Health care systems across the globe are integrating mental health services into primary care. Recently, Dr. Ohad Avny and colleagues from Clalilt Health Services and Talbieh Psychiatric Clinic affiliated with Hadassah-Hebrew University Medical School in Jerusalem, Israel, completed a literature review of collaborative care models in Israel and other countries.

In the article, the authors call for implementing more psychiatry liaison services in primary care to address the high rates of psychopathology. They also cite evidence that collaborative care models are effective and that primary care physicians are motivated to work within psychiatry liaison models. I reached out to Dr. Avny, the lead author of the article, to ask a few additional questions.

 

1. What is the state of the mental health care system in Israel overall?

Currently mental health care in Israel is going through an ongoing process of reform. All mental health care will eventually be managed by the 3 large HMO health care systems. Up to now, mental health care was financed directly by the state. The argument for this change is foremost financial and medical (growing gap between mental health care in the provinces in Israel as compared to the metropolis areas). As there is growing shortage of psychiatrists and financial strict management I have a sense mental health care is pending crisis. And so primary care physicians who are on the “front line” will share more of this burden.

 

2. What prompted you to do a literature review of collaborative care in Israel and other countries?

As a primary care physician I can relate to my own clinical experience in my clinic. I have been practicing in my HMO clinic for the last 16 years. I am leading my HMO clinic with six family physicians. Our patients are in the Geriatric “range” and as such need a multi-disciplinary approach.

We have in our district an ongoing psychiatric collaborative enterprise where we have a psychiatrist attending our clinic every two weeks. We refer patients and consult on phone. With time due to my personal interest and growing involvement in my patient’s lives ( 16 years is a hell of a long time) I started dealing more and more with psychosocial aspects of my patient’s illnesses and narrative . I found it challenging not to stigmatize patients with psychiatric diagnosis on the one hand and yet be able to diagnose and treat those who suffer from mental health diseases. Our collaborative model has empowered me as the main care giver in patients suffering from depression and anxiety disorders. And as I was a bit skeptical of my competency as a family practitioner, less experienced and trained than psychiatrists, I started looking for evidence supporting this model. To my joy my clinical “hunch” for treating my anxious and depressed patients was supported by RCT.

I was thrilled to see that family physicians who treat depression and anxiety of their patients with some collaborative backup model are no less successful and sometime are more successful than psychiatrists providing standard care.

 

3. How often do mental health and medical professionals in Israel collaborate with each other to help a patient?

In Jerusalem there are 20 large HMO clinic who have this psychiatric collaborative model. Yet it does not exist as an organizational project in other parts of Israel. There are some collaborative enterprises – but these are local initiatives. We have another long standing collaboration model with an endocrinologist who has been with us for the last 14 years. She consults with us once a month by reviewing patients cases without their presence. So you can imagine we have upgraded our knowledge and competency in diabetes management and more. In a sense, since both the psychiatrists and the endocrinologist have been with us for so many years they are actually part of our team and so these consults are enjoyable, fun, and informal which keeps us running together, fighting burnout. 

 

4. What needs to happen for mental health treatment to become part of all regular and routine medical treatment?

I would say:

1. Increased personal interest of primary care physicians to address psychiatric issues,

2. Available backup of a mental health provider – psychiatrist for stat consult and formal assessment if needed

4. Establish close collegial relationships with physicians in subspecialties who are in your collaboration team. Their motivation has to be “pumped” up since burden of care is also at times overwhelming for them.

5. Patience!! Patience!! Patience!!! And accept the fact that you will always be behind schedule.

 

Ohad Avny is a certified Israeli family physician. He attended a one year fellowship program in Geriatrics in Canada UFT at Bay Crest Center for Geriatric Care. He is involved in undergraduate medical training (medical humanities, and family clerkship) and post-graduate training in family residency. He has special interests in psychiatry, palliative care, and medical humanities. He is married with three children.