Collaborative Care Successful in Urban Setting but Many Patients Choose Not to Participate

Despite a high rate of screening minority patients for anxiety and depression in seven primary care centers that used the Collaborative Care Model (CoCM), only 56% of eligible patients engaged in care, and 25% did not return for at least one follow-up appointment, a report in Psychiatric Services has found. Nevertheless, 58% who received care under the model had significant clinical improvement.

“These findings are sobering and indicate that even with the CoCM, considered a gold-standard behavioral health integration model in primary care, more work is needed to identify and overcome barriers to engaging vulnerable patients and advance the model’s impact,” wrote Michelle Blackmore, Ph.D., of the Montefiore Medical Center in New York and colleagues.

CoCM has an extensive evidence base, and care provided under the model is reimbursed by the Centers for Medicare and Medicaid Services. Beginning in 2015, CoCM was implemented in seven primary care practices serving patients from racial-ethnic minority groups in the Bronx and lower Westchester counties of New York state. Many of the patients were predominantly Medicaid beneficiaries.

In total, 88,236 of patients (87%) were administered the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7) in a primary care visit. Of these, 11,886 (13%) screened positive for clinically significant depressive or anxiety symptoms, and 6,849 (8%) had clinically significant comorbid anxiety and depression.

In total, 5,247 patients (56%) engaged in CoCM—defined as completing an initial assessment with a preliminary diagnosis and agreeing to start treatment—during the three-year study; 3,957 had one or more follow-ups after 10 to 14 weeks, during which the PHQ-9 or GAD-7 was again administered. For patients with at least one follow-up by 10 to 14 weeks, 58% had improved scores on the PHQ-9, GAD-7, or both; 19% of patients with depression and 20% of patients with anxiety were in remission (defined as scores of less than 5 on the PHQ-9 and GAD-7).

Twenty-five percent of patients who were eligible for collaborative care did not return for at least one follow-up appointment after agreeing to start treatment. Perceived stigma about mental illness, transportation problems, and family and work responsibilities may have impeded engagement, the researchers wrote.

“Improving the engagement of vulnerable patients in integrated models such as the CoCM can enhance receptivity and access to behavioral health treatment, representing key steps toward addressing health care inequity and increasing population impact,” the researchers wrote. “However, our findings also highlighted a significant need for targeted CoCM modifications to improve initial and ongoing patient engagement for this patient population.”

For more information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

(Image: iStock/Pornpak Khunatorn)

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New York State Project Shows Progress in Reducing Use of Seclusion, Restraint for Children With Mental Illness

Three New York State mental health treatment facilities participating in a project to decrease the use of seclusion and restraint for children with severe emotional disorders demonstrated significant decreases in restraint and seclusion episodes per 1,000 client-days, according to a report published online Friday in Psychiatric Services in Advance titled "The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project." Moreover, each facility identified specific activities that contributed to success, including ways to facilitate open, respectful two-way communication between management and staff and between staff and youth, and greater involvement of youth in program decision making.

The intervention used by the three facilities included training, on-site mentors and peer specialists, and on-site consultation from the Office of Technical Assistance of the National Association of State Mental Health Program Directors (NASMHPD). The intervention’s primary methodology was implementation of NASMHPD’s “Six Core Strategies to Reduce the Use of Seclusion and Restraint.”

The study authors examined data from the New York State Incident Management and Reporting System on restraint and seclusion episodes per 1,000 client days over a four-year period (2007–2011). Qualitative data were collected via notes from facility consultations, site visits, steering committee reviews, site conference calls with the New York State Office of Mental Health (OMH), and site reports.

At facility one, the number of incidents per 1,000 client-days decreased from 67 to 25; at facility two, the decrease was from 63 to 7; and at facility three, the decrease was from 99 to 13.

“The primary finding of this project was that the creation of coercion- and violence-free environments where use of restraint and seclusion is markedly decreased requires a major commitment by all staff over an extended period to fully understand and internalize the strategies involved and embrace the changes in facility culture,” Lloyd Sederer, M.D., medical director of the New York State Office of Mental Health and a coauthor of the report, told Psychiatric News. “In New York, OMH is promoting facilities’ engagement in learning collaboratives so that facilities can reduce use of restraint and seclusion and realize significant positive outcomes."

For related information, see the Psychiatric News article, "Psychiatric Hospital Aesthetics Affect Seclusion, Restraint Use."

(Image: Rikke/shutterstock.com)

N.Y. Child Psychiatrists Collaborating to Provide Consultation to Primary Care

Five university-based divisions of child and adolescent psychiatry (CAP) in New York are collaborating to provide education and consultation to primary care physicians in the state around issues related to mental health care of their patients. The “Child and Adolescent Psychiatry for Primary Care” (CAP-PC) initiative, sponsored by a grant from the New York State Office of Mental Health, funds the five CAP divisions from the University at Buffalo, Columbia University, Hofstra/North Shore/Long Island Jewish, University of Rochester, and SUNY Upstate Medical University (Syracuse) to provide phone, face-to-face, and telepsychiatry consultation to pediatricians and family physicians caring for children in more than 90 percent of the state.

Additionally, the five divisions have chosen to partner with the Resource for Advancing Children's Health (REACH) Institute—a national organization established 2006 to develop education for primary care physicians in child mental health—to provide a formal “mini-fellowship” in “Assessment and Management of Child and Adolescent Mental Health.” That mini-fellowship consists of three days of intensive training in evidence-based assessment and treatment of common problems seen among children in primary care offices: ADHD, depression, anxiety, and aggression.

The initiative represents a critical element of integrated health care: extending the expertise of experts in psychiatry to primary care and other practitioners.

“This is a remarkable and unprecedented collaboration among academic institutions to improve mental health care of children,” child psychiatrist David Kaye, M.D., (pictured above) CAP-PC project director at the University of Buffalo, told Psychiatric News. “To have primary care face this squarely and take it into mainstream practice is a welcome step in destigmatizing mental health problems, promoting access to care, and making the kind of strides we need to make in order to assure treatment for all, and prevent disability and reduce risk.”

For information about other efforts to collaborate across disciplines in the care of children and adolescents, see the Psychiatric News article, “Innovative `Buddy System’ Teaches Collaboration.” Also see the Psychiatric Services study, "Clinicians' Utilization of Child Mental Health Telephone Consultation in Primary Care: Findings From Massachusetts."

Nobel Laureate Comments on Biology of Psychiatric Disorders

In an op-ed essay that appeared in the May 28 New York Times, David Brooks claimed that psychiatry is not really a science, but a semi-science. This claim prompted Eric Kandel, M.D., to respond in his own op-ed essay, which appeared in the September 6 New York Times. In addition to being a professor at Columbia University, Kandel was a recipient of the 2000 Nobel Prize in Physiology or Medicine.

"The reason that Mr. Brooks is understandably conflicted about seeing psychiatry as a medical discipline is that we do not understand the biological substratum of most psychiatric disorders, and certainly we are nowhere near understanding them as well as we understand disorders of the liver or the heart," Kandel told Psychiatric News. "But the fact is that we are beginning to make some progress, and although it is slow, it is accelerating. I wrote the New York Times response to give the reader a few examples of that."

For example, "We are beginning to discern the outlines of a complex neural circuit that becomes disordered in depressive illnesses," he wrote. "Helen Mayberg, at Emory University, and other scientists used brain-scanning techniques to identify several components of this circuit, two of which are particularly important." They are the subcallosal cingulate region, "which mediates our unconscious and motor responses to emotional stress," and the right anterior insula, "a region where self-awareness and interpersonal experience come together."

Moreover, he wrote, "ANY discussion of the biological basis of psychiatric disorders must include genetics. Most mutations produce small differences in our genes, but scientists have recently discovered that some mutations give rise to structural differences in our chromosomes. Such differences are known as copy number variations....Matthew State, at the University of California, San Francisco, has discovered a remarkable copy number variation involving chromosome 7. An extra copy of a particular segment of this chromosome greatly increases the risk of autism, which is characterized by social isolation. Yet the loss of that same segment results in Williams syndrome, a disorder characterized by intense sociability."

Click here for Kandel's New York Times essay, "The New Science of Mind."

New York to Move Many With Mental Illness to Community Housing

Yesterday, the state of New York agreed to settle a decade-long lawsuit allowing 4,000 people with mental illness the opportunity to move out of adult group homes and into their own apartments “in the most integrated setting appropriate to their needs.” The consent decree requires that New York set up at least 2,000 supported-housing units and hire staff to advise the residents. The state will also provide coordination of psychiatric and general medical care, employment services, assertive community treatment, and crisis services, among other services.

Seriously ill patients, those considered dangerous, or those requiring nursing care are not covered by the settlement.


“We are happy to see that the state will devote more resources to the housing needs of severely mentally ill people and allow them the opportunity to leave adult homes in cases where it is desired and clinically appropriate,” Glenn Martin, M.D., president of the New York State Psychiatric Association and recorder of the APA Assembly, told Psychiatric News. “We strongly support the goal of reintegration into the community to maximize each person’s potential and believe it is fundamental to good care and outcome.”

The lawsuit was filed after the New York Times reported that operators of the for-profit group homes provided poor care or needless medical treatment to the residents. An independent reviewer will monitor the implementation of the agreement.

For more in Psychiatric News about community care of individuals with mental illness, click here. Also see Psychiatric Services here.

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