Integrated Care, Revisited

May, 2023. Some time ago I served as president of the American Psychiatric Association (APA), and my presidential theme was “Integrated Care.” The 4 priorities I specified were (1) psychiatry is part of the house of medicine, (2) our patients have a right to quality treatment, (3) fragmented care is not quality care, and (4) research and education provide the best blueprint for our future. Others before me had made similar appeals. For example, a position statement was posted by the APA in 2009 which stressed that integrated care is more than the simple co-location of 2 distinct services, but requires interdisciplinary communication, collaboration, and coordination of service delivery. I totally agreed with this position, but I felt at the time that it needed to be planted downstage and centerstage. In 2013, I focused on these ideas in an editorial in this journal entitled “Integrated Care,”¹ in which I emphasized “the need for trainees and early career colleagues to learn to work in collaborative partnerships rather than in solo specialty practice.”

How have we done since then? I’d say we have made a lot of progress, particularly as we emphasize “person-centered care.” By moving beyond “checkbox medicine” and algorithm-driven formulas, though these can be important and useful, we are rediscovering individualized medicine, matching the right patient to the right treatment.

Bipolar disorder is a prevalent and often highly disabling medical illness. In the old days, when the therapeutic benefit of lithium was first identified, “lithium clinics” sprang up, and for a while the belief was that all you needed was to get the patient into “chemical balance” and then merely monitor the patient’s lithium levels. We know now, of course, that psychosocial treatment is essential as a component of treatment, as is careful medical management for frequently occurring symptoms such as pain, migraines, neurocognitive difficulties, and others. In this issue of the Journal, Sylvia and colleagues present a persuasive model of integrated care for patients with bipolar disorder, developed at Massachusetts General Hospital (MGH). They call it the Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). It is an elegant, intensive, patient-centered program that promotes appropriate levels of care and close monitoring by a treatment team “consisting of psychiatrists, other psychologists, resource specialists, peer support specialists, patient navigators, trainees, and neuropsychologists during their weekly meetings.”

I look forward to future reports on the effectiveness of this program. I’d emphasize particularly the importance of coordinating care with the patient’s primary care provider or family physician, in addition to the patient’s outpatient psychiatrist. As described, one source of referrals will be from MGH and community primary care medical practices, and one of the key components of the Collaborative Care Model is collaboration among the patient’s health care providers. Research has shown that a number of serious medical conditions co-occur at higher rates in patients with bipolar disorder than in the general population.² And that circles me back to my first APA priority, that psychiatry is part of the house of medicine. In my presidential address, I referenced a 1935 issue of Fortune magazine, in which the first 2 principles involved in “the Menninger therapy” were itemized: (1) The synthesis of the medical and psychological approach, and (2) The individualization of treatment. During my many years as Chief of Staff at the Menninger Clinic, these principles remained paramount. And the program called FITT-BD, described here, aligns well with these longstanding guideposts of care.