Collaborative Care: A Promising New Model of Health Care
Collaborative care is improving medical and mental health care.
Posted Sep 12, 2019
Existing conventional treatments and the current model of care do not adequately address the complex challenges of mental illness
Available conventional treatments and the dominant model of mental health care do not adequately address the complex challenges of mental illness, which accounts for roughly one-third of adult disability globally. Unmet treatment needs of depressed mood are one of the most serious public health concerns globally. These circumstances call for radical change in the paradigm and practices of mental health care, including improving standards of clinician training, exploring novel treatment modalities, developing new research methods, and changing current models of mental health care delivery.
In this post I briefly review challenges facing mental health care, focusing on depressed mood. The deficiencies of current mainstream treatments and models of care have led to collaborative care models in primary care settings that incorporate conventional biomedical therapies such as psychotropic medications and psychotherapy, as well as evidence-based complementary and alternative medicine (CAM) approaches. In a future blog post, I will discuss emerging research, which shows that collaborative care more adequately addresses the complex needs of patients with severe psychiatric disorders and medical disorders.
The enormous personal, social and economic cost of mental illness
Mental illness accounts for about one-third of the world’s disability caused by all adult health problems and results in enormous personal suffering and socioeconomic costs (Anderson 2011). Severe mental health problems, including major depressive disorder, bipolar disorder, schizophrenia, and substance use disorders, affect all age groups and occur in all countries.
Inadequate mental health services: a global problem
In developed countries, elderly individuals, minorities, low-income groups, uninsured persons, and residents of rural areas are less likely to receive adequate mental health care, and most people with severe mental health problems receive either no treatment or inadequate treatment for their disorders (WHO Health Action Plan). In the US the situation is even worse in large metropolitan areas, where most outpatient mental health clinics are located resulting in a large and growing gap between mental health care needs of the population and available resources. This gap is becoming ever wider in suburban, semirural, and rural areas throughout the US and is related to the fact that the medical subspecialty of psychiatry is one of the oldest workforces in medicine, with many psychiatrists nearing or past the age of retirement. Combined with increasing vacancies in psychiatry residency training programs, the staffing pipeline for psychiatrists is shrinking (Hawryluk 2016). Relying exclusively on psychiatrists to solve the problem of improved access to mental health care is clearly not a realistic approach.
Depressed mood is the leading cause of disability among U.S. adults
Despite the increased availability of antidepressants during the past few decades, limited efficacy, safety issues, and high treatment costs have resulted in an enormous unmet need for treatment of depressed mood. It is estimated that 350 million individuals experience depression annually (Demyttenaere 2004). On average, it takes almost 10 years for an individual to obtain treatment after symptoms of depressed mood begin, and more than two-thirds of depressed individuals never receive adequate care (Depression: Fact sheet 2017). Enormous psychological, social, and occupational costs are associated with depressed mood, which is the leading cause of disability in the US for individuals aged 15 to 44 years with annual losses in productivity in excess of $31 billion (Kessler 2012). Suicide is currently the second leading cause of death in 15 to 29-year-olds, resulting in enormous social disruption. Between 10 and 20 million depressed individuals attempt suicide every year and approximately 1 million complete suicide. In response to these alarming circumstances, in 2016 the World Health Organization (WHO) declared depression to be the leading cause of disability worldwide (Nguyen 2017).
In response to increasing concerns over the global crisis in mental health care, in 2012 WHO published “Mental Health Action Plan 2013-2020” (WHO Health Action Plan) and set forth 4 major objectives:
- More effective leadership and governance for mental health
- Provision of comprehensive, integrated mental health and social care services in community-based settings
- Implementation of strategies for promotion and prevention
- Strengthened information systems, evidence, and research
The promise of collaborative care
In addition to limited access to mental health care caused by scarce mental health resources and financial hardship, the social stigma associated with seeking specialty mental health services prevents many individuals with depressed mood or other severe mental health problems from seeking and obtaining adequate care. These circumstances call for refining the existing model of care into a truly collaborative care model in which patients receive both medical and mental health care in the same clinic setting. According to the Agency for Healthcare Research and Quality collaborative care is “care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”(Lexicon 2017).
Small community-based mental health clinics are shifting the context in which mental health care takes place in tandem with services aimed at wellness and prevention in primary care settings. Implementing such collaborative care programs on a large scale will provide important opportunities for research that will help clarify which conventional and CAM approaches are most effective for preventing and treating mental illness. These findings could be used to design more effective and cost-effective treatment approaches used in collaborative care settings. The shift toward collaborative care in primary care clinics that includes both conventional treatments and CAM interventions will raise current standards of medical and mental health care to a higher level, resulting in more effective and cost-effective solutions to common mental health problems, while reducing the stigma associated with seeking mental health care.