Caroline Cassels

May 12, 2011

May 12, 2011 — Greater integration of psychiatry into mainstream medicine, vigilant monitoring of insurance providers' response to the mental health parity law, innovating to address the shortage of psychiatrists, and assessing the impact of the Affordable Care Act are just some of the issues topping a packed agenda for the American Psychiatric Association's (APA's) incoming president John Oldham, MD.

Dr. John Oldham

Senior vice president and chief of staff at the Menninger Clinic and professor and executive vice chair of psychiatry and behavioral sciences, Baylor College of Medicine in Houston, Texas, Dr. Oldham will assume leadership of the APA at the APA's 2011 Annual Meeting this month in Honolulu, Hawaii.

"During my term I really want to emphasize integrated care and [psychiatrists'] partnership with primary care and the mainstream medical nature of psychiatric disorders," Dr. Oldham told Medscape Medical News.

He added a more "coherent, coordinated collaborative care system" would significantly advance healthcare in general and mental healthcare in particular by taking a more holistic approach to patient care.

Currently, medicine is so "super-specialized" that no one health professional has the responsibility for looking at the whole patient.

"If you ask someone about their last doctor's visit, you are likely to hear 'my cardiologist' or 'my dermatologist' or 'my allergist'. It is rarely 'my doctor'. Medicine is now so super-specialized we have almost completely moved away from having a single medical point person who has the whole picture.

"Often specialists don't even have access to the records of a patient's other doctors. We have to recognize this type of fragmented care is not quality care," said Dr. Oldham.

No Health Without Mental Health

Healthcare is definitely moving toward greater integration with initiatives like patient-centered medical home facilities and accountable care organizations, which tie health outcomes of a designated patient population to physician reimbursement.

These new models are "essentially a system version of the old general practitioner who did everything."

Behavioral health needs to be a critical component of these new systems, and the APA is working to ensure that it "has a seat at the table" as these new models proliferate across the country.

"Psychiatrists can't be the only ones saying 'There is no health without mental health.' I think the general medical world is much more receptive to this concept than they used to be, but nevertheless I think it is still underappreciated," said Dr. Oldham.

Psychiatrists can't be the only ones saying 'There is no health without mental health.' I think the general medical world is much more receptive to this concept than they used to be, but nevertheless I think it is still underappreciated.

Part of this underappreciation is attributed to the stigma often associated with mental illness. In fact, he said, psychiatrists themselves often experience some of the stigmatizing burden their patients feel, although this too is changing.

"We're no longer in the era when mental illness is attributed to having a weak backbone or because someone wasn't treated well as a child. We now know depression, for example, is a complex medical disease that is an independent risk factor for cardiac death and leads to immunosuppression and hyperactivity of the adrenal stress hormones...and on and on. It destabilizes medical conditions and medical conditions destabilize depression," he said, and he noted that depression has been identified as the number 1 priority among the top 20 illnesses, accounting for 95% of Medicare expenditures in the United States.

Gaming the System?

Close and vigilant monitoring of the mental parity legislation, which became law in 2008, is another of this year's priorities.

The federal legislation ensures that coverage of mental health treatment is on par with coverage for other health conditions. The APA lobbied for more than 20 years to get the law passed, and although its passing is a "major step forward" in ending discrimination against psychiatric patients, it is only half the battle.

Limiting the total number of paid hospital days [for psychiatric patients] is a major inequity that remains, so we have to work on that. We also have to watch to be sure that insurance companies aren't gaming the new system and figuring out loopholes, and believe me, they're trying.

"We are at a very much better place in terms of the legal requirements, but there is still a need for further strengthening [of the law]. It's great to say insurance companies have to provide equivalent benefits such as copays and other stipulations for patients. But then of course that's only true if they actually provide mental health benefits," said Dr. Oldham.

He added that there has been some indication that some insurers may actively be looking for "loopholes."

Further legislative steps are needed to ensure "true parity." For example, there is currently a limit on the total number of days psychiatric patients can have coverage for inpatient days in psychiatric hospitals, a situation that does not apply to patients with other illnesses.

"Limiting the total number of paid hospital days [for psychiatric patients] is a major inequity that remains, so we have to work on that. And we also have to watch to be sure that insurance companies aren't gaming the new system and figuring out loopholes. Believe me, they're trying."

Doing More With Less

Using innovative technologies to address a shortage of subspecialist psychiatrists and extending psychiatric services to underserviced areas is another top priority, said Dr. Oldham.

For instance, training programs in geriatric psychiatry, child and adolescent psychiatry, addiction psychiatry, and psychosomatic psychiatry "are not strongly subscribed.

"There may be a number of reasons for that, including the financial cost of doing an extra training year. Nonetheless, workforce issues are very important. We are also looking at developing the use of video technology to reach patients in rural areas."

I think we can increase our reach with the workforce we have if we can do a better job of utilizing some of the available technologies that, in many instances, are quite remarkable.

Using a computer and video camera to reach patients in rural and remote areas could potentially make treatment available from a psychiatrist hundreds of miles away. Dr. Oldham says that other models of providing long-range consultation are being implemented, such as a program at the Cleveland Clinic that provides US State Department employees working overseas with access to a designated team of US specialists.

Challenges, including addressing potential confidentiality issues and legal concerns, remain, but Dr. Oldham said the profession "can't back away from the challenge because this is where the whole field of medicine is moving.

"I think we can increase our reach with the workforce we have if we can do a better job of utilizing some of the available technologies that are quite remarkable," he said.

ACA: The Perfect Storm?

Another APA concern is the Affordable Care Act (ACA), which was signed into law by President Obama in March 2010 as part of healthcare reform. Under the ACA, an estimated 32 million more patients will receive health coverage, a phenomenon with major cost implications.

We are enrolling huge numbers of patients while limiting and potentially cutting physician reimbursement so savagely, it amounts to what I call a 'perfect storm'.

"We are enrolling huge numbers of patients while limiting and potentially cutting physician reimbursement so savagely it amounts to what I call a 'perfect storm'."

Dr. Oldham said the APA is currently reviewing the legislation and will soon be circulating a briefing document to its members outlining the issues most relevant to psychiatrists.

Although the ACA may have its downside, it has also has a number of positive aspects, including the fact that it will make it illegal for insurers to deny coverage if patients have preexisting medical conditions.

Best Blueprint for the Future

Research and education, said Dr. Oldham, are the best blueprint for a strong future. Some of the most promising areas of research lie in genomics and personalized medicine.

"Most psychiatric disorders are very similar to other medical disorders in that they have a significant heritable risk. They are complex multiple polygenic disorders, so the more we can identify risk profiles in an individual, the more this will lead to developing effective personalized treatment plans."

In addition, brain imaging is taking psychiatry in "enormous new directions." Clinical trials often include highly select patients who don't always represent those presenting in a clinician's office, so findings are not always applicable or relevant to 'real-life' patients.

Like genomics, brain imaging will increasingly offer physicians the opportunity to identify patterns in the brain to guide selection of the most beneficial treatment for an individual patient.

I teach psychotherapy as a biological treatment and we have good evidence that, if it is done right and for long enough, it can change brain anatomy and stimulate neurogenesis.

"I teach psychotherapy as a biological treatment, and we have good evidence that, if it is done right and for long enough, it can change brain anatomy and stimulate neurogenesis. I use the analogy that it is like learning a second language — it is hard work and you have to do it long enough and be willing to do your homework, but if you persevere it can make a big difference."

Similarly, he said, imaging studies have shown that selective serotonin reuptake inhibitors and other types of antidepressant medications can produce changes in the brain. But they affect different areas of the brain than psychotherapy.

"It's no surprise then that sometimes you need both types of therapies in order to achieve the optimal result. All of this research is exploding, and as it continues to advance it will move us toward a greater capacity to personalize and tailor treatment for individual patients. These are some of the very exciting directions we are moving towards in psychiatry," said Dr. Oldham.

Dr. Oldham will deliver an address at the opening session of the APA's 2011 Annual Meeting on Sunday, May 15.

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