Leveraging collaborative care to improve access to mental health care on a global scale
Authors: Jürgen Unützer, Andrew D. Carlo, Pamela Y. Collins
Journal: World Psychiatry (2020)

In most parts of the world, there are not enough mental health professionals to meet the demand. Psychiatrists, with critical expertise in treating patients with severe mental illness, diagnosing complex multimorbidity, and prescribing medications, are in particularly short supply. As with many other health-related inequities, this shortage is disproportionally pronounced in lower-income, rural and poorly resourced settings. To put the problem into perspective, high-income countries have more than 100 times as many psychiatrists as low-income countries1. Growing awareness of the global unmet need for mental health services has led to a number of efforts to extend the "reach" of psychiatrists by fostering partnerships with other health care professionals, mostly in primary care. There is a rich history of the implementation and evaluation of such models, which are often collectively termed "mental health integration" , "behavioral health integration" or simply "integrated care" . Some strategies for integration focus on coordination and communication between psychiatrists and primary care providers (coordinated care), while others physically co-locate the two professions in the same space (co-located care). Still other models emphasize population-health principles, and include systematic communication and coordination between a team of providers working in concert to address all of the health care needs of each patient (fully integrated care). One such model, collaborative care, leverages task-sharing and the services of a team of providers to deliver person-centered, evidence-based treatment of common mental health problems, such as depression and anxiety, in primary care settings. Specifically, collaborative care utilizes a trained behavioral health care manager to conduct assessments, collect data with common screening instruments such as the Patient Health Questionnaire-9 (PHQ-9), and provide evidence-based brief psychological interventions, such as motivational interviewing, behavioral activation, or problem-solving treatment. Care managers also support the longitudinal management of psychiatric medications prescribed by primary care providers, with guidance from a designated psychiatric consultant, who may be located on-site or elsewhere and connect via telehealth technologies. In evidence-based collaborative care programs, clinical outcomes are tracked using an electronic registry, and care managers keep in regular contact with patients to make sure that nobody falls through the cracks. During regular case-review sessions, the psychiatric consultant and the care manager review the entire patient caseload, focusing on those who present diagnostic challenges or are not improving with treatment as expected. Psychiatric consultants make diagnostic and treatment recommendations to the care manager, who works with the patient's primary care providers to implement these recommendations. Patients who are not improving may be referred for an in-person or virtual psychiatric evaluation, or to additional specialty mental health, medical or social services as clinically indicated. The collaborative care team communicates with the primary care provider on a regular basis, to provide updates on treatment progress and to make adjustments to the treatment plan as needed. Although originally studied for depression in primary care2, collaborative care has since been evaluated in more than 80 randomized controlled trials (mostly in the US and other high-income countries) for a variety of common mental health problems3, 4, and the vast majority of studies have shown that it is superior to usual care. According to the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington, evidence-based collaborative care includes five core principles: patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care5. In addition to their application in well-controlled experimental settings, collaborative care programs that follow these core principles have been successfully adopted in numerous settings worldwide, including lower-income countries and locations with little access to on-site mental health specialists6. Although the collaborative care model is highly effective and robust to different health care environments, it is not without challenges related to implementation and sustainability. Like other health services interventions that are first studied in well-resourced and highly controlled settings, it can experience a substantial "voltage drop" when implemented in real-world settings without close attention to fidelity or the core principles outlined above. A growing body of literature has focused specifically on the application of collaborative care in low- and middle-income countries, and recent reports have highlighted a number of barriers, such as the lack of technological resources or reliable sources of electricity, insufficient government or health system coordination, mental health stigma, a scarcity of skilled workers, inadequate buy-in from local leaders, a lack of access to medications, and financing challenges7, 8. Successful implementation of collaborative care requires an organized primary care system, which is able not only to address acute medical problems, but also to provide ongoing care for chronic or recurrent health problems. Difficulties notwithstanding, collaborative care remains one of the best studied and most effective approaches to improving access to mental health care around the globe. Several recent studies have identified strategies to overcome common implementation and sustainability barriers, such as mobilizing and leveraging existing community resources, engaging with global advocates, and framing mental health integration as a pathway to improving the health care system at large8. Several studies have demonstrated the feasibility of providing population-based mental health care using these models in low- and middle-income countries, including the Programme for Improving Mental Health Care (PRIME) and the Emerging Mental Health Systems in Low- and Middle-Income Countries (EMERALD) in parts of Africa and Asia9. In summary, collaborative care is an extensively evidence-based model for the treatment of common mental health problems in diverse primary care settings. With dire psychiatrist shortages globally, there is growing interest in ways to "leverage" scarce resources and bring mental health expertise to the places where it is most needed. Although the majority of studies of collaborative care to date have been conducted in high-income countries, an emerging body of literature suggests that common barriers can be overcome and that this approach can be successfully adapted and operationalized in lower-resource settings.