Looking at Psychiatry Through a Population Lens

Over the past few years, we have seen increasing interest in a new area of psychiatry called “integrated care” or “collaborative care,” and today I have the privilege of writing the first in what will become a monthly Psychiatric News column that explores the joys, challenges, and limitations of practicing in this new model of care.

October marked an important milestone in American Health Care. Key provisions of the Affordable Care Act became effective that may eventually give as many as 62 million Americans new or more complete insurance coverage for mental health care. This is wonderful news for many of our patients, but it will also create challenges to our existing mental health system.

Early in my career, I had the opportunity to take additional training in public health and to learn about the challenges of caring for populations of patients rather than simply thinking about the people who find their way to our offices. Psychiatrists are an important part of our physician workforce, but research suggests that only 1 in 10 adults living with a mental disorder will see a psychiatrist in any given year. This is partly due to lack of access. More than half of the counties in the United States do not have a single practicing psychiatrist or psychologist, and the simple truth is that we will never have enough psychiatrists to meet the mental health needs of most Americans.

If every psychiatrist practicing in the United States spent 30 hours in direct patient care each week, and 3 percent of Americans needed mental health care at any given time (a conservative estimate), the average patient would get about five minutes with a psychiatrist each week. Those living in rural America would have about 90 seconds, barely enough time to say hello and goodbye. In residency, we learn how to do a 50-minute session, and in practice we may learn how to provide briefer, more focused visits (for example, 20-minute medication management or 30-minute brief psychotherapy sessions), but nothing has prepared us to meet the needs of the large populations of patients who need mental health care.

Meanwhile, patients need help, and they are most likely to get it in primary care. More than 25 million Americans leave a primary care provider’s office with a prescription for an antidepressant medication each year, and our primary care colleagues are well aware of the fact that they are stepping into the gap shouldering much of the burden of mental health care in this country. They also know that they don’t have the breadth of experience with psychotherapy and psychotropic medications to effectively treat all the patients they see, and they are looking to psychiatry for help.