Note: This article originally published in the Medical Board of California’s Summer 2017 newsletter.
Dr. Robert M. McCarron
Co-director, UC Davis TNT PCP Fellowship
Communications Director, Steinberg Institute
Most of us are familiar with the recent reports on the alarming disconnect between supply and demand for psychiatric services in the United States. Many of us grapple with the consequences in our day-to-day practice. Here are some numbers to consider: According to a 2017 report by the National Council for Behavioral Health, the ratio of psychiatrists to population in the U.S. declined by 10 percent between 2003-2013. Nearly half the nation’s psychiatrists are private practitioners who operate on a cash-only basis. Another recent study found 55 percent of counties in the continental U.S. have no psychiatrists, and 77 percent have a severe shortage.
Meanwhile, demand for mental health services is on the rise. Depression is now a leading cause of disability in the U.S. Estimates indicate one in four families are struggling with some aspect of mental illness. A recent Milbank Memorial Fund report said among children ages 9 to 17, as many as one in five may have a diagnosable psychiatric disorder.
Primary care practitioners are living with the fallout. An estimated 40 percent of patients seen in a primary care setting on any given day have an active psychiatric problem. Meanwhile, half the patients referred by a primary care provider for psychiatric treatment are unable to access services.
Exacerbating the gap in appropriate care: The vast majority of primary care providers have suboptimal training in psychiatric diagnosis and treatment.
The UC Davis Dept. of Psychiatry and Behavioral Sciences has taken the lead on a novel effort to expand the workforce equipped to provide basic psychiatric treatment. We call it the Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship. The idea is to train front-line providers in the essentials of primary-care-based psychiatry. We train primary care providers to recognize symptoms of common psychiatric conditions, complete a quick and targeted assessment, and provide evidence-based treatment using cognitive therapy techniques, motivational interviewing and appropriate medications.
Are we creating a replacement for psychiatrists? No. Our fellows are trained in the basics of treating mild to moderate illnesses, including anxiety and depression. Patients with more serious conditions still would be referred to specialists.
UC Davis launched the fellowship in 2016, enrolling 35 fellows from around California. This year, we’ve increased the class to 49. It’s a year-long program, designed so fellows can complete the training while continuing to work. Fellows attend two intensive weekends of instruction with our faculty, all of whom have dual training in psychiatry and primary care. The rest of the course is completed remotely, and involves biweekly web-based instruction; an hour of individual training each month with a mentor; and regular call-in office hours with faculty.
The cost of the program is $15,000 per fellow, and we discourage providers from paying out of pocket. What we’re finding is that health plans see the value, and have stepped forward to cover the costs.
As the program continues, we’ll be actively measuring outcomes. Our expectation is to see fewer hospitalizations for psychiatric issues, a decrease in suicides, a decrease in opioid use, and an increase in appropriate use of prescriptions for psychotropic medications.
For now, UC Davis is the only health system in the country offering this brand of cross-training. We plan a partnership with UC Irvine that will expand our reach in Southern California, and are in discussions with medical centers in other states about replicating the model.
In addition, a bill pending in the California Legislature would help ensure that general practitioners are trained to recognize the signs of mental illness. The Steinberg Institute, a nonprofit public policy institute dedicated to improving mental health care, is sponsoring Assembly Bill 1340 by Assemblymember Brian Maienschein. The bill would amend the state’s Business and Professions Code to require that the Medical Board of California consider including in its continuing medical education requirements a course on integrating mental and physical health care in primary care settings, especially as it pertains to children.
We’re on the front end of what we hope will be a nationwide movement to grow our mental health workforce and provide a quality system of integrated care.