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Expanding Access to Mental Healthcare: The Path to Integrating Psychiatry in Primary Care

Op-Med is a collection of original articles contributed by Doximity members.

The shortage of psychiatrists in our health care system has reached a critical level, creating significant barriers for millions of individuals in underserved communities to access mental health care. This scarcity has profound consequences, impacting people's daily functioning, work productivity, and social interactions. The growing concern over the lack of mental health providers in underserved areas calls for immediate action to address this issue before it worsens.

The 2023 American Psychiatric Association meeting recently shed light on a novel approach to increase access to mental health care: integrating psychiatry into primary care. This editorial explores the key points discussed in the meeting and emphasizes the urgent need for integrated care, with psychiatry as a core component of primary care specialties.

Led by Dr. Sasidhar Gunturu and his team, the session titled, “I Need a Psychiatrist but Can’t Find One: An Introduction to the Integrated Care Elective to Increase Access to Care,” sought to raise awareness about the escalating and unmet mental health care needs in underserved communities. They highlighted the integrated care model, the introduction of the Psychiatry in Primary Care Elective, and advocated for psychiatry to become an essential part of primary care specialties by illustrating the expansion of the Bronxcare Health system. The session emphasized the importance of addressing gaps in mental health care training to improve access to care and enhance patient outcomes.

Data from the National Institute of Mental Health in 2021 revealed that approximately 57.8 million individuals in the United States were diagnosed with a mental health condition though only 47.2% received treatment. Although there has been some progress over the years, with the percentage of adults receiving mental health services increasing from 13.0% in 2002 to 16.1% in 2019, these numbers are far from satisfactory. They highlight the significant unmet need for mental health care services in our communities.

Examining the current state of mental health provider deficits, the American Medical Association in 2019 reported a total of 41,133 actively practicing psychiatrists in the United States. These numbers revealed disparities among states, with California having the highest number of psychiatrists (5,935) and Wyoming having the lowest (42). The national average stood at 806.5 psychiatrists per state. Shockingly, 1,446 out of 3,135 counties in the United States had at least one psychiatrist, leaving the majority of counties without access to this crucial specialty. The psychiatrist-to-population ratio varied significantly, with the District of Columbia having the highest ratio (50.1) and Idaho the lowest (5.3). Such imbalances in the distribution of mental health providers underline the urgent need for innovative solutions.

The COVID-19 pandemic has further strained and burdened the mental health care system. The crisis has increased the demand for mental health services while limiting access to in-person care. Mental health providers have faced heightened strain and disruptions to ongoing treatment, widening mental health disparities. Additionally, health care workers have experienced significant emotional tolls as they navigate the challenges of the pandemic. These circumstances require effective interventions to ensure that mental health care remains accessible despite the prevailing circumstances.

A population analysis conducted in 2018 projected a contracting psychiatrist workforce through 2024, with a potential shortage ranging from 14,280 to 31,091 psychiatrists, depending on the psychiatrist-to-population ratio used. Although a slow expansion should begin in 2025, it remains uncertain whether the shortage will be fully resolved by 2050. This worrisome outlook demands immediate attention and the development of strategies to address the projected shortage.

The session highlighted the implementation and success of Integrated Care Services at the Bronxcare Health System, where mental illness screening is enhanced within primary care clinics. Collaborative care, collocated care, and PCP coaching are utilized to empower primary care providers to effectively address common mental health disorders. The stepped-up care model ensures a systematic workflow for patient management, which includes primary care providers managing behavioral health needs, colocated care, and collaborative care, which offer intensified and team-driven approaches to patients. There is evidence of positive outcomes, including enhanced treatment adherence and reduced utilization of acute care services. PCPs, behavioral health care managers, and psychiatric consultants play crucial roles in this integrated care framework.

The stepped-up care model involves primary care providers managing behavioral health needs and determining the appropriate level of care based on the patient's presentation. Colocated care provides patients with more intensive care than collaborative care but is less specialized than traditional psychiatric care. Patients are evaluated by primary care providers and referred to social workers for an initial assessment before scheduling appointments with on-site psychiatrists. Collaborative care, a team-driven approach, involves a multidisciplinary team consisting of a PCP, case manager, and psychiatrist. This approach utilizes measurement-based, evidence-based, and population-focused strategies to optimize patient engagement and treatment outcomes.

The most novel and most emphasized part of the session was the introduction of The Psychiatry in Primary Care elective, which offers residents and medical students a valuable opportunity to gain hands-on experience in managing behavioral health conditions within a primary care setting. The elective includes a rotation, lectures, and a quality improvement project to enhance participants' knowledge and skills. It covers various behavioral health conditions encountered in primary care and equips participants with the necessary skills to effectively manage mental health comorbidities. 

As per the speakers, the elective has yielded positive outcomes, with participants reporting expanded knowledge and recognizing the benefits of the integrated care model for both primary care providers and patient care. To further expand the integration of psychiatry in primary care, advocacy for psychiatry as a core component of primary care specialties is crucial. Additional mental health training and the implementation of similar elective programs can bridge the gap between mental and physical health care.

In conclusion, the integration of psychiatry in primary care proved vital to address the increasing mental health care needs in underserved communities. Comprehensive training in primary care psychiatry empowers future health care providers to effectively manage behavioral health conditions, especially where there is an acute shortage of psychiatrists. Advocating for the integration of psychiatry in primary care specialties and expanding similar programs across other health systems will improve access to mental health care and enhance patient outcomes. Currently, psychiatry is not a core component of internal medicine or family medicine programs. Recognizing psychiatry as a core requirement of primary care is essential to meet the diverse needs of patients. It is time to act and ensure that mental health care is accessible to all who need it. However, we must recognize the value of psychiatry as a core component of primary care and work towards its integration to meet the diverse needs of patients.

Drs. Jaka and Patel have no conflicts of interest to report.

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Illustration by Diana Connolly

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