consults by telephone between GP and psychiatrist(located elsewhere); they encouraged GPs to immediately direct the patient to their onsite behavioural healthcare provider(BHP)–often a nurse or trained social worker–with a “warm handoff” who in turn provided case management, basic problem-solving, and psychotherapy; they set up consultation meetings between the psychiatrist and the BHP to review difficult cases each week; they set up registries of patients to avoid any “falling through the crack”; they used defined outcome measures based on tools that assess depression, anxiety, social functioning, etc.; they organized programs that used evidence-based treatments; they used “stepped care” in which more difficult clinical situations led to greater mental health support and eventually a psychiatric evaluation; they figured out legal liability issues for informal and formal consults; and, most importantly, they demonstrated good outcomes. In sum, this is a new model with two additional players: the onsite BHP (caseload 30-60); the offsite, more flexible, limited liability consulting psychiatrist. It is a model in which GPs and specialists enjoy a healthy collaboration and rewarding teamwork.
The vision is population-based: rather than think of each patient and his/her needs, the entire demographic of unserved clients in primary care with unaddressed behavioural health needs is considered. The numbers are great, some estimate up to 70% of high utilizers of GP services or 20-30% of the total GP caseload have behavioural health needs. The GP is the workhorse, writes the prescriptions, and remains in charge and responsible; the GP is empowered and supported –in stepped fashion–by a team of behavioural care specialists including a psychiatrist.
It is a new model which will take some getting used to, but it appears to be taking off in parts of the U.S. and Canada. The reports back are favourable, as both clinicians are experiencing better outcomes and patients find the services satisfactory. The status quo is unacceptable: behavioural issues in primary care are overlooked, under treated, or inappropriately treated the majority of the time (unfortunately and surprisingly); good outcomes occur perhaps 20% of the time (in particular, in reference to success of an antidepressant trial by a GP). Again, any individual patient or GP may do much better than this, but from a population perspective, things must change.
We are actively looking at the overloaded mental health and substance use system in Nanaimo/Central Island. As meetings roll out early 2014, I will be there, trying to pitch in. The psychiatrists and GPs of this fine town can find a equitable solution, I think. The way forward looks rather hopeful, don’t you think?