For over 20 years, the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model has offered improved care for patients in need of psychiatric care in the primary care setting. At Brigham and Women’s Hospital, a collaborative care paradigm modeled on IMPACT is in the final stages of being rolled out to primary care practices throughout the system.
“This approach can also be valuable because it can facilitate more frequent clinical contacts with an interdisciplinary team around the assessment of a treatment response,” said Jane L. Erb, MD, psychiatric director, behavioral health integration into primary care. “We know that when PCPs have the proper tools, this practice can work well for many patients, like those with mild cases of depression or anxiety. At the same time, when a patient has greater needs, it’s important to have a system in place to ensure they get the specialized care they need.”
David S. Kroll, MD, associate vice chair for program development in the Department of Psychiatry, noted that depression is the leading cause of disability in the United States and suicide is the 10th leading cause of death. Even in a large metropolitan area like Greater Boston, however, patients can struggle to access psychiatric care services.
“The IMPACT model organizes the management of depression screening and referrals into a more systematic approach,” Dr. Kroll said. “Patients who just need first-line treatments can get them right away through primary care, while those who don’t respond or have more complex problems can be prioritized for referral to a psychiatry clinic.”
Making Depression Screening Central to Care
At the Brigham, depression screening has become a central part of care, in the same way that patients are screened for conditions like cardiovascular disease or diabetes. Questionnaires to screen for depression are given to patients to fill out in the waiting room, and PCPs can follow up with anyone who screens positive during their appointment.
Primary care offices have depression care specialists on staff to guide patients and later check in with them about issues like prescription fulfillment, side effects and the effectiveness of medications and counseling. At the Brigham, social workers collaborate with support specialists who proactively help patients with this treatment as well as other health conditions like diabetes and high blood pressure.
“The goal of this program is to administer first-line treatments to patients with straightforward cases of depression. This applies to the majority of the cases we see,” Dr. Kroll said. “First-line care may be medication or psychotherapy, or a combination of the two. This system works well because patients don’t have to wait to get an appointment with a psychiatrist who will ultimately give them the same treatment.”
Comprehensive Care for Complicated Health Issues
Dr. Erb noted that because many of the Brigham’s patients have complicated health issues requiring multiple medications, a primary care doctor should be taking the lead in managing all the prescriptions.
“The PCPs have a consulting psychiatrist to advise them on specific medications,” she said. “But because so many classes of drugs and conditions have side effects that affect patients psychologically or can interact with one another, it’s important to have someone with a comprehensive view who can put all the pieces together.”
According to Dr. Kroll, this approach can also be valuable because most patients see their PCPs more frequently than they would see a psychiatrist. As a result, if the treatment is not working or adjustments need to be made, the problem will be recognized sooner.
“The backbone of collaborative care is a treatment approach called measurement-based care,” Dr. Kroll explained. “This is a systematic way for us to map out each patient’s trajectory. It gives us a very good view of how they’re doing. The Brigham is bringing this kind of care into our routine practice throughout psychiatry.”