September, 2013. Readers of these editorial pages will recognize the importance that I have ascribed to shifts taking place in healthcare in our country—from silo-based specialty practice to integrated care. Evidence is mounting that for many patients, particularly those with persistent and combined physical and psychiatric conditions such as diabetes and depression, integrated care produces better results and is more cost-effective. This transition, however, is far from fully implemented and in many locations remains more at the conceptual level than at the level of accomplished reality. The uneven nature of this changing terrain is inevitable and understandable given the many challenges involved, such as the need for trainees and early career colleagues to learn to work in collaborative partnerships rather than in solo specialty practice, the need to develop integrated fee structures for such collaborative care, and many more changes from the ways we have traditionally done busi- ness. Furthermore, it is very clear that there will be no “one size fits all” model that will be universally appropriate for all patients. For example, a need will remain for individual psychotherapy for many patients, a treatment that need not be embedded in an integrated care setting. Other patients will need pharmacotherapy, which can be prescribed either by psychiatrists or by primary care practitioners, and here workforce issues and specialty expertise become prominent concerns.
In this issue of the Journal, Carey and colleagues analyze evidence-based practice data from a report by the Agency for Healthcare Research and Quality, to develop 13 high-priority research needs that could result in a comprehensive roadmap for the integration of mental health and substance abuse treatment with primary care. Prominent among these recommendations are the need to integrate primary care into specialty mental health settings where patients with severe and persistent mental illness receive ongoing treatment, the need for models of integrated care that are appropriate for a range of patients with varying psychiatric and physical diagnoses, and the meaningful use of information technology in these models of care. It is certainly my personal hope that these recommendations will stimulate new research funding opportunities and the development of research protocols that can ultimately guide us as we move forward in the transition toward integrated care.
Also in this issue of the Journal, Dhamane and colleagues report a careful analysis of a large dataset on the use of second-generation antipsychotics, to evaluate the potential effect of a major Consensus Statement on metabolic monitoring of patients taking these medications. The Consensus Statement was developed jointly by the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity. Disappointingly, although the Consensus Statement recommends that patients taking second-generation antipsychotics be regularly monitored for glucose, lipids, body mass index, and blood pressure, Dhamane and colleagues found that the publication of the Consensus Statement alone did not make a significant difference in rates of metabolic monitoring in almost 25,000 patients examined over a 7-year period. The authors conclude that health systems need to adopt a more proactive approach, including enhanced education and training, along with computer-generated reminders and incentives. About two-thirds of the practice sites in this study were primary care providers and, of the specialty providers, fewer than 1% were psychiatrists. I would argue that the needs identified by the Consensus Statement might more successfully be carried out if psychiatrists or other behavioral health specialists were truly integrated into these primary care settings—perhaps this is one provider network where one of the research priorities identified by Carey et al. could be carried out.
John Oldham, MD