Psychiatry and Primary Health Care: Beyond Integration, Toward Fusion?

As health care is redesigned and primary health care reemphasized, the move toward integrating behavioral health care with primary medical care appears to be accelerating across the country. It’s now broadly accepted that a number of models, such as the Collaborative Care model from Seattle and the related DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) program, have demonstrated the clinical value of integrating care delivery. In addition, numerous other approaches utilize psychiatrists and other behavioral health professionals as providers, collaborators, consultants, and supervisors in collaboration with a primary medical care team.

This is all well and good. Yet, when a psychiatric colleague posed the following question in an informal email to a group of psychiatrists (including me) working on integration, I came up short. Here’s the question: “Do we have the evidence to show that psychiatrists, including child and adolescent psychiatrists, lead to better outcomes than (primary medical) teams that have access to other mental health professionals, but not directly to psychiatrists?”

I wasn’t alone in not being able to bring to mind clear evidence of the specific value of psychiatry in primary health care beyond the limited role found in collaborative care studies. One of our colleagues reported that he spent 20 minutes doing a PubMed search for studies and could find nothing; I didn’t have any better luck.

Because I make my living, in part, by working as a psychiatrist in a Federally Qualified Health Center (FQHC) in Pittsburgh, where we pride ourselves on providing whole person, whole life primary health care, the question stuck with me. As I thought about it, it occurred to me that what psychiatry can do for primary medical care may be limited relative to the contribution other mental health providers can make—BUT (this is a big but) for 2 important considerations.

First, it’s important to consider the unique functions of a psychiatrist in primary care.

No other behavioral health profession can provide the same competencies. Efforts to determine the effectiveness of team-based mental health care that do not note the presence or absence of these competencies in the team are not really evaluations of what a psychiatrist can contribute. Without these competencies, a primary health care team will be unable to address the full extent of psychiatric challenges that are likely to be present in a population of patients seeking primary health care.

The many patients with psychiatric challenges whom a primary health care team is unable to fully care for are likely to leave the practice. As a result, the outcomes that “psychiatrically light” primary medical care teams attain are going to be based on a sample of patients with lesser morbidities than a team in which a psychiatrist is more fully able to exercise his or her unique competencies.