July, 2004. I had the opportunity several months ago to represent the American Psychiatric Association (APA) and testify at the first meeting of a new Committee of the Institute of Medicine (IOM), called “Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.” Citing the published IOM report, Crossing the Quality Chasm, the Committee identified six aims for the delivery of quality health care—that it be 1) safe, 2) effective, 3) patient-centered, 4) timely, 5) efficient, and 6) equitable. Those presenting testimony were asked to address in what ways healthcare for mental and substance use disorders diverges from these aims, what strategies should be employed to improve these defects in behavioral healthcare quality, and to what issues the IOM Committee should give priority in its study.
The APA had, coincidentally, recently issued its own report, “A Vision for the Mental Health System,” which identified 12 principles for the nation’s mental health system and emphasized the need for improved continuity of care, integration of mental health and substance abuse treatment, patient and family-centered treatment, and equitable health benefits for all patients. These recent developments follow the Surgeon General’s 1999 report on mental health and the 2003 Final Report of the President’s New Freedom Commission on Mental Health, which underscored the mainstream nature of psychiatric disorders and the crucial need to abandon the no longer defensible disconnect between psychiatry and the rest of medicine. As a colleague of mine put it recently, people are finally realizing that the “head bone is connected to the body bone.” A consensus is clearly building that brain disorders are medical disorders, squarely placing our patients in the same rooms as those with medical/surgical illnesses.
In my testimony to the IOM Committee, I focused on the importance of “partnerships.” Among the partnerships that are critically important are those between psychiatrists and primary care and family physicians. Gone is the day when we have any business claiming that all patients with psychiatric conditions should be seen only by psychiatrists. There are not enough psychiatrists to handle the workload, patients with psychiatric and substance use disorders often are seen only in primary care, and in many rural areas, the local family doctor is the only game in town. We need to work together as partners, relying on evidence-based practice guidelines, to provide the best possible collaborative care.
These principles are illustrated in this issue of the Journal. As Krakowski and Czobor point out, patients who may be suicidal often present to their family physician with somatic concerns; this study clarifies how to identify suicidal patients, especially those who might also be at risk for violence. The importance of drug-drug interactions is critical in the management of patients on monoamine oxidase inhibitors, as reviewed in an article by Fiedorowicz and Swartz that was the second-place winner in the Journal’s annual resident paper competition. Such interactions include concerns about non-psychiatric medications and dietary ingredients, all of which must be effectively communicated to all physicians participating in the care of the patient. A third paper in this issue, by Levy et al., presents a careful study of the cardiac status and QTc interval in patients on high doses of ziprasidone; this has been an area of potential concern but these results show a substantial safety margin. Finally, Landon and Barlow provide an extensive review of the use of cognitive-behavioral techniques in the treatment of panic disorder, a disorder that is often initially evaluated in a family medicine setting, since presenting symptoms are usually somatic in nature.