Enhancing mental health services in primary care settings

The need for mental health services in the United States and the societal burden of untreated mental illness have been well recognized and documented.

In addition to the financial cost, untreated mental health conditions are associated with low quality of life, mortality, and several comorbidities. Despite the high need for mental health services, only a fraction of patients receives such services, leading to a significant treatment gap. The cause of this discrepancy has been attributed to a variety of factors, including insurance challenges and cost of healthcare; the stigma associated with mental illness; and the shortage and unequal distribution of psychiatrists.

While there is a common misperception that the shortage and unequal distribution of psychiatrists predominantly affect rural areas, the increased need for mental health services means that the treatment gap impacts suburban and urban communities as well. Historically, to overcome this barrier to accessing healthcare services, psychiatrists have had to travel to underserved regions or patients have had to leave their communities to receive treatment. Both scenarios have been stressful for patients and psychiatrists, due to the burden, cost and time associated with travel. In addition, such temporary solutions can lead to disruptions in patient care, lower patient engagement, and lower patient satisfaction.

Over the past decade or so, telepsychiatry services have significantly expanded as an effective approach to help address barriers to patient care, bypassing the need to travel and providing patients with the opportunity to receive treatment remotely while remaining at home or within their local healthcare facilities. By providing direct patient care, telepsychiatry has been invaluable in addressing the issue of unequal distribution of psychiatrists, delivering services to hard-to-reach patient populations across multiple settings. However, the shortage of psychiatrists continues to present a significant challenge to expanding mental health services, even after introducing telepsychiatry. Training more psychiatrists will take time and is unlikely to keep up with the increasing demand for mental health services, which means that the shortage of psychiatrists is likely to persist. Consequently, innovative approaches are urgently needed to enhance the capacity of primary care services to address the need for mental health treatment. One such approach has been the use of telepsychiatry consultations through direct patient care. However, this method requires that the consulting psychiatrist evaluate individual patients, and consequently, continues to be limited by the shortage of psychiatrists. This has led to the emergence of another telepsychiatry consultation model, the E-consult Model, which has gained significant momentum and support.

E-consult Model
The E-consult Model relies on integrating psychiatric consultation services into primary care settings, by virtually staffing telepsychiatrists within healthcare facilities and systems. The psychiatrists become credentialed within healthcare facilities and provide remote consultation services during scheduled and recurring blocks of time. The goal is to enhance patient access to mental health services within primary care facilities.

The E-consult Model includes three components that can be utilized separately or in combination, depending on the varying needs of the primary healthcare facility:

1- Videoconferencing: The patient’s in-person team, including primary care physician, case manager or psychotherapist, schedules videoconferencing sessions during regular recurring blocks. The team can present to the psychiatrist those cases that pose particular mental health treatment challenges for the team. This approach is mainly educational. The psychiatrist provides broad diagnostic guidance, general recommendations for medication management, and input into other treatment recommendations.

2- E-question: Through the electronic health record (EHR) or other HIPAA-compliant methods of electronic communication, the team sends the psychiatrist general questions that do not require a chart review. This component as well is primarily educational, as the psychiatrist answers patient-nonspecific questions ranging from diagnostic considerations to drug-drug interactions, to the next recommended step in the treatment algorithm of a specific psychiatric condition.

3- E-consultation: This approach is patient specific. Through the EHR, the treatment team sends an e-consultation linked to a particular chart, with one or more questions regarding diagnostic and treatment recommendations. The psychiatrist performs a comprehensive chart review and provides feedback that resembles that of a consultation note, including an assessment and recommendations. The recommendations often cover a description of risks and benefits of medications, possible drug-drug interactions, monitoring of medication levels, follow up laboratory tests, as well as psychotherapy suggestions and level of care recommendations.

As access to mental health services continues to be a challenge and given the shortage of psychiatrists, innovative approaches are urgently needed to overcome the barriers impeding access. E-consults decrease wait times, as patients receive mental health treatment in a primary care setting, either instead of or while awaiting to be seen by a psychiatrist (either in person or via videoconferencing). Furthermore, e-consults bypass the stigma that might prevent patients from seeking care through a psychiatrist, by supporting the mental health treatment they receive in primary care settings. The E-consult Model provides treatment teams in primary care systems the opportunity to significantly enhance their capacities to provide mental health services, by providing education, guidance, and support to the in-person team, in an efficient and cost-effective manner.

About the Authors:
David Cohn
David Cohn is the Founder and CEO of Regroup Therapy. David holds an MBA from IE Business School in Madrid, Spain and a Bachelor’s Degree in Economics from Colorado College. He served in the US Peace Corps in Guatemala and advised global CIOs as Director for Latin America, and Southern Europe with CEB.

Hossam Mahmoud, MD MPH
Dr. Hossam Mahmoud is the Medical Director at Regroup Therapy. He is a board-certified psychiatrist, licensed in Illinois and Massachusetts. He is a Clinical Assistant Professor at Tufts University School of Medicine and holds a Masters of Public Health from the American University of Beirut, Lebanon.

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