Tuesday, September 24, 2013

Should Psychiatrists See Patients?


Today's Wall Street Journal has an article on a new model of psychiatric care: the psychiatrist serves as a consultant to the primary care doctors and the psychotherapist.  The psychiatrist hears about the patient, but if my read is right, the psychiatrist has a large caseload and never actually sees the patients.  


In Getting Mental-Health Care at the Doctor's Office: Providers Take Integrated Approach, With Patient Numbers Set to Jump Under New Law and Psychiatrists in Short Supply,

Melinda Beck writes:

As the consulting psychiatrist for four primary-care practices, Dr. Ratzliff confers weekly with 10 care managers who follow the patients closely, provide counseling and chart their progress in electronic registries. She helps devise treatment plans and suggests changes for those who aren't improving.

"I get to touch so many more lives than I would if I were seeing these patients in person," she said.

I'm speechless.  The article goes on:


In some practices, psychiatrists and psychologists work alongside primary-care providers on cases. In others, primary-care doctors prescribe antidepressants or other medications, and care managers—typically licensed clinical social workers—confer weekly with patients to monitor progress, often using a standardized nine-question depression quiz.
Many care managers also provide cognitive behavioral therapy and other counseling. "The goal is to give patients the skills to approach problems differently," said Jürgen Unützer, a University of Washington psychiatrist, who has helped more than 1,000 clinics nationwide adopt the model.

Many studies have shown that integrated care can reduce patients' depression and cut costs. One University of Washington study of 1,800 patients found that providing a year of integrated care cost $600 a patient but saved an average of $4,000 in lower medical bills over the next four years.

Still, integrated care is a big adjustment for psychiatrists, whose training typically focuses on one-on-one relationships.

It's good that more people are able to get help.  It's good that money is saved and that this is so economical ($600/year for mental health treatment, wow!)  And primary care providers already prescribe for the majority of patients, so adding a therapist and a psychiatrist to consult with may well be an improvement, but shouldn't patients with serious mental illnesses still see a psychiatrist?