Beyond the Constraints of Categorical Thinking: Issues of Collaboration

Editor’s note: Third in a 3-part series | Part II

Collaboration seems to be the order of the day. Studies find high rates of comorbid medical and behavioral conditions, and various models of clinical collaboration have yielded good results. Similarly, many primary care physicians acknowledge the value of psychiatric consultations regarding psychotropic medications. However, this is only one approach to collaboration, namely, one rooted in diagnostic categories.

This approach is limited. Should our priority be finding patients with clinical depression or anxiety in primary care? Diagnosis is the logical starting point when medication is the answer. This is not to suggest neglecting diagnosable disorders, but there may be other top priorities from a care delivery or population perspective. Widely effective solutions not rooted in diagnosis may be a higher priority.

It will seem scandalous to many people to question collaborative care. Yet the mainstream approach may not be working, as suggested by the latest research on diabetes. Rates have increased in the past decade and only 21% of diabetic patients are meeting all clinical goals. This is demoralizing given concerted efforts to modify well-known risk factors and to provide comprehensive care.

What should change? Might this prompt a resurgence in emphasis on collaborative care? If so, it may be the wrong collaborative care. It may favor a focus on diagnosing behavioral disorders and treating them with appropriate medications. While there is nothing wrong with such work, it may not produce any better results in aggregate a decade from now. It may help many but neglect the needs of most.

Traditional care approaches miss something fundamental about illness, namely the role of behavior. Our field has behavior in its name, but we tend to focus on behavioral health disorders rather than the endless ways behavior impacts health and illness. Why? Psychiatry tends to overshadow psychotherapy. A focus on diagnosis takes priority over the complex role of everyday behavior.

Therapists do not dispense their services the way prescribers dispense pills, namely following a diagnosis. They see needs and meet them. They know people present with a range of symptoms, some meeting a diagnostic category. Helping earlier is better, both for behavioral disorders like depression and for minimizing behaviors that can worsen medical conditions.

Consider this simple behavioral view of co-occurrence. People may be depressed or anxious, but the critical question is how their behavior impacts their medical condition. People skip needed medications, and so they deteriorate. People gain weight and so they struggle with metabolic syndrome. People isolate and disregard their health. And so on. Behavior drives health status.

The role of behavior in health and illness is stunning in its range and impact. Neither our existing medicines nor our current system for delivering therapy is adequate to address the challenge. Any response must be broad. Many believe a good start may be to shift a large segment of trained therapists into the primary care setting. They can help more people there with brief interventions.

This is not collaborative care as we know it today. These new therapists recruited to primary care cannot wait for referrals from PCPs to do their work. They need data-driven protocols for finding people in need. They would then provide brief interventions, introduce patients to digital self-care tools, refer some for more intensive therapy or psychiatric evaluation, and provide ongoing, routine follow-ups.

Primary care is powerful. Patients are expected to visit at least annually, with no stigma for showing up, and PCPs can normalize problems long hidden in the shadows. This means helping people earlier with tools derived from psychotherapy. Behavioral health diagnoses are not required. We do not need collaborative care so much as a new primary care with behavioral health a core dimension.

A new approach does not change clinical realities. We still need psychiatrists to diagnose and treat people with medications. We still need therapists to provide intensive therapy for some. Yet we must reorient our systems of care to accommodate the primacy of behavior change in physical health. We must reorganize care delivery with clinicians on the frontlines who can help change behavior.

Comorbidity is a medical term. Co-occurring medical disorders are less the concern here. The neglected connection is that between medical and psychosocial domains.  Both impact our health. We need to reframe healthcare’s foundation to prioritize each, placing medicine and therapy on the same plane. Healthcare might then become optimally effective. We might witness a powerful, new collaboration.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.