Despite Joint Care Effectiveness, PCPs Face Barriers for Success

Despite the success of joint consultations, PCPs reported feeling overwhelmed by, unprepared for, and incapable to respond to patients' mental health problems.

As the effectiveness of joint consultations between primary care providers (PCPs) and psychiatric providers for mental health patients become more apparent, studies focused on the barriers and benefits of collaborative care have increased.

A study led by Stéphane Saillant (pictured), MD, chief-medical for Emergency Psychiatry and Liaison Psychiatry Services at the Neuchatel Center of Psychiatry (CNP) in Switzerland, member of the Swiss Medical Association's Federation of Psychiatry-psychotherapy, shed light on the collaborative approach between PCPs and psychiatric care providers.

Saillant and colleagues retrospectively analyzed reports of “psychiatric evaluations conducted between October 2010 and August 2012 (n=182) in the Primary Care Service of the Geneva University Hospitals.” They carried out a set of 4 focus group discussions with 23 physicians-in-training intended to “explore their experience and perceptions of the joint consultations.”

They found that joint consultations were helpful for both patients and health care providers. The researchers pointed out that prior to experiencing joint consultations many physician respondents felt that although 43.6% of their patients suffered from mental health problems, they perceived difficulties in caring for these patients.

"In order to help doctors, they need to know the mental health professionals to begin with, which is often not the case,” Saillant told MD Magazine. “Psychiatrists must also focus efforts to popularize their activities and work.”

Data revealed that on a scale of 1 to 7 (1= no difficulty, 7= very difficult) physicians reported that they did face difficulties in caring for their patients with mental health problems (mean = 4.5, sd= 1.1). Saillant reported that in all 4 of the focus groups physician participants “talked about mental health problems as not part of their area of competence” and that many physician participants reported feeling overwhelmed by, unprepared for, and incapable to respond to patients' mental health problems.

Despite that, they discovered that with 68.7% of the 182 patients receiving joint consultations, “the PCP's initial diagnostic impression” of the patient's disorder was confirmed. Post-joint consultation, 59.9% of patients were returned to PCP care with “no additional input from a psychiatrist” required.

Interviews with PCPs revealed that joint consultations allowed them to feel more confident about their role in patient mental health care. PCPs also commented that they saw joint consultations as a means of learning more about how to approach patients' mental health. According to Saillant, about 90-95% of patients with psychological problems are seen only by PCPs.

“In Europe, there is a model of collaborative care, such as group practices, which bring together the private practices of general practitioners and psychiatrists, thereby increasing the possibilities for collaboration,” Saillant told MD Magazine. “It is often due to frequent exchanges between the two professions that the level of confidence of general practitioners in psychiatry can be increased.”

Saillant highlighted several barriers PCPs face when tasked with collaborative care, including making the time to reflect with their paired professional and vice versa, as well as the feeling of being overwhelmed by certain patients whom they believe are “not sufficiently trained and therefore are incompetent to help.”

According to Saillant, the push towards joint consultations can provide practical training and encouragement to improve mental health care, but there needs to be more research on best practices connected to collaborations.

Emily Wood, PhD, with the University of Sheffield in the UK, who led a 2017 study reviewing PCP treatment of depression with a focus on the barriers to collaborative care, told MD Magazine that PCP burnout is an additional concern for those treating mental health patients.

"Conditions like depression can make a consultation quite lengthy and when you are time pressured, it can seem easier to focus just on diabetes (for example)," Wood said. "Many professionals see depression as the proverbial ‘can of worms’ that they would rather not open."

Wood and colleagues' did a systematic review of 18 studies, which revealed that often a lack of "readiness" for change on an organizational, cultural, or daily practice level was the largest barrier to implementation of collaborative care.

"A huge issue remains the problem that many do not see mental health care as equally important as physical health care," Wood told MD Magazine. "This is a problem for organizations and the way they are funded but also for some individual PCPs. However, numerous studies have found that presence of depression worsens outcomes for comorbid physical health conditions. Ignoring the depression makes treating the physical health condition harder."

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