Integrating psychiatric care into primary care: The VA example

For the better part of the last two decades I have practiced psychiatry in a variety of different American health care systems, and over these years I have, on numerous occasions, heard psychiatric services referred to in manner that imply (often subtly) that such services are not medical care.  These references come not only from patients, but nurses and doctors (including myself) too.

“Yes Mr. Jones you need to follow up with your regular medical doctor about that issue.” Or, “Dr. Jain, I went to see my medical doctor and he told me my blood pressure was high.”

Yes, I have been guilty of propagating this false dichotomy myself, and I too end up colluding with this societal misperception that somehow psychiatric care is not medical care, but something separate or distinct from other medical services. I think I did it because, on a day to day basis, when I am busy in clinic it is easier to collude than to get into a debate about semantics.

Still, in today’s blog I want to highlight the fact that this artificial distinction between physical and mental health perpetuates much of the stigma and misperception that, we as a society, have toward mental illness. But, most importantly, I want to convey my belief that when mental and physical well-being are separated, health care becomes poor in quality.

When I did my medical school training in Great Britain, every single medical school student was required to complete a 3-month (minimum) rotation in psychiatry and, furthermore, psychiatry was one of the specialties that had to be passed, in clinical exams, at finals before your MD would be granted.  Why, might you ask, should a ENT surgeon/dermatologist/ER physician-to-be  need to spend so much time training in psychiatry?

First, the majority of British medical students become primary care doctors.  The system is set up that way, so there are relatively few spots for specialty training (e.g. cardiology or plastic surgery) and there is much more emphasis for medical students to become primary care doctors.  This is based on the premise that that is what the country needs so that is what medical schools should provide.

It’s well known that a significant percentage of patients seen in primary care have a mental illness or disorder as a primary problem.  In fact, most prescriptions for psychotropic medications are written in primary care, hence it is logical that every British medical graduate be well versed and adept in diagnosing, treating, and managing psychiatric disorders.

Second, if one looks at mental illness from a sheer epidemiological point of view, no physician can afford to not be well trained in the fundamentals of psychiatric practice.  I, as a psychiatrist, may or may not, in my career, treat a patient who also develops a testicular tumor, needs bypass surgery, or has a fractured hip, but epidemiologically speaking, my colleagues in urology, cardiology, and orthopedics will treat patients who have comorbid depression/anxiety or even severe mental illness such as bipolar disorder or psychosis.  For this reason, it makes sense that these providers have some awareness or understanding of such disorders.

My experience with U.S. health care is different; the business side of U.S. medicine has a tendency to favor medical specialties that are procedure-based or that generate flash technologies that can be promoted and attract more market share.  Unfortunately, psychiatry often fares poorly when it comes to such business strategies.  Mental illness can be chronic, take time to treat, and there is rarely a quick fix or magic cure.  Moreover, mental illness can be associated with a downward drift (like when someone becomes psychotic, they lose their job, and then their health insurance).

In the U.S. health care business, the specialty of psychiatry is often not given a seat at the table.

I think this, in part, explains this nonsensical divide between “medical” and “psychiatric” that we often have in health care.  Of course, it is a fallacy. Mental health and physical health are intricately link on every level, from a cellular level to a more macro perspective of how human beings navigate their day to day life.  In my view, a sophisticated health care system should reflect this intricate relationship and integrate primary and psychiatric care.  (Get rid of this false distinction or separation by physically placing both services in one clinic, side by side.)

One American health care system has been a leader in integrating primary care and mental health care. That system is the Veterans Health Administration (VA). Unlike many other U.S. systems (which place more emphasis on treating individuals), the VA is charged with taking care of a population: veterans. This mission guides where the VA places emphasis, so whatever the prevalent issues are for this population becomes the area where the VA will place emphasis and resources.

The VA aims to meet the needs of the population it is serving, and hence gives psychiatry a seat at the table.

With more than 1,000 outpatient clinics, the VA is the largest health care system in the U.S., and it has a very clear sense of its population. Over the past 15 years, the VA has not only participated in some of the biggest studies of integrated care, but has made a commitment to provide patient-centered integrated care to its population.

For the last two years I have been in the role of medical director of the primary care-behavioral health team at the VA Palo Alto Health Care System, and I spend most of my days right here at the interface between physical well-being and mental health.  Contrary to some of my previous experiences in health care, the last two years have taught me the following:

  • Our colleagues in primary care place very high value on psychiatric and psychological consultation from colleagues.
  • The clinical work is very rewarding and in many ways bypasses a lot of the frustrations we often feel as physicians working in fragmented health care systems.
  • As a specialist, your experience and knowledge can add enormous benefit in making health care more streamlined and patient-centric. There are many opportunities for psychiatrists to act as educators to both colleagues and patients about common misperceptions surrounding mental disorders and mental health care.
  • Being a consultant for and working closely with a team of professionals from various specialty backgrounds helps your own career development. It prevents you from getting rusty in areas of medicine other than psychiatry and keeps you on the cutting edge of how health care systems are evolving to meet the needs and demands of all stakeholders.

Integrated care is the way of the future, and I feel fortunate that I work in a system that is at the cutting edge of such innovation.

Shaili Jain is a psychiatrist who blogs at Mind the Brain on PLOS Blogs, where this article originally appeared on June 12, 2014.

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  • guest

    Certainly the concept behind integrated care cannot be faulted. The clinicians providing treatment for the patient’s medical and psychiatric needs must work closely together in order to ensure that the patient receives the best quality care. It is well known that the life expectancy of the seriously mentally ill is dramatically shortened compared to the general population, and one factor is their limited access to reasonable-quality medical care. Good coordination of care between psychiatric and medical providers is a critical element of caring for these patients well.

    However, when one looks at how “integrated care” is being delivered these days, often it appears to be method of rationing access to mental health care, rather than a model of improving communication between providers. It may be that the VA’s model of integrated care is different, however, the model that is being promoted nationally, articulated by the University of Washington, appears to be increasingly the model that is being implemented.

    In the University of Washington model, the psychiatrist rarely lays eyes on the patient personally. Instead, he or she functions as a “consultant” to a “care manager” who has limited psychiatric training herself and assesses the patient using the Personal Health Questionnaire (PHQ) the scores for which are then tracked across the population of patients that the care manager “manages.” The care manager is directed to discuss with the psychiatric consultant any patients whose PHQ scores are outliers in the population, and the psychiatrist offers suggestions for treatment, generally without seeing the patient herself.

    At a recent grand rounds I attended, a proponent of integrated care proudly presented a case she had “managed” in which a patient was struggling with substance use and depression. Eighteen months after his initial presentation to the “care team” he was discovered to have a history of treatment for ADHD, was placed on a stimulant and improved dramatically. The presenter was excited to discuss this very positive outcome. The rest of us in the audience wondered why one would be proud of it having taken 18 months to clarify a critical aspect of the patient’s psychiatric history, one that presumably could have been discovered immediately, had the patient been seen promptly by a competent psychiatrist with time to do an adequate work-up.

    This result, however, becomes less surprising in light of a recent article promoting “integrated care”.” Written by a University of Washington faculty member to describe his day in an integrated care setting, he explains that he spends one hour “supervising” the care of between 50-60 patients followed by three hours in which he sees 5-6 new cases which are too complex/acute for the care manager.

    Other articles I have seen on this topic bemoan the fact that our psychiatric residents are not rushing to embrace this model. I would suggest that perhaps the reason they are doing it is this: many of us went into psychiatry so that we could interact with patients in a more personal and leisurely way, A clinic in which a lightly trained “care manager” actually gets to interact with the patient, while a psychiatrist takes legal and clinical responsibility for a high volume of patients most of which they never get to see, does not begin to meet that need.

    As with anything else in medicine these days, I think we need to beware of a noble-sounding concept being used, perhaps cynically, perhaps not, to present a model of care which does not benefit either patient or clinician, but rather the bottom line.

    • DeceasedMD

      Two fields that are both poorly compensated and have a shortage. Why not combine? I met a Psychiatrist at a vA in Phoenix who said he had no choice but to manage both PC and psych issues in his pts given they had virtually no access to PC so he was it.
      I agree with you, this would just be a way to further short change psych pts. And probably a good way the “thought leaders” would try to get rid of psychiatry. Already several psych programs have closed secondary to poor reimbursement. What a world.

      • guest

        In my healthcare system, I frequently manage my patient’s medical needs, with the assistance of a nurse practitioner, and if needed, an IM consultant. I think it’s a model that works very well, probably better than having psychiatric patients managed by PCPs with some remote input from a psychiatrist.

        • DeceasedMD

          So it sounds like this model is already happening in a way.

          • James O’Brien, M.D.

            I have a question for the author. Is he seeing patients or advising on treatment?

          • DeceasedMD

            Excellent question. Most or at least many of the articles on KMD are from “thought leaders” that are physician managers that clearly identify with the aggressor and under the guise of efficiency want to help control the working docs who are in the trenches seeing pts. This author I don’t know.

          • Shaili Jain

            please see my reply above. Don’t worry, I am a doctor “in the trenches” for sure. I spend 75% of my work week providing direct patient care.

          • James O’Brien, M.D.

            That’s great for you and the patients. I can’t imagine providing advice without an exam and patient interview. As I pointed out to a defender of Collabo-care recently, if you tried to pull that during your CL rotation in residency, they would have thrown you out.

          • Shaili Jain

            I agree we cannot give up on the fundamentals of good medical practice, listening to the story and doing a through exam. Any management recs are useless without this, dangerous even

          • DeceasedMD

            I thought your blog was more genuine and those were you’re honest thoughts to improve. I can’t find your reply though in the posts that you mentioned.

        • Shaili Jain

          Very true, good point it can go the other way too

      • James O’Brien, M.D.

        Psychiatry may be relatively poorly compensated but there are a lot of advantages in terms of lifestyle especially if you have a no insurance practice. It’s actually a great field right now with high demand but I don’t like what’s happening with what the major organizations and how they are trying to change it.

        • DeceasedMD

          I can see that. I find it rather– well–creepy following the trends in medicine in general and psychiatry as a field where the training is turning into psychopharmacology. Psychiatry giving up therapy a bad move I think and all these low level degrees and frankly nutty types taking over in ways that are way inappropriate. But doesn’t it really depend on the part of the country you live in as to getting a good private practice started? I would think there would be a lot of competition in big cities and rural areas are rough places for any practice. But I can see being rid of insurance has to be very freeing.

          • James O’Brien, M.D.

            There are a lot of psychiatrists in LA and NY but the demand is heavy and most of us are booked well in advance.

            Psychopharm has been incredibly oversold, and therapy, which is more effective for most people (not as much for the more seriously mentally ill) ignored. Anyone with good training who looks and acts like they have their act together and who can fade those trends and be intellectually honest will do well. Some people really like it when you suggest psychotherapy and yoga instead of antidepressants for mild mood disorder. Which is the right advice. Bad for business short term but the good will is priceless.

            Liberation from insurance is a splendid thing. I am fortunate that I can compensate a relatively low paying treatment practice by doing some med legal work. That’s another thing to get into in order to get off the grid.

          • DeceasedMD

            If I am not being too nosy, do you mostly write reports or do you have to testify? I know being an expert witness is lucrative but I cannot think of much more pressure than that. Is this contract work through the state? whatever it is you do not have an easy job.
            As for this blog I just realized a huge flaw in teh idea of PCP combined with psychiatry. Would these pts or any pt want to be examined by their psychiatrist? I would think that would make them more paranoid. Bad idea the more I think about it. Wonder what your thoughts are?

          • James O’Brien, M.D.

            I want to make it clear when I complain about the state of medicine I am doing so mostly from my recent experience as a patient . I saw what ACA and other changes were doing to friends and colleagues. I saw a lot of the problems coming and steered clear a long time ago. When I advocating fighting the system, that’s because i’ve done it and prevailed. It’s not theoretical for me. I’m on the other side and it is much better.

            It depends on the kind of work you do If it’s medimal or personal injury you might have to testify but it’s usually a depo, not court. Have a contract signed in advance with your fees including transportation, no-show, cancellation, minimum appearance fees all clearly spelled out, because you have to be clear when you are dealing with attorneys. If you do work comp, you will get deposed but in California, you don’t have to go to court unless it morphs into subrogation.

          • DeceasedMD

            . I congratulate you getting through the system prevailing as a pt. Please teach the rest of us.

          • Shaili Jain

            I am embedded in primary care twice a week, pts come to the same clinic where they see their pc doc and see me in an exam room where I do my history and exam and treat. Our experience, increases access to care, less stigma than assoc with the going to the mental health clinic. Please note, we don’t see smi or acutely unwell I.e psychosis etc in primary care, they are seen in specialty clinic. The idea is evaluate and treat mild to moderate issues in primary care, increase access and convenience but keep more severe cases for specialty my where they need to be

          • guest

            Now this is the way that integrated care should work. But it’s not the model that the APA and the University of Washington are promoting.

            I think we have to be careful to be very detail-oriented, and when we support integrated care, we need to specify that we are talking about a model of care where the psychiatrist is co-located with the primary care clinic in order to provide timely and coordinated services, DIRECTLY to the patients.

            What we should not be supporting, in my opinion, is a model of integrated care which is a Trojan Horse for a watered-down version of psychiatric care in which the patient never gets to see a psychiatrist, only a lightly-trained clinician who is “supervised” by a psychiatrist.

            We all should be paying more attention to these details. Details are what a profession lives and dies by.

  • buzzkillerjsmith

    I see psychiatric pts every day, often referred from psychologists for a med consult.

    The typical diagnoses are major depression, GAD, social phobia, other phobias, PTSD from time to time. Sometimes in combo with personality disorders, often with substance abuse. It is not rocket science to treat these pts–certainly easier than most significant internal organ derangements.

    But only if the pts do well. If they don’t, I contact a psychiatrist and get a phone consult, usually regarding medications. If the pt continues to do poorly, I get an in-person consult with the psychiatrist. This happens in 10% to 20% of cases.

    If I suspect bipolar, I get an in-person psych consult. A firm diagnosis is necessary here as the pt will need to be put on meds indefinitely. I often then follow the pt myself. If the pt has borderline personality disorder, I usually refer. These pts are often just too much work and we family docs just don’t have the time.

    Treating garden-variety depression and anxiety is actually satisfying and these folks usually do well with psychotherapy and/or meds.

    • guest

      The problem with that model: the insurance company for the patient with borderline personality doesn’t pay the psychiatrist any more than they pay you for managing a difficult patient, so if a psychiatrist accepts insurance, and their entire practice consists of those patients whose needs are so complex and time-consuming that the PCP doesn’t have time for them, the psychiatrist’s practice will typically not make enough money to pay overhead.

      This is why more and more psychiatrists don’t accept insurance, I think. It’s sort of the same principle as having mid-levels see the uncomplicated primary care patients, while the MD sees only the complex and difficult cases. After a while, burnout becomes a probability, to say nothing of declining reimbursements as the management of the patient population requires more and more in the way of uncompensated coordination of care activities on the part of the clinician.

      I believe that there are ways to create care delivery models that actually improve care for these patients at the same time that reasonable working conditions for the clinicians are preserved. However, since the main players in creating delivery systems now are third-party payors and academic centers with no strong interest in our working conditions, we are ending up with delivery systems which in many cases treat MDs abusively.

      • buzzkillerjsmith

        No doubt. Caring for complicated pts is a financial loser, both for us and for the shrinks.

      • Shaili Jain

        I agree, these are very valid points. We need more credit for non billable parts of care that are essential, humanistic and key to quality care

        • guest

          Yes, that’s true across all specialties, not just psychiatry…

  • buzzkillerjsmith

    A couple other comments. Dr. J. is right that integrating psych and primary care makes clinical sense, but I am not sure that he understands our world. I don’t blame him for that–we all live in our own little worlds.

    1. The psychiatrists want us to be mini-psychiatrists.

    2. Everyone wants us to give preventive care.

    2. CorpMed wants us to be clerks.

    3. Our pts want us to manage all their med problems in a very short visit.

    4. Our families and friends want to see us once in a while.

    5. Perhaps most crucially, everyone wants us to be more available, even after hours, to keep pts out of the damn ER.

    None of these expectations would be unreasonable if we had only one or two placed on us.

    I’m not whining here. My life is pretty dang good. Just observations.

    And it is a truth long recognized that people who have unrealistic expectations are bound to be disappointed. Sorry.

    • DeceasedMD

      I would not say that psychiatrists want PC to be mini psychiatrists. I think that is mangled care at work. Nobody wants to deal with all the hard cases. But agree with the rest of what you said.

  • ninguem

    I have a standing rule with stuff like this.

    Whenever there is a post about how some medical procedure or specialty field should be moved over to primary care, it means whatever that procedure or medical field may be, it is guaranteed to be time-consuming and pays little or nothing.

    • guest

      Exactly.

  • James O’Brien, M.D.

    There are two integrated models.

    The first has the psychiatrist as a C+L who actually sees patients.

    The second, which amazingly has the endorsement of the APA, is the collaborative care model in which the psychiatrist never sees the patient.

    https://www.youtube.com/watch?v=Z8Kx0GxSle0

    In my opinion, the second it the gateway to the complete marginalization of the field. And eventual replacement by a software program.

    Looks like psychiatry and internal medicine are the front runners in the race to deliberate and willful self-immolation.

    • DeceasedMD

      That was sickening to listen to. Another weak leader without a spine. Any idea why he would be so—–what else to call it but masochistic?

    • guest

      Why aren’t we doing something about this?? We’re all sitting around like sheep while the APA promotes a care model that serves our patients poorly and our profession even less well.

      • DeceasedMD

        That is an excellent question. I know that even on the Murphy bill, the word was the APA was very weak in their pseudo endorsement of it and for whatever reason the APA is afraid of these crazy anti psychiatry groups. I have no clue of why.

        • guest

          Not everyone who opposes the Murphy bill is antipsychiatry. Some oppose it, because it’s a bad bill.

          • DeceasedMD

            I agree that not everyone opposing is antipsychiatry. Was not my point. My point was about the APA. I am repeating what the psychiatrist involved who spoke directly to the APA rep and the Murphy committee felt very strongly about the APA’s position.

            Just curious, on a side note, why do you think it is a bad bill?

          • guest

            I oppose the bill, because I believe if it passes, it will actually discourage more people from seeing a psychiatrist. I wouldn’t see one if I knew I had less rights than patients with other illnesses. What college student is going to talk to any mental health professional once they learn information they shared can be handed over to their parents without their permission? This bill reinforces the stigma associated with mental illness – that psychiatric patients should be treated as “less than” patients with other illnesses.

            The bill also makes it more difficult for psychiatric patients to keep their medical information away from family members, family members who in some cases are the problem to begin with. Psychiatric patients should have the same rights to privacy as any other patient. I think the fact that it has “family” in the title of the bill is an indication that the priorities are misguided. The priority should be the patient, not the family

          • DeceasedMD

            It is an interesting debate. You bring up some good points. I guess there is no law that will fix crisis mental health and definitely not one size fits all. I thought the bill just gave the psychiatrist more latitude to make the best decision for the pt-not that they legally for ex. had to talk to family as an example. Any laws that tell a professional doc how to practice are insulting and ineffective.
            I find it interesting that most people in general have a fear of being committed. It has always intrigued me how more often than not these people meet absolutely no criteria for commitment. And even if they did, it is impossible that they would ever get even put on a hold. Yet psych pt or not, they vehemently fear being locked up but have no logical reason to fear. Yet the ones that desperately need psych hosp. it seems to me need more containment and boundaries, but seldom ever get their foot into a psych hospital.

          • guest

            Yes, I think most people in general fear being committed, and that’s why I think making it easier to commit people will make that fear even greater, thus driving more people away from care. Would anyone voluntarily want to talk to a psychologist like Murphy or a psychiatrist like Torrey? I bet not. I know I would not have seen a mental health professional in college had I had to worry that they had the authority to talk to my parents behind my back if it was in my “best interests” as this law permits. I wouldn’t have gone, period. I don’t think we want to make people more afraid of seeing a psychiatrist, and this law will certainly do it.

            I understand the other guest’s POV; however, the law permits the psychiatrist more latitude even with patients with problems like major depression – it’s not limited to schizophrenia, bipolar disorder, etc.

            I have a relative with schizophrenia, and having that diagnosis doesn’t mean she always lacks insight or shouldn’t be able to make her own decisions regarding whether to take meds or not. If she’s incompetent to make decisions, then yes decisions should not be made by her – the law already allows for that. I support leaving the commitment standards as is and instead actually financing community based care, which we have yet to do. Otherwise, if this law is passed you will have to force even more people into treatment, because people who fear force aren’t going to go voluntarily.

          • DeceasedMD

            Actually the standards to commit are so very high now that no one gets in. And the fact there is a huge lack of psych beds I find more frightening. I believe there are more -or at least half the population for severe mental illnesses land up in prisons instead of psych hosptitals. which is worse?
            I think the law only pertains to severely mentally ill pts in crisis. It does not pertain to people with mental illnesses that are functioning or have some difficulty functioning. I think you or your relative may not realize that there will never be over hospitalizing psych pts as there are no beds even for people that need it. But for the pts that need it they often die because of the lack of help. Even Creigh Deeds senator in Va. knows this all to well with a son who committed suicide for lack of a hospital bed.

          • guest

            The bill changes the standard to “need to treat.” This means anybody who needs treatment and rejects it is at risk. That’s setting the standard way too low. I am not opposed to involuntary treatment, but it needs to remain very difficult to do. I agree we need more beds.

            I think if someone is competent to make decisions, they should be able to put their prescription in the trash if they so choose, just as a person with any other illness is able to do. These drugs are not benign, and I don’t think we should decide those kind of risks for people who don’t want to accept those risks.

          • DeceasedMD

            In the end it will depend on the psychiatrist’s judgment and more than that, will there be any beds available? It’s a fine line between someone who is really suffering from SMI and not able to make competent decisions for themselves and those that “choose” not to get tx. What is the average stay these days if you don’t mind me asking? I know it is very hard with so few resources. I think the first thing that could be done without changing any laws is just increase the number of beds available but just does not seem to happen.

          • guest

            I think that’s what concerns me. If it’s based on the psychiatrist’s judgment they will most likely opt for treatment however they can make that happen. There is a tendency to assume that if the psychiatric patient rejects the treatment it must be because of their illness, which is kind of a ridiculous assumption when you consider the number of patients with diabetes and hypertension who routinely reject treatment advice. Lack of insight certainly isn’t limited to psychiatric patients. Heck, if we make need to treat the standard it will be time to start rounding up all those diabetic and hypertensives and force them to take their meds.

            My relative has schizophrenia but she can articulate the reason she does not want to take antipsychotics anymore – they didn’t get rid of the voices and they almost doubled her body weight. I think as long as she isn’t harming anyone else she has earned the right to say enough already. This bill would permit a psychiatrist to put her in AOT over her objections, objections that are quite rational and accurate.

            I don’t know the average length of stay, I’m sure you probably know better than I do. I would imagine it depends upon the location. I would definitely support legislation that increases the number of beds and increases access to outpatient care, as long as it doesn’t take more rights away from people who already face enough stigma as it is. Need to treat is just too low of a commitment standard and is ripe for abuse.

          • DeceasedMD

            I can understand your concerns. But in the state where I live NO ONE gets admitted. I really mean that. even people that really need it.
            No one is going to force your cousin to take meds if she is not hurting anyone or herself. She sounds like she has ways of managing her illness and has made a decision. it is true that these meds can cause weight gain and I think you may be in part responding to her fears.
            Psychiatrists are too busy taking care of crisis. They are not there to force anyone into taking meds.
            This bill is not meant for your cousin as she does not sound like she is in crisis. Crisis for ex is like the fellow in Seattle that heard voices from the Columbine killer and acted upon them and killed a student and harmed a few others. He was hospitalized in the past but from what I read in the paper there was little intervention. The Santa Barbara mass murderer who refused treatment and was playing with a loaded gun. His family knew about his homicidal thoughts and his roommate who left said he was playing with a loaded gun and acting strange. But no one could help him. And finally Creigh Deeds, a senator in Va. whose son was bipolar and thought he was satan. He lived with his dad. Is it safe to live with a relative who you know wants to harm you or himself but is not vocally saying that literally? Unfortunately that ended badly as well. The son committed suicide and physically harmed his dad before killing himself. that is who this law is for. Truly not a stable person with a mental illness like your cousin.

          • guest

            I’m know I’m beating a dead horse here…
            If the bill were just about people who were threatening to kill other people, then I would support it but it’s not. Anyone who rejects psychiatric treatment is at risk of forced treatment under this bill. There is zero protection for those patients. I don’t want to see more situations like the one in Boston where someone is committed for months on end for something as subjective as somatoform disorder. I would imagine that situations like that aren’t all that common, but the fact that they happen at all is enough to convince me that there needs to be some serious checks on that kind of power. We don’t need more situations like that.

            We don’t even have enough beds for patients who are a threat to self or others. I think they should make that the focus instead of widening the net.

          • DeceasedMD

            no worries. Just had one more thought. I think your own worries might be making you concerned in ways that are really not in the bill. It only involves pts in crisis. serious danger to self or others. It is not for anyone in between. really. i don’t know anything about the Boston case. what happened? it sounds remarkable as no one will pay for any pt to be in a psych hospital for that long. I believe you but it is remarkable as the average stay is a few days. that’s all.

          • guest

            No, I’ve read the bill, and it’s very clear that in order to qualify the patient doesn’t have to be a danger to self or others. They just have to be “persistently or acutely disabled” based on the psychiatrist’s judgment and unwilling to accept voluntary treatment. They even say at another point a patient who “may be dangerous.” So, the patient hasn’t made any threats but the psychiatrist decides they are disabled from their mental illness, or “may be dangerous” someday, guess what the patient has no right to say no to what is being offered. That’s a terrible standard, and we have seen how that worked out in the past. There were numerous abuses of the lax standards for commitment. This swings things too far in the other direction.

            Google Justina Pelletier and you will see what I’m referring to with the involuntary commitment for somatoform disorder. I don’t want to see a patient committed for somatoform disorder. Way too subjective of a diagnosis, and they don’t really have an effective way to treat it anyway. I was also reading the other day about a psychiatrist who was trying to get someone involuntarily committed for hoarding. Forced treatment for hoarding? Do atypicals work for hoarding? The criteria needs to be stringent to protect people from this kind of stuff.

            Again, if it were only about those who were a danger to self or others (and I’m not talking about someone who may, kinda sorta, could be, maybe someday a danger to self or others) then I might be persuaded. But, it’s not.
            The bill also permits a psychiatrist to override a patient’s wishes to keep information from their family, singling out psychiatric patients as deserving less rights then patients with other illnesses. That’s not right.

          • JR DNR

            Kid was being seen at one hospital, and one of her specialists moved to a different hospital. She had a flare up so she was sent there to see him. An intern at that hospital diagnosed her with somatoform disorder and had her removed from the custody of her parents.

            I’ve read up on that law too, and the way it’s written is completely open to a random doctor – like the intern in Justina’s case – making a call and deciding who “needs” treatment. The DSM5 expands mental illness to just about everyone. It’s a disaster waiting to happen.

            I feel my state already goes far enough. Danger to self, others, or incapable of caring for oneself (such as a severe mental disability, dementia, or those who are mentally ill and homeless due to their illness as a few examples).

            Of course, the people I know who are severely mental ill are in residency programs to help the mentally ill with both shelter and treatment. I think that is much better than a lockdown somewhere.

          • guest

            The law is intended to address issues related to the care of people with severe biological mental illnesses such as bipolar disorder, schizophrenia and psychotic depression, not people who are seeing a therapist for more psychologically-related issues.

            In the SMI population, a huge barrier to efficient and effective care is that with deinstitutionalization, families are now required to provide very significant support in terms of shelter, finances, and supervision of all aspects of care. These patients are frequently unable to live independently in the community, and our society has not seen fit to provide the type of wraparound social supports that were envisioned when we got rid of state hospitals.

            However, the families who are expected to provide these critical supports after a patient is discharged from the hospital are frequently excluded from any planning or information sessions related to the care of the patient.

            It’s as if you had a family member who underwent open-heart surgery and five days later arrived on your doorstep, needing significant post-op nursing care, but with no instructions and no support.

          • DeceasedMD

            Exactly. I do understand. That is why I was curious why you do not think it’s a good bill. In a crisis situation, shouldn’t families have the right to have their relative be evaluated? I suppose in some instances that could be a bad thing, but in general why is that not a good thing from what you are seeing day to day? I would imagine your pts that are fearful of family involvement will be regardless of the actual law and you seem rather diligent. i am sure you would do what is appropriate for that situation. Wouldn’t that law help rather than hinder? I am not trying to change your mind seriously. I was actually thinking it could be helpful for families in crisis and help the psychiatrist.

          • guest

            Sorry, there are two guests responding here. Our POV is very different. I wish I had picked a more unique name, but I guess I’m stuck with this one.

          • JR DNR

            You can still go in and change your name, and it will change your old posts to have your new name.

          • guest

            Thanks for the info! I will see if I can figure that out. I know all the “guests” get confusing.

          • JR DNR

            I appreciate your comments so it’s nice to have a name associated with them.

          • Ladyimacbeth

            Thank you for your kind comment. (I get a little passionate about things, ha!)

          • Patient Kit

            OMG! You’ve made me so unreasonably happy today! One of our “guest”s has changed her name! You picked a really good one too, Ladymacbeth! Now I won’t get you mixed up with anyone else or think you said something that you didn’t say! :-D

          • Ladyimacbeth

            It does get confusing. Thanks, to JR DNR for letting me know how easy it was to change it. I always figured I was stuck with the name unless I created a new account wtih a new email, so I didn’t do anything about it earlier.

          • guest

            I support increased funding for social supports for people with severe mental illness. What I don’t support is loosening the criteria to forcibly treat, and taking away a patient’s right to privacy.

      • James O’Brien, M.D.

        He’s not President anymore. That ended in May.

        But he is the typical tenured academic who is idealistic and indifferent to the realities of private practice because he doesn’t live in that world.

        • guest

          Actually he was always a pretty pragmatic guy, a lot less ivory-towerfied than others.

          But I think you are right that in general academicians tend to hold community practice in low regard. Which is kind of self-defeating, since a part of their jobs involve having residents to train, and most residents end up practicing in the community…so if they kill off the profession, there will be limited demand for the training programs at which they are faculty.

          • DeceasedMD

            I am not so sure about the academician part causing this. If anything they should be even more concerned about the best way of practicing psychiatry one would think. I thought one of the first things he said was about saving costs. but I don’t want to hear his nauseating speech again. I think there a lot of political forces behind this that are at play that are unknown to anyone outside of the organization-much like all these weak medical organizations. One of the psychiatrists involved in a political bill told me that the APA was essentially spineless (my own words) and seemed apprehensive and fearful about the anti psychiatry groups reaction.

          • James O’Brien, M.D.

            It’s not a mystery. He’s an academician at Columbia. His politics are going to be far left.

            The APA has been acting more and more like CCHR lately, labeling critics and skeptics and antipsychiatry and dangerous. But Scientology can only dream of inflicting the damage to psychiatry that APA has done not only through its politics but through the publication of the pseudoscientific monstrosity called DSM5.

          • guest

            Just wait until ICD-10 coding goes into effect in 2015. Coding conventions for ICD-10 are in direct conflict with coding conventions for some key diagnoses in DSM-5. It’s going to be a mess.

          • James O’Brien, M.D.

            Good. A nerd fight between the AMA and the APA. I hope they knock each other out.

          • James O’Brien, M.D.

            I don’t think he’s pragmatic at all, he’s clearly an idealist who thinks the false promise of parity and the ACA are wonderful. Note the incredibly wrong predictions he makes:

            https://www.youtube.com/watch?v=et1xzavRVOw

        • DeceasedMD

          the first things out of his mouth were about lower costs. Not sure its academia that plays in but politics . In a way these guys are pretty much IMHO becoming like politicians not academicians. And a lot of political forces at play that no one outside of these organizations really knows what goes on internally.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I have a couple of questions for the psychiatrists here, if that’s okay.
    1) There was a joint statement regarding integration published by the primary care associations together with the APA, but the P there stands for Psychology not Psychiatry, so what exactly is it they want to integrate? and how do these things play together (or not)?
    2) This is about terminology. There is interchangeable use of mental health and behavioral health in this context. Turning this around, I guess I understand what mental illness is, but is there something like “behavioral illness”? Or is behavioral health not related to illness?
    And are these two questions connected by any chance?

    • guest

      It’s hard to say what kind of dog the psychologists have in this hunt, so to speak. I believe that they see integrated care as providing some opportunities to provide care that they don’t get to do now. The only problem with that is that what the system really wants behavioral health consultants to do is advise on prescribing psychiatric medications, not provide therapy or extended diagnostic services, which is what psychologists do. A challenge for practicing psychologists these days is that third party payers increasingly don’t want to pay for PhD level psychotherapy providers, when they can pay LCSW-level or Masters-level therapists less, so psychologists are getting squeezed out of traditional psychotherapy practices.

      In terms of “mental health” versus “behavioral health,” the term “behavioral health” is preferred these days as (supposedly) being a more holistic term that encompasses not just biological mental illness, but a range of other problems. The issue to me is that the use of the term “behavior” has a faint ring of blaming the patient for his or her illness, since “behavior” sounds like something that somebody might have some control over.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Thank you.

  • DeceasedMD

    Being severely mentally ill and paranoid and being physicially examined by your psychiatrists as PCP is a recipe for more paranoia.

    • Shaili Jain

      To clarify: I am not acting as a primary care doc, I come to the primary care clinic and offer psychiatric clinic in the primary care setting. I am not physically examining pts, just meeting patients where they are at

    • guest

      Oh, I rarely do a physical exam on a patient. If they want me to look at a rash, or if they’ve been assaulted and their injury needs to be examined right away, I do. But in normal circumstances I ask the NP to do the exam and then we confer on treatment.

  • iphone12

    If the PCP has a psychiatrist as a consult in his/her office, my concern is if a patient has an issue that isn’t immediately resolved, this person will be pawned off on the psychiatrist instead of the PCP looking harder to find the underlying cause. Anyone want to tell me why I shouldn’t be concerned?

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