Treating the Whole Patient

UW Faculty Drives Inventive Approaches to Mental Health Care

Dr. Jürgen Unützer knew his research into new models of mental heath care delivery was on the right track when a patient described feeling like a tennis ball. This patient had a combination of health problems associated with diabetes along with alcohol problems and depression. As is common in the current health care system, the patient was being bounced around to different specialists to treat his individual symptoms. Dr. Unützer was concerned that patients like this, with a combination of behavioral health and medical conditions, were falling through the cracks and not receiving care that treats the whole person.

"The patient expects that the various providers are all talking to each other, but that is often not the case," he says. "Who’s connecting the dots? Patients expect their care providers to sync up and know what’s going on with all of their conditions."

Researchers and professors at the UW, such as Dr. Unützer, are driving innovative ways to improve access to high quality mental health care delivered in a manner that treats the whole person. Their efforts are focused on health care models that integrate behavioral health services into the primary care clinic and other heath care arenas, where the patients already receive care and have established provider relationships. Known as collaborative or integrated care, these models put the patient at the center of a health team – including their physician, a care coordinator and a psychiatric consultant – that collaborates on a patient’s treatment plan.

Going Where the Patients Are 

Mental health disorders can be challenging to properly treat in the primary care setting. There are several reasons for this: physicians may have too little time with patients or lack the support they need to to proactively assess the effectiveness of treatment, or the patient may not know how to talk to their doctors about mental health concerns.

But diagnosing and treating mental illness in primary care clinics can be important first steps for improving a person’s general health. There is increasing evidence linking chronic diseases with mental health.

"Individuals who are depressed are at higher risk for chronic diseases such as obesity and diabetes," says Dr. Taryn Lindhorst, associate professor at the University of Washington School of Social Work. "This is because when you are depressed, normal eating or exercise patterns can be changed."

Likewise, she explains, the worry and stress that go along with serious chronic illnesses can increase the risk for mental health problems. Patients with undiagnosed or untreated mental illness may turn to harmful behavior patterns, such as alcohol abuse, to self-medicate, which can cause further health-related problems.

The principles of integrated mental health are aligned with the patient-centered medical home, a health care model that is gaining in popularity across the U.S. These approaches use the primary care clinic as the central point of treatment and communication for all providers caring for a particular patient. A care coordinator, usually a nurse or social worker, works closely with the primary care provider to engage the patient in mental health treatment and follow up with them at home. The goal is to treat the patient in one place, therefore preventing the tennis ball effect, improving the quality of their care and lowering health care costs. (Figure 1)

Click to enlarge image.

Figure 1: An example of an integrated mental health care model, based on an illustration by the Washington State Mental Health Integration Program (MHIP) via the AIMS Center website.

And it works. The IMPACT study, led by Dr. Unützer, professor and vice-chair in the UW Department of Psychiatry & Behavioral Sciences and chief of Psychiatric Services at the UW Medical Center, has been shown to double the effectiveness of usual care for depression while lowering health care costs. This study is one of the largest depression treatment trials ever conducted, focusing on depressed older adults. Half of the enrolled study participants received IMPACT collaborative care and the other half received normal care (including referrals to specialty mental health care).

Of the 1,801 patients who participated in the study, IMPACT patients had lower average costs for all their medical care over a four year period – about $3,300 less – than patients receiving usual care. IMPACT patients were also twice as likely to have a 50% or greater improvement in depression symptoms, reported less physical pain, better quality of life and higher satisfaction with their care.

The demand for these types of patient-centered health care models is rising across the country. "Once people understand that integrated mental health is a smarter way to help patients get better, the demand for these types of health care models will increase," says Dr. Unützer. "But the supply for trained professionals is limited."

Team Training 

To help increase the supply of trained professionals, the Advancing Integrated Mental health Solutions (AIMS) Center at the UW has trained over 5,000 clinicians and assisted over 600 primary care clinics with implementing integrated care programs. As its director, Dr. Unützer, who also served as senior scientific advisor to the World Health Organization and advisor to the President’s New Freedom Commission on Mental Health, helps to train a range of health care professionals, through webinars, workshops and an online Certificate in Integrated Behavioral Health.

This approach is similar to how the UW School of Social Work trains professional social workers through their Integrated Health-Mental Health concentration in the Master of Social Work Extended Degree Program. Graduates of the MSW concentration work in health care settings, the mental health system and community-based programs. "Social work focuses on the person in their environment and how to strengthen the individual’s internal, family and community resources," explains Dr. Lindhorst. "We study specific skills such as how to engage people based on their cultural interpretations of their health conditions, which determines how likely a person is to seek out treatment as well as how well they follow their treatment plans. Frequently, social workers use skills such as crisis intervention, motivational interviewing and problem solving to help people cope more effectively."

However, this type of team-based approach is not without its challenges. Clinical specialists are usually trained to focus on their own specialty instead of working closely with other providers to offer integrated care for the whole person. Dr. Unützer uses the analogy of musicians in an orchestra. Each musician receives separate, specialized training in one instrument, such as a violin or flute. But if these musicians never practice together, chances are they will not sound very good playing as a group.

Overall, one of the ultimate goals is to remove the stigma associated with mental health treatment and to help patients get better faster. Integrated care that is provided in the primary care setting can help patients receive the care they need and ultimately can lead to healthier, happier lives. Dr. Unützer explains, "my wish is for mental health to become a part of health, so that there is less fear and stigma around it."

To learn more about the UW's Certificate in Integrated Behavioral Health, call 206-685-8936 or, toll free, 888-469-6499. To learn more about the UW MSW Extended Degree Program, visit the UW School of Social Work website.