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.

View 71 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories