Teaching Integrated Care

This issue of Academic Psychiatry includes five articles [1–5] focusing on teaching tomorrow’s psychiatrists about integrated care, and the American Psychiatric Association’s Council on Medical Education and Lifelong Learning (CMELL) recently released its report on “Training Psychiatrists for Integrated Behavioral Health Care” [6]. Why is integrated care education important, and what do these reports tell us about how to teach this? Only 1 in 8 people in the USAwith a mental health disorder consults a psychiatrist [7]. Most people who seek care do so in primary care settings. In fact, for decades primary care has been recognized as the “de facto mental health system” [8]. Access to mental health specialty care is poor, and at least half of people referred do not follow up [9]. Integrated care models were designed to close this gap and provide access to mental health care for the maximum number of people. Behavioral health care can be integrated into primary care in a number of different ways, including co-location of a mental health provider or consultant within a primary care setting, telemental health, and collaborative care models, in which psychiatrists collaborate with primary care providers and behavioral health care managers to optimize the mental health of a clinic or care system. Collaborative care, especially for depression, has been shown in multiple studies and metaanalyses to improve access, outcomes, and costs of mental health care, thus accomplishing the “triple aim” of the US health care system [10, 11]. Given the effectiveness of such integrated care models and the increasing focus on patientcentered care, medical homes, and providing integrated behavioral and primary medical care under the Affordable Care Act, many psychiatrists will take on new roles as consultants, educators, and team leaders within interprofessional behavioral health teams working in primary care settings. Psychiatric education needs to prepare tomorrow’s psychiatrists for these roles. At the same time, patients within the mental health system, especially with chronic mental illnesses, have significantly earlier mortality than the general population, primarily due not to suicide but to chronic medical problems exacerbated or caused by low socioeconomic status, poor access to and adherence with primary medical care, and side effects of psychotropic medications [12]. In recent years, there has been increasing focus on the responsibility of psychiatrists to ensure adequate primary medical care for such patients, bringing with it the challenge of determining how psychiatry trainees should be prepared to do this. The reports in this issue focus on integrated care education across the spectrum, from medical students to psychiatry residents, subspecialty fellows, and psychiatrists in practice. The Dube and Verduin paper [1] and their CMELL report section [6] discuss integrated care education for medical students. Currently, medical student education in psychiatry seldom includes integrated care settings or experiences, although some schools provide elective integrated care experiences or longitudinal integrated clerkships that follow the same patients across different specialties and clinical services, which may or may not be integrated. The CMELL report [6] provides a number of recommendations regarding medical student exposure to effective integrated care services and psychiatrist role models, as well as education in interprofessional and interdisciplinary communication. Seeing psychiatrists working at the interface of primary care and mental health may also destigmatize psychiatry as a career choice for some students. * Deborah S. Cowley dcowley@u.wahington.edu