Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Lisa Rosenthal. She's Chief of the Division of Consultation Psychiatry at Northwestern Medicine. Dr. Rosenthal is here to discuss the Northwestern Medicine West Health Accelerator, an initiative aimed at expanding access to psychiatric services in primary care and how this collaboration is transforming mental healthcare through evidence-based practices and technology.

Dr. Rosenthal, thank you so much for joining us today. As we get into this topic, can you briefly discuss the role of collaborative care models in improving mental health outcomes, particularly when it comes to primary care settings?

Dr. Lisa Rosenthal: Well, I'd love to, and thank you so much for inviting me to talk about this topic. The collaborative care model is an evidence-based model of care developed at the University of Washington. So, we can't take credit for the model, but we have implemented one of the more successful programs using that model.

The model is really interesting because it relies on population health perspectives and methods to make sure that patients are screened for psychiatric symptoms within primary care. That is little bit of magic compared to Psychiatry as usual because, when you screen patients, you really eliminate healthcare disparities and biases. So, traditionally, we waited for patients to ask for psychiatric referrals, or we relied on a physician impression or interpretation of patient symptoms. But we really need to be thinking about psychiatric symptoms, just like we think about blood pressure and screen patients for it. So, it's one of the things that improves mental health outcomes because we're reducing disparities, but we're also identifying patients at an earlier stage. And so, there are a lot of other things about the collaborative care model that are particularly helpful in primary care, partly because it's team-based. We are joining primary care to take care of their patients and we bring the treatment to the patients where they are instead of referring them elsewhere. And patients really like the opportunity to be treated in their trusted primary care office.

The one other thing I love about the collaborative care model is that we really use a component of the model called treatment to target, meaning that we make sure that patients get better. We don't just prescribe medicines or therapy and say goodbye. We are rescreening patients. We are following them carefully over time. And if they're not improving, we change their treatment, just like any good doctor would do if somebody's blood pressure wasn't responding to their first medication trial. So, we think that the collaborative care model is not only the most evidence-based opportunity to address mild to moderate depression and anxiety, but it does have some special components, including population health models that really help patients get better.

Melanie Cole, MS: I love this initiative. First of all, we've got this mental health epidemic that we're seeing in this country today certainly, and the medical home aspect of it, where you're able to spot these things earlier and make it easier on the patient is just such a great initiative. Tell us about this collaboration between Northwestern Medicine, West Health, and the Meadows Mental Health Policy Institute.

Dr. Lisa Rosenthal: Well, I love that you mentioned the crisis of mental health in our country. And I want to say one disclaimer, which is that unhappiness is not mental illness. And we try very hard to separate people who are struggling for a variety of social reasons, which is incredibly common from patients who really are suffering from major depressive disorder or anxiety disorders. And I think that's really important. That doesn't mean we can't provide support for many people, but we do want to make sure that we're not treating diseases that people don't have, or overdiagnosing common social problems as mental illness.

But I am really excited about this collaboration between Northwestern Medicine, West Health, and the Meadows Mental Health Policy Institute. It's pretty unique. West Health decided that they were interested in helping their patients-- they are located in California-- have better access to psychiatric treatment. And they identified Northwestern as a place where we were already doing this work and already committed to this work. And so, they really decided that they wanted to supercharge our program to determine the best practices within collaborative care and to help us help others so that the model could be disseminated more broadly.

The problem of collaborative care is that despite the incredible evidence base with more than 90 randomized controlled trials, the implementation of the model is quite low. And so, this collaboration that's funded by West Health up to about $8 million has a goal to supercharge the model and help disseminate it more broadly. So, we aim to figure out are there factors that we can address that would make the model easier and more successful.

Melanie Cole, MS: So, how does the accelerator plan specifically enhance access to mental health services for primary care patients? Tell us a little bit about how the model itself works.

Dr. Lisa Rosenthal: So in the model, access to Psychiatry is brought to the patient. As I mentioned, we use population screening. So, CMS has a mandated requirement for depression screening in primary care. And for that, we use the PHQ-2 that is given to every patient in primary care. And that's a national mandate. That's a federal mandate. And all the primary care offices are held to that as well as to the idea that they need to be referred to care when that screening is positive. So, we do the population screening, the PHQ-2, and then we ask primary care to follow up with PHQ-9s or GAD-7s, which are screening tools for depression and anxiety. And if the score of those tools is 10 or higher, their patients are eligible to be referred to our program where they're met by what's called a behavioral care coordinator who schedules a screening with them and does a full psychiatric assessment. The model is interesting because I, as a psychiatrist, don't actually meet the patient, but I do meet with the behavioral care coordinator once a week and we discuss all of the new patients they've met, as well as any patient who's not improving or has questions. And then, they transmit information back to the patient and to the primary care provider.

And so, for right now, our focus is on mild to moderate depression and anxiety. In time, we hope to look at a variety of diagnosis and maybe even other settings within healthcare to try to integrate Psychiatry more broadly and address symptoms in patients in a variety of settings. But this all will improve access to treatment. It doesn't necessarily improve access to specialty psychiatry care, but we do plan to keep careful track of whether or not patients who can't be treated within our program do have successful linkage to specialty care.

Melanie Cole, MS: As we think about access to this kind of specialty care, and it is difficult these days to find practitioners. And if you do, they're very busy. What do you see, Dr. Rosenthal, as some of the most significant barriers to early intervention in mental health? How does this initiative aim to overcome them?

Dr. Lisa Rosenthal: Well, I could talk all day about barriers, it's not just a problem for our patients, it's a problem for us in psychiatry, and it's a problem for everybody in healthcare. I think that some of the big ones are stigma. And that is, in some ways, a no-brainer, right? Everybody now knows about stigma, about patients with psychiatric symptoms, but there's also a lot of stigma about psychiatry itself and our treatments and our diagnoses, and sometimes about the doctors who choose psychiatry as a practice.

I want to be clear that, within psychiatry, we have many evidence-based treatment options and the collaborative care model is not based just in medications, but we also use therapy, as well as other types of coaching. Just like for patients who have hypertension, it's not just pills. We want to talk about diet and lifestyle and sleep and many other things. So, stigma is a huge barrier to access and to implementation of collaborative care, but we're hoping that by bringing our program to primary care, that we're really going to lower some of that barrier. Only about 50% of patients who are referred to psychiatric treatment ever actually try to follow up, and only about 20% of them even make appointments. So, we really need to do a better job of making sure that patients who have need can get care.

Some of the other things that we're doing is providing a lot more education within primary care. So right now, we're rolling out some education, not just about our model, but about the treatment of anxiety and depression and optimizing that care. And as I mentioned, screening all patients is a critical piece of this, making sure that we're not missing people by not asking them. So, we need to screen patients early. We need to prevent mental health crisis and poor health outcomes. So, that's the other thing is that we are getting more and more data about how depression and anxiety is maybe a signal for bad outcomes in all kinds of diagnoses, including diabetes and cardiovascular health and even cancer. So, we really want to find patients early and address depressive symptoms. There's an impact of depressive symptoms on illnesses. And then, of course, there's an impact of illness on depression. If we could treat depressive symptoms and improve basic things like hypertension and blood sugar, maybe we will find evidence that we can also improve cardiovascular outcomes, for example.

Melanie Cole, MS: Well, you just segued beautifully into my next question when you mentioned data, because in this technology age that we're in, and with the advent of televisits since the pandemic, and the technology and electronic data sharing, there's so much out there now. How will the accelerator leverage technology and data analytics to enhance psychiatric care and patient outcomes? How is that going to benefit this, as you say, crises and hopefully better patient outcomes?

Dr. Lisa Rosenthal: Well, this is one of the areas where I am so grateful to West Health for the opportunity here, to build this accelerator because we now have partners within quality and safety, data analytics, IT, and medical informatics to help us identify and improve patient health. And those things are hard to come by and hard to pay for, particularly in Psychiatry. And so, we now have a work stream it's called, looking at data and analytics for our patients. And so, not only are we going to be tracking outcomes, but we're also going to be doing things like optimizing diagnosis and identification of patients at need and figuring out where they go and what happens after they get better.

The other place where, of course, data and analytics is important is improving value. So often, people talk about the cost of Psychiatry, but we haven't been very good at demonstrating our value. And that's not just our value to patients, but also to payers and providers of all kinds. So, we provide value to primary care, and value to health systems. And I think that that's really critical to support increased adoption of integrated psychiatry programs. And so, we're going to use data to prove our value.

Melanie Cole, MS: Can you share any success stories or early outcomes from the Collaborative Behavioral Health Program that highlight this impact?

Dr. Lisa Rosenthal: Well, yes, of course, I have many success stories that make us feel pretty good. One of my favorites actually was a person who was in healthcare leadership who reached out to me. Because not only were they excited about having the program for patients within our care system, but they had actually been a patient themselves. They told me that they might not have sought care without the program and its screening, and they said they knew they would not have been able to get better so quickly or easily without our program. They took the time to reach out to me and say all of this, that they were so grateful for the care that they received and so happy that other people in our healthcare system were going to be able to benefit from the program. And it always feels good to help patients, but it's especially nice when that patient is also a healthcare worker. And so, that's my favorite success stories. But if you want more, I'm happy to provide them.

Melanie Cole, MS: I love this topic, Dr. Rosenthal, and your passion and compassion come through when you're telling these kinds of stories and how this initiative will work. As we get ready to wrap up, speak to other providers here. How do you envision the accelerator influencing mental healthcare practices beyond Northwestern Medicine, and potentially on a national scale, because this could be a real game-changer and change the landscape of mental healthcare access disparities and barriers in this country.

Dr. Lisa Rosenthal: Well, of course, that would be a dream come true, really. And with the funding and collaboration of West Health and Meadows, we have a huge opportunity because both of those organizations do a lot of national work, including on the federal level, as well as on the local level here with the Illinois Psychiatric Society. We're working on some bills to see if we can accelerate, literally accelerate adoption of the collaborative care model.

I think that it's important to get the word out. I like to joke that people sometimes think of Psychiatry as somewhere on a continuum between Dr. Phil and witchcraft. And it makes me laugh, but it's also sort of true, right? Like, people don't understand. And I think that what a psychiatrist does is so similar to what a cardiologist does, right? We treat a group of illnesses that impact a body system, and we try to improve morbidity and mortality in our patients with a variety of evidence-based interventions. And it's not mystical, magical, or ineffective. There's a lot of public media and other ideas floating around that psychiatry doesn't work, or that our medications are not effective, and the reality is that our medications are just as effective as many other treatments within the field of Medicine. And we really want to get that word out, as well as be helpful to our colleagues in other systems and healthcare specialties, so that we can help them take care of their patients.

Melanie Cole, MS: Beautifully said, and it's not just the community in the crisis that we're seeing. You mentioned one of your colleagues. I mean, there is a burnout and an issue with healthcare workers in general. So, this is across the board, an incredible initiative that could really have such wider reaching implications.

I thank you so much for all the great work that you're doing and for joining us today and sharing all of this excellent information. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.