- Email: [email protected]
Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents
Psychosomatics 2015:]:]]]–]]]
& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents Hsiang Huang, M.D., Andres Barkil-Oteo, M.D.
Background: Job descriptions for psychiatrists will change significantly over the next decade, as psychiatrists will be called on to work as caseload consultants to the primary care team. Objective: The purpose of this pilot study was to examine the effects of an American Association of Directors of Psychiatric Residency Training–approved collaborative care curriculum on caseload consulting skills among psychiatry residents. Methods: In 2014, 46 psychiatry residents (5 postgraduate year 1s, 10 postgraduate year 2s, 22 postgraduate year 3s, and 9 postgraduate year 4s) from 5 academic psychiatry residency programs in the New England area were given the 2-hour pilot collaborative care curriculum. Participants were asked to complete an anonymous survey at both the beginning and the end of the workshop to rate their comfort level
in aspects of collaborative care psychiatry (7 items from SBP4 psychiatry milestones) based on a Likert scale (1—not at all, 2—slightly, 3—moderately, and 4 —extremely). Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop. Results: The pretest mean score for the group was 2.9 (standard deviation ¼ 0.44), whereas the posttest mean was 3.51 (standard deviation ¼ 0.42), p o 0.0001. Only 15% (n ¼ 7) of residents reported having some form of primary care or ambulatory specialty care consultation experience while in training. Conclusion: This brief collaborative care curriculum significantly improved resident confidence in milestone criteria related to population health and case-based consultations. (Psychosomatics 2015; ]:]]]–]]])
INTRODUCTION
found on consultation-liaison/psychosomatic medicine services because it is population-based and delivered in primary care settings. Collaborative care interventions are based on group information: systematic screening, active case identification, and patient registries. Direct patient care is delivered by a primary care provider and a behavioral care manager, using evidence-based algorithms. Weekly systematic case
The goal of providing access to high-quality care at a low cost requires a fundamental change in the way health care services are organized and delivered.1 It is recognized that comorbid behavioral health conditions such as depression contribute to increased disease burden and health care costs.2 Given that more patients with behavioral health needs receive their care in primary care settings than in specialty psychiatric settings,3 psychiatrists have an opportunity to work in primary care settings to help provide needed high-quality and low-cost care on a population level.4 Many approaches to integrating behavioral health care have been developed, but the strongest evidence currently exists for collaborative care.5 This approach is different from the traditional consultation models Psychosomatics ]:], ] 2015
Received March 1, 2015; revised March 22, 2015; accepted March 23, 2015. From Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA (HH); Department of Psychiatry, Yale School of Medicine, New Haven, CT (AB-O). Send correspondence and reprint requests to Hsiang Huang, M.D., 1959 NE Pacific Street, Box 356560, Seattle 98195; e-mail: hhuang@cha. harvard.edu & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org
1
Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents reviews by a psychiatric consultant and the care manager are provided for patients who do not improve on specified behavioral health outcomes (e.g., on the Patient Health Questionnaire-9). As noted in a recent American Psychiatric Association report, the continuum of medical education must prepare physicians “to deliver this sort of patient-centered, team-based, measurement-based, and populationoriented care.”6 However, most psychiatry training programs do not have curricula teaching skills in collaborative care.7–9 The experience at many programs with an “integrated care” option is typically either through a hospital-based consultation-liaison service or a psychiatric practice that is co-located with a primary care clinic. We believe that these settings do not allow psychiatric trainees to learn to approach care from a population health perspective or to incorporate measurement-based evaluations. To meet this educational need, we have developed a 2-hour curriculum that teaches these essential skills to trainees. For residency programs that do not have clinical settings to support collaborative care, this brief module can be used to provide an appreciation of population health with a focus on key integrated care skill sets, such as using validated instruments (e.g., Patient Health Questionnaire-9), provision of stepped care, and being a caseload consultant. The purpose of this article is to describe the results of the pilot curriculum in increasing competency among psychiatry residents in key areas of collaborative care. METHODS This American Association of Directors of Psychiatric Residency Training–approved model curriculum (and
TABLE 1.
currently under peer review at MedEdPORTAL) was developed by the authors to teach principles of collaborative care while addressing several Accreditation Council for Graduate Medical Education Psychiatry milestones (SBP4). The learning objectives are described in Table 1. The curriculum contains a facilitator guide, suggested readings and videos to review before the session, 2 modules (60 minutes each) to explain the main concepts, and interactive clinical cases through which the residents learn to think and act like a psychiatric consultant in a primary care setting. Through the case simulations, they are encouraged to use the advantages of the collaborative care model while learning to recognize the limitations of practicing in such a setting. During the session, residents practice administering validated clinical instruments such as the Patient Health Questionnaire-9 for depressive disorders, Generalized Anxiety Disorder Questionnaire for anxiety disorders, and Composite International Diagnostic Interview for bipolar disorder.10–12 In 2014, one of the authors (H.H.) delivered this curriculum to 5 adult psychiatry residency programs in the New England area. Resident participants were asked to fill out an anonymous survey at the beginning and end of the workshop to rate their comfort level by applying the following aspects of collaborative care psychiatry: (1) Describes the difference between consultant and primary treatment provider, (2) describes differences in providing consultation for the system or team vs the individual patients, (3) provides consultations to other medical services, (4) clarifies the consult question, (5) assists primary treatment care team in identifying unrecognized clinical care issues, (6) discusses methods for integrating mental health and
Learning Objectives for Collaborative Care Curriculum
Knowledge Understand the case for collaborative care Understand the model of collaborative care and be familiar with the growing evidence base
2
Skills
Conceptually understand and be ready to use a population health perspective and validated scales in caring for patients Use screeners effectively to aid in diagnostic evaluation Recognize the basic elements and principles of collaborative care Perform psychiatric consultation Demonstrate increased comfort in communications with both care managers and primary care providers
Attitudes
Examine their own experiences and opinions of existing outpatient mental health systems while considering collaborative care psychiatry's potential for delivering more integrated and population-based care Be open to making a diagnosis in the absence of a direct assessment Integrate the patient's own and other providers' perspectives into a common understanding of the patient's problems and presentation
www.psychosomaticsjournal.org
Psychosomatics ]:], ] 2015
Huang and Barkil-Oteo medical care in treatment planning, and (7) provides integrated care for psychiatric patients through collaboration with other physicians. Ratings were based on a Likert scale (1—not at all, 2—slightly, 3— moderately, and 4—extremely). Residents were also asked if they had prior experience in primary care consultation and to provide general feedback on the curriculum after it was delivered. Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop. Statistical analyses were performed using STATA 11. Curriculum evaluation was performed as part of a quality improvement project and was exempted from approval by an institutional review board. RESULTS In total, 46 residents (5 postgraduate year [PGY]1s, 10 PGY2s, 22 PGY3s, and 9 PGY4s) from 5 academic psychiatry residency programs were included in this pilot collaborative care curriculum. Overall, 7 (15%) residents reported having some form of primary care or ambulatory specialty care consultation experience while in training. The pretest mean score for the group was 2.9 (standard deviation [sd] ¼ 0.44), whereas the posttest mean score was 3.51 (sd ¼ 0.42), p o 0.05. When stratified by residency year, all subgroups had statistically significant changes (p o 0.05) in their confidence level before and after the course (PGY1: pretest mean ¼ 2.54 (sd ¼ 0.12) and posttest mean ¼ 3.11 (sd ¼ 0.34); PGY2: pretest mean ¼ 2.77 (sd ¼ 0.33) and posttest mean ¼ 3.31 (sd ¼ 0.48); PGY3: pretest mean ¼ 3.02 (sd ¼ 0.47) and posttest mean ¼ 3.55 (sd ¼ 0.37); and PGY4: pretest mean ¼ 3.14 (sd ¼ 0.44) and posttest mean ¼ 3.87 (sd ¼ 0.18). The most common recommendation from residents for improving this curriculum was the inclusion of more case reviews in which trainees are able to play the role of the caseload consultant. DISCUSSION Collaborative care—in which primary care providers, care managers, and psychiatrists work as a team and take a population-based approach to treating patients—is a rapidly growing field of behavioral health care. More than 70 randomized, controlled studies have demonstrated the efficacy as well as cost-effectiveness of this Psychosomatics ]:], ] 2015
approach.13 This model of care delivery has the potential to provide more patients with increased access to the expertise of psychiatrists, specialists who are currently in short supply. Current clinical psychiatric training is largely focused on the direct provision of patient care in tertiary settings, with much of a resident's time spent on working with complicated cases on inpatient units. Residents have some responsibility as consultants, typically in inpatient settings but occasionally in outpatient clinics. In this pilot study of a brief interactive collaborative care curriculum for psychiatry residents in the New England area, we found that the course significantly improved resident confidence in milestone criteria related to population health and case-based consultations. Only 15% of residents had any previous experience working in primary care/ambulatory settings. Some residents indicated that this was the first time that they have heard of collaborative care. The curriculum was generally well received by residents, with many residents asking for more case exercises in performing indirect consultations and providing recommendations to the primary care team. To date, these collaborative care models have largely been implemented outside of academic settings. Training programs have an opportunity to match the demands of the market by helping develop residents' skills in this area. This curriculum and other similar educational initiatives will help future psychiatrists become more effective in their clinical roles in our ever-changing health care system. The strengths of this curriculum include that it is brief and “ready-made” (a facilitator guide is included), uses a flipped classroom teaching method, and is shown to increase competency in caseload consulting skills as defined by the psychiatry residency training program milestones. Furthermore, the curriculum can be taught in academic programs with limited access to clinical integrated care opportunities. A potential limitation of the pilot study findings is that this curriculum was presented only at academic centers in the New England area. CONCLUSION Job requirements for psychiatrists will change significantly over the next decade given the movement of our health system toward more efficient and cost-effective treatment. Specifically, psychiatrists will be called on www.psychosomaticsjournal.org
3
Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents to work effectively as caseload consultants to the primary care team. Given the structural changes in the U.S. health care system, there is a need to prepare psychiatry trainees via curricula in collaborative care to improve health on a population level and increase the value of behavioral health services.
Drs. Huang and Barkil-Oteo have no potential conflicts of interest to disclose.
FUNDING/SUPPORT
We would like to thank Shireen Cama, M.D. for her thoughtful review of the manuscript, for which no compensation was received.
This research was supported by the following grant from the Health Services Division of NIMH: T32 MH20021-14. Dr Huang was also supported by the Fulbright Scientific Mobility Scholar Program.
CONFLICT OF INTEREST
ADDITIONAL CONTRIBUTIONS
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27(3):759–769 2. Katon WJ: Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003; 54(3):216–226 3. Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC: Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry 2006; 163(7):1187–1198 4. Aquino PR, Huang H: The early-career psychiatrist: getting started in a career in integrated care. Psychosomatics 2014; 55(5):519–520 5. Katon W, Unutzer J: Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry 2011; 33(4):305–310 6. Summers R, Rapaport M, Hunt J, et al. Training psychiatrists for integrated behavioral health care. Report: American Psychiatric Association Council on Medical Education and Lifelong Learning, 2014. 7. Huang H, Barkil-Oteo A: The early-career consultation psychiatrist: preparing psychiatry residents for the integrated care wave. Psychosomatics 2014; 55(6):740–741
4
www.psychosomaticsjournal.org
8. Cerimele JM, Popeo DM, Rieder RO: A resident rotation in collaborative care: learning to deliver primary carebased psychiatric services. Acad Psychiatry 2013; 37(1): 63–64 9. Cowley D, Dunaway K, Forstein M, et al: Teaching psychiatry residents to work at the interface of mental health and primary care. Acad Psychiatry 2014; 38(4): 398–404 10. Kessler RC, Akiskal HS, Angst J, et al: Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0. J Affect Disord 2006; 96(3):259–269 11. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606–613 12. Spitzer RL, Kroenke K, Williams JB, Lowe B: A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10):1092–1097 13. Thota AB, Sipe TA, Byard GJ, et al: Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med 2012; 42(5):525–538
Psychosomatics ]:], ] 2015
& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents Hsiang Huang, M.D., Andres Barkil-Oteo, M.D.
Background: Job descriptions for psychiatrists will change significantly over the next decade, as psychiatrists will be called on to work as caseload consultants to the primary care team. Objective: The purpose of this pilot study was to examine the effects of an American Association of Directors of Psychiatric Residency Training–approved collaborative care curriculum on caseload consulting skills among psychiatry residents. Methods: In 2014, 46 psychiatry residents (5 postgraduate year 1s, 10 postgraduate year 2s, 22 postgraduate year 3s, and 9 postgraduate year 4s) from 5 academic psychiatry residency programs in the New England area were given the 2-hour pilot collaborative care curriculum. Participants were asked to complete an anonymous survey at both the beginning and the end of the workshop to rate their comfort level
in aspects of collaborative care psychiatry (7 items from SBP4 psychiatry milestones) based on a Likert scale (1—not at all, 2—slightly, 3—moderately, and 4 —extremely). Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop. Results: The pretest mean score for the group was 2.9 (standard deviation ¼ 0.44), whereas the posttest mean was 3.51 (standard deviation ¼ 0.42), p o 0.0001. Only 15% (n ¼ 7) of residents reported having some form of primary care or ambulatory specialty care consultation experience while in training. Conclusion: This brief collaborative care curriculum significantly improved resident confidence in milestone criteria related to population health and case-based consultations. (Psychosomatics 2015; ]:]]]–]]])
INTRODUCTION
found on consultation-liaison/psychosomatic medicine services because it is population-based and delivered in primary care settings. Collaborative care interventions are based on group information: systematic screening, active case identification, and patient registries. Direct patient care is delivered by a primary care provider and a behavioral care manager, using evidence-based algorithms. Weekly systematic case
The goal of providing access to high-quality care at a low cost requires a fundamental change in the way health care services are organized and delivered.1 It is recognized that comorbid behavioral health conditions such as depression contribute to increased disease burden and health care costs.2 Given that more patients with behavioral health needs receive their care in primary care settings than in specialty psychiatric settings,3 psychiatrists have an opportunity to work in primary care settings to help provide needed high-quality and low-cost care on a population level.4 Many approaches to integrating behavioral health care have been developed, but the strongest evidence currently exists for collaborative care.5 This approach is different from the traditional consultation models Psychosomatics ]:], ] 2015
Received March 1, 2015; revised March 22, 2015; accepted March 23, 2015. From Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA (HH); Department of Psychiatry, Yale School of Medicine, New Haven, CT (AB-O). Send correspondence and reprint requests to Hsiang Huang, M.D., 1959 NE Pacific Street, Box 356560, Seattle 98195; e-mail: hhuang@cha. harvard.edu & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org
1
Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents reviews by a psychiatric consultant and the care manager are provided for patients who do not improve on specified behavioral health outcomes (e.g., on the Patient Health Questionnaire-9). As noted in a recent American Psychiatric Association report, the continuum of medical education must prepare physicians “to deliver this sort of patient-centered, team-based, measurement-based, and populationoriented care.”6 However, most psychiatry training programs do not have curricula teaching skills in collaborative care.7–9 The experience at many programs with an “integrated care” option is typically either through a hospital-based consultation-liaison service or a psychiatric practice that is co-located with a primary care clinic. We believe that these settings do not allow psychiatric trainees to learn to approach care from a population health perspective or to incorporate measurement-based evaluations. To meet this educational need, we have developed a 2-hour curriculum that teaches these essential skills to trainees. For residency programs that do not have clinical settings to support collaborative care, this brief module can be used to provide an appreciation of population health with a focus on key integrated care skill sets, such as using validated instruments (e.g., Patient Health Questionnaire-9), provision of stepped care, and being a caseload consultant. The purpose of this article is to describe the results of the pilot curriculum in increasing competency among psychiatry residents in key areas of collaborative care. METHODS This American Association of Directors of Psychiatric Residency Training–approved model curriculum (and
TABLE 1.
currently under peer review at MedEdPORTAL) was developed by the authors to teach principles of collaborative care while addressing several Accreditation Council for Graduate Medical Education Psychiatry milestones (SBP4). The learning objectives are described in Table 1. The curriculum contains a facilitator guide, suggested readings and videos to review before the session, 2 modules (60 minutes each) to explain the main concepts, and interactive clinical cases through which the residents learn to think and act like a psychiatric consultant in a primary care setting. Through the case simulations, they are encouraged to use the advantages of the collaborative care model while learning to recognize the limitations of practicing in such a setting. During the session, residents practice administering validated clinical instruments such as the Patient Health Questionnaire-9 for depressive disorders, Generalized Anxiety Disorder Questionnaire for anxiety disorders, and Composite International Diagnostic Interview for bipolar disorder.10–12 In 2014, one of the authors (H.H.) delivered this curriculum to 5 adult psychiatry residency programs in the New England area. Resident participants were asked to fill out an anonymous survey at the beginning and end of the workshop to rate their comfort level by applying the following aspects of collaborative care psychiatry: (1) Describes the difference between consultant and primary treatment provider, (2) describes differences in providing consultation for the system or team vs the individual patients, (3) provides consultations to other medical services, (4) clarifies the consult question, (5) assists primary treatment care team in identifying unrecognized clinical care issues, (6) discusses methods for integrating mental health and
Learning Objectives for Collaborative Care Curriculum
Knowledge Understand the case for collaborative care Understand the model of collaborative care and be familiar with the growing evidence base
2
Skills
Conceptually understand and be ready to use a population health perspective and validated scales in caring for patients Use screeners effectively to aid in diagnostic evaluation Recognize the basic elements and principles of collaborative care Perform psychiatric consultation Demonstrate increased comfort in communications with both care managers and primary care providers
Attitudes
Examine their own experiences and opinions of existing outpatient mental health systems while considering collaborative care psychiatry's potential for delivering more integrated and population-based care Be open to making a diagnosis in the absence of a direct assessment Integrate the patient's own and other providers' perspectives into a common understanding of the patient's problems and presentation
www.psychosomaticsjournal.org
Psychosomatics ]:], ] 2015
Huang and Barkil-Oteo medical care in treatment planning, and (7) provides integrated care for psychiatric patients through collaboration with other physicians. Ratings were based on a Likert scale (1—not at all, 2—slightly, 3— moderately, and 4—extremely). Residents were also asked if they had prior experience in primary care consultation and to provide general feedback on the curriculum after it was delivered. Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop. Statistical analyses were performed using STATA 11. Curriculum evaluation was performed as part of a quality improvement project and was exempted from approval by an institutional review board. RESULTS In total, 46 residents (5 postgraduate year [PGY]1s, 10 PGY2s, 22 PGY3s, and 9 PGY4s) from 5 academic psychiatry residency programs were included in this pilot collaborative care curriculum. Overall, 7 (15%) residents reported having some form of primary care or ambulatory specialty care consultation experience while in training. The pretest mean score for the group was 2.9 (standard deviation [sd] ¼ 0.44), whereas the posttest mean score was 3.51 (sd ¼ 0.42), p o 0.05. When stratified by residency year, all subgroups had statistically significant changes (p o 0.05) in their confidence level before and after the course (PGY1: pretest mean ¼ 2.54 (sd ¼ 0.12) and posttest mean ¼ 3.11 (sd ¼ 0.34); PGY2: pretest mean ¼ 2.77 (sd ¼ 0.33) and posttest mean ¼ 3.31 (sd ¼ 0.48); PGY3: pretest mean ¼ 3.02 (sd ¼ 0.47) and posttest mean ¼ 3.55 (sd ¼ 0.37); and PGY4: pretest mean ¼ 3.14 (sd ¼ 0.44) and posttest mean ¼ 3.87 (sd ¼ 0.18). The most common recommendation from residents for improving this curriculum was the inclusion of more case reviews in which trainees are able to play the role of the caseload consultant. DISCUSSION Collaborative care—in which primary care providers, care managers, and psychiatrists work as a team and take a population-based approach to treating patients—is a rapidly growing field of behavioral health care. More than 70 randomized, controlled studies have demonstrated the efficacy as well as cost-effectiveness of this Psychosomatics ]:], ] 2015
approach.13 This model of care delivery has the potential to provide more patients with increased access to the expertise of psychiatrists, specialists who are currently in short supply. Current clinical psychiatric training is largely focused on the direct provision of patient care in tertiary settings, with much of a resident's time spent on working with complicated cases on inpatient units. Residents have some responsibility as consultants, typically in inpatient settings but occasionally in outpatient clinics. In this pilot study of a brief interactive collaborative care curriculum for psychiatry residents in the New England area, we found that the course significantly improved resident confidence in milestone criteria related to population health and case-based consultations. Only 15% of residents had any previous experience working in primary care/ambulatory settings. Some residents indicated that this was the first time that they have heard of collaborative care. The curriculum was generally well received by residents, with many residents asking for more case exercises in performing indirect consultations and providing recommendations to the primary care team. To date, these collaborative care models have largely been implemented outside of academic settings. Training programs have an opportunity to match the demands of the market by helping develop residents' skills in this area. This curriculum and other similar educational initiatives will help future psychiatrists become more effective in their clinical roles in our ever-changing health care system. The strengths of this curriculum include that it is brief and “ready-made” (a facilitator guide is included), uses a flipped classroom teaching method, and is shown to increase competency in caseload consulting skills as defined by the psychiatry residency training program milestones. Furthermore, the curriculum can be taught in academic programs with limited access to clinical integrated care opportunities. A potential limitation of the pilot study findings is that this curriculum was presented only at academic centers in the New England area. CONCLUSION Job requirements for psychiatrists will change significantly over the next decade given the movement of our health system toward more efficient and cost-effective treatment. Specifically, psychiatrists will be called on www.psychosomaticsjournal.org
3
Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents to work effectively as caseload consultants to the primary care team. Given the structural changes in the U.S. health care system, there is a need to prepare psychiatry trainees via curricula in collaborative care to improve health on a population level and increase the value of behavioral health services.
Drs. Huang and Barkil-Oteo have no potential conflicts of interest to disclose.
FUNDING/SUPPORT
We would like to thank Shireen Cama, M.D. for her thoughtful review of the manuscript, for which no compensation was received.
This research was supported by the following grant from the Health Services Division of NIMH: T32 MH20021-14. Dr Huang was also supported by the Fulbright Scientific Mobility Scholar Program.
CONFLICT OF INTEREST
ADDITIONAL CONTRIBUTIONS
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27(3):759–769 2. Katon WJ: Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003; 54(3):216–226 3. Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC: Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry 2006; 163(7):1187–1198 4. Aquino PR, Huang H: The early-career psychiatrist: getting started in a career in integrated care. Psychosomatics 2014; 55(5):519–520 5. Katon W, Unutzer J: Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry 2011; 33(4):305–310 6. Summers R, Rapaport M, Hunt J, et al. Training psychiatrists for integrated behavioral health care. Report: American Psychiatric Association Council on Medical Education and Lifelong Learning, 2014. 7. Huang H, Barkil-Oteo A: The early-career consultation psychiatrist: preparing psychiatry residents for the integrated care wave. Psychosomatics 2014; 55(6):740–741
4
www.psychosomaticsjournal.org
8. Cerimele JM, Popeo DM, Rieder RO: A resident rotation in collaborative care: learning to deliver primary carebased psychiatric services. Acad Psychiatry 2013; 37(1): 63–64 9. Cowley D, Dunaway K, Forstein M, et al: Teaching psychiatry residents to work at the interface of mental health and primary care. Acad Psychiatry 2014; 38(4): 398–404 10. Kessler RC, Akiskal HS, Angst J, et al: Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0. J Affect Disord 2006; 96(3):259–269 11. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606–613 12. Spitzer RL, Kroenke K, Williams JB, Lowe B: A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10):1092–1097 13. Thota AB, Sipe TA, Byard GJ, et al: Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med 2012; 42(5):525–538
Psychosomatics ]:], ] 2015