President's Column

Health care in the United States has been characterized by mind-body dualism; mental and physical disorders are treated separately, with priority given to physical health. Most of our health-care dollars are devoted to infectious and chronic disease, with relatively low patient co-pays. In contrast, far fewer resources are allocated to mental health concerns, with poorer patient access to services and higher co-pays.1-4

Our training programs reflect this dualism with "mental" and "medical" health providers trained separately and greater resources and prestige assigned to medical training. This has resulted in an imbalance in numbers of well-trained, well-paid providers strongly favoring the medical profession5,6 and a failure of medical and mental health providers to work together to meet patients' needs. The result has been poor quality, expensive health care in which mental health needs often go unrecognized and many patients are subjected to multiple tests and visits with specialists — at considerable cost — in an effort to diagnose the underlying physical disease. Even when patients' mental health concerns are correctly diagnosed, they often go untreated because of poor access to well-trained providers, inadequate insurance coverage, higher co-pays or the stigma associated with a mental health condition.7,8

The U.S. Preventive Services Task Force guidelines for depression screening in primary care is a case in point: "The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The USPSTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place."9 In other words, if there is insufficient access to mental health, primary-care screening for depression is not recommended. In contrast, no such limitations are placed on recommended screening for breast or colorectal cancer.10,11

As part of health-care reform, there has been considerable emphasis placed on patient-centered care; the patient is viewed as a whole person cared for by an interprofessional health-care team that includes both medical and mental health expertise. There are many advantages to this approach, not the least of which is the opportunity to address the patient's mental health needs in a nonstigmatizing environment. This approach is expected to yield higher quality care, at lower cost, with greater patient satisfaction.12

The implications of patient-centered care for psychological service delivery are considerable. Mental health services will no longer be delivered primarily by solo-practice mental health practitioners. Instead, mental health care will be routinely provided as part of larger inter-professional group practices and in institutional settings. Further, the mental health expert on the team will need a flexible armamentarium of interventions, and cannot rely solely on the traditional 50-minute psychotherapy session. In addition, the mental health expert must be able to address a host of other behavioral issues important to health and well-being — medical regimen compliance, pain management, coping with disability or a life-threatening diagnosis, lifestyle behavior change.

If psychology is to become a significant player in patient-centered care, psychologist practitioners will need to become part of the larger health-care community. This will require adapting to a culture of evidenced-based practice and treatment guidelines, as well as communication and collaboration with a wide range of health providers from varying backgrounds. To be members of patient-centered health-care teams, psychologists will need to diversify and expand their skills. This will require substantial changes in our training programs as well as opportunities for psychologists to re-train in this new model of health-care delivery.

Medicine and other health professional associations are already training students in patient-centered care and the delivery of health services through interprofessional practice teams.13 Professional psychology needs to embrace this paradigm shift if it is to have a role in the health-care teams of the future. If it does not, other mental health professionals will step into this role.

Expanding psychology's role in health is a core component of APA's strategic plan, highlighting the important role psychology should play in the patient-centered care teams of the future. However, this will require practicing psychologists — including those who train them — to embrace an expanded role for psychology as health-care providers collaborating with other professions within a larger health-care system. I hope professional psychology can successfully navigate this paradigm shift; quality patient care depends on it.

References

1Mark et al. U.S. spending for mental health and substance abuse treatment, 1991-2001. Health Affairs, 2005. Available at: www.hetinitiative.org/media/pdf/MHSATrends.pdf

2Wang et al. Twelve month use of mental health services in the United States. Archives of General Psychiatry, 2005. Available at: http://archpsyc.ama-assn.org/cgi/reprint/62/6/629.pdf

3Trivedi et al. Insurance parity and the use of outpatient mental health care following a psychiatric hospitalization. JAMA, 2008,300:2879-85

4Young et al. Quality of care for depression and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61.

5Rich et al. Medicare Financing of graduate medical education. J Gen Intern Med. 2002, 17(4): 283–292.

6Robiner W. The mental health professions: workforce supply and demand, issues, and challenges. Clin Psychol Rev. 2006,26:600-25.

7Snowden and Yamada. Cultural differences in access to care. Annu Rev Clin Psychol. 2005, 1:143-66.

8Trude and Stoddard. Referral gridlock: Primary care physicians and mental health services. J of Gen Int Med. 2003; 18:442-449.

9U.S. Preventive Services Task Force. Screening for depression. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm

10 U.S. Preventive Services Task Force. Screening for breast cancer. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

11U.S. Preventive Services Task Force. Screening for colorectal cancer. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

12Davis et al. A 2020 vision of patient-centered primary care. J Gen Int Med. 2005, 20:953-957

13Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. Available at https://www.aamc.org/download/186750/data/core_competencies.pdf