Mood Disorders Center to Expand Mental Health Care Access through Collaborative Care Model

Cheryl McCullumsmith, MD, PhD, at the UC Academic Health Center. Photo by Cindy Starr.

In a world where psychiatrists are in short supply and psychotherapy is difficult to access, how does a community begin to meet the needs of thousands of individuals who could benefit from mental health care? The answer lies in a novel approach with a strong evidence base known as the Collaborative Care Model, says Cheryl McCullumsmith, MD, PhD, Associate Chair for Clinical Integration in the University of Cincinnati’s Department of Psychiatry and Behavioral Neuroscience and a member of the UC Mood Disorders Center.

Dr. McCullumsmith, who came to UC in 2013 from the University of Alabama at Birmingham, began implementing the model this month at UC Health’s resident internal medicine clinics at Hoxworth Center in Clifton and at the Margaret Mary Hospital system in Batesville, Indiana.  The collaborative care clinic will be staffed by Jocelyn Weber, a depression care manager, and Cal Adler, MD, a psychiatrist and Co-Director of the UC Mood Disorders Center.

“The goal of the Collaborative Care Model is to provide evidence-based depression care to larger populations of people,” Dr. McCullumsmith says. “It seeks to make the process of getting care flow better and to get people the level of care that they need in the most appropriate setting.”

The model, developed largely at the University of Washington, provides mental health care through a coordinated process that follows patients in their primary care clinic and escalates care as needed.

Patients are first screened for depression by their primary care physician with a series of nine questions covering the main symptoms of depression, including cardinal symptoms of feeling sad, hopeless, or lethargic, and being uninterested in activities once considered enjoyable.

This type of screening, Dr. McCullumsmith says, has become increasingly used in primary care settings. And for a while, the medical profession assumed that such screening alone might solve the problem of depression. “But it didn’t really happen because primary care doctors have so many things on their plate already,” she says. “You need to know when to switch antidepressants, for example, and when it is safe to increase the dose. And that is something primary care doctors do not always have time to do.

“We also know that the combination of therapy and medication works best, especially in people with moderate or severe depression. And primary care doctors often can’t get patients into therapy, because there are not enough therapists. And if they refer their patient to psychiatry, there’s a shortage of psychiatrists.”

Enter a new provider: the depression care manager

The beauty of the Collaborative Care Model is that it inserts a new provider into the equation: a depression care manager, who is either a social worker or a psychologist. When a patient tests high for depression in his or her screening by the primary care physician, the patient is referred to the depression care manager. The depression care manager then evaluates the patient and discusses the case in a weekly meeting with a psychiatrist. The psychiatrist makes a medication recommendation; the depression care manager relays that to the primary care physician; and the primary care physician writes a prescription. The patient then continues to be followed by the depression care manager, and further recommendations are made until the patient improves.

The depression care manager may also provide six to eight sessions of psychotherapy, usually problem-solving therapy or motivational interviewing. After an appropriate interval, the patient is evaluated again, and any additional recommendations are once again forwarded to the primary care physician. In cases involving severe or complex depression, the depression care manager will refer the patient to a psychiatrist.

“Collaborative Care will allow us to offer resources we have not been previously offer to our patients with depression,” notes Eric Warm MD, an internal medicine physician and the Richard W. & Sue P. Vilter Professor of Medicine at UC. “It is a great example of bringing care to where patients need it most.”

Stephen Rush, MD, an assistant professor of psychiatry and behavioral neuroscience, will implement the Collaborative Care Model in a partnership with the Margaret Mary Hospital system in Batesville. “As part of our ongoing collaboration with Margaret Mary Hospital, we will be helping them manage mental health in their primary care, obstetrics-gynecology and oncology clinics,” Dr. McCullumsmith says.

Through the Hoxworth clinic, where internal medicine residents do some of their training, Dr. McCullumsmith sees another benefit: the opportunity to train a new generation of young physicians in how best to treat depression in the primary care setting.

Will one depression care manager be sufficient for the primary care practice at Hoxworth Center? Time will tell.

“What we’re doing is a pilot in the sense that we’re determining what our needs are,” Dr. McCullumsmith says. “The collaborative care model is one of the most studied and evidence-based models in psychiatry. It enables an efficient, effective flow of patient care. We can identify those who need additional support, free up needed specialist psychiatrist time and provide excellent and accessible depression management care.”

— Cindy Starr

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