TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.
Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.
There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”
Dr. Jeffrey Borenstein
Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.
According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.
Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.
Chet Burrell
Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.
By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.
It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.
Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”
Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.