Whack-A-Mole: Navigating the Pitfalls of Collaborative Care Psychiatry

Background: The Collaborative Care Model (CoCM) is an increasingly important method of improving access to psychiatric care. While effective at serving the needs of certain patients, there are multiple challenges in this model of care, as is illustrated in this case.



Case: 64-year-old woman presents to her primary care provider (PCP) with complaints of "zapping" leg pain for the past two years, which only occurs when her husband is at home with her. Her symptoms have worsened to the point that that she and her husband cannot cohabitate, and he has recently started living in their locked basement due to fear of violent outbursts.

Discussion: It took over one year from the time of referral to the patient eventually seeing the psychiatrist, due to pitfall one: delay in diagnosis. Initially this was diagnosed as peripheral neuropathy, likely because many PCPs are not familiar with somatic delusions. Eventually, when referred to the psychiatrist, pitfall two came up: the patient did not show up for scheduled visits because she did not believe that she had a psychiatric problem. In the meantime, the psychiatrist was asked to advise the PCP’s office on how to handle this patient. While this is often the model of collaborative care, this relies on the integrity of the story as told by the patient’s family and/or other providers, pitfall three. Because the psychiatrist had spoken to the patient’s daughter and gathered additional collateral on this patient, the psychiatrist was frustrated with PCP staff who naively believed that the patient was the victim when she had a long-standing history of manipulative and violent behavior. After educating the team about the complexity of this case, the patient was seen by the psychiatrist, who recommended psychiatric hospitalization. Then came pitfall four: educating staff on the emergency petition process versus waiting for a direct admission. Because of staff and patient preference, she was put on a waiting list and ultimately psychiatrically hospitalized. The patient was diagnosed with Major depressive disorder with psychotic features and started on risperidone. Her somatic delusions improved some-what and neurovegetative symptoms improved in the hospital. After 46 days in the hospital, the patient was discharged back to the care of the collaborative care psychiatrist. The hospital had offered her a traditional psychiatrist, but the patient declined. Here comes pitfall five: the collaborative care psychiatrist is only on site once per month and this patient requires more intense care, including possibly a long-acting injectable (LAI); it is unclear if a PCP site would be able to continue an LAI due to nursing comfort at a PCP site.

Conclusion: While collaborative care was advantageous in getting this patient into care, there are limitations that make care difficult to implement for a complex patient.

References:

Whitfield J, et al. Remote Collaborative Care With Off-Site Behavioral Health Care Managers: A Systematic Review of Clinical Trials. J Acad Consult Liaison Psychiatry. 2022 Jan-Feb;63(1):71-85.

Howland M, et al. C-L Case Conference: Chronic Psychosis Managed in Collaborative Care. J Acad Consult Liaison Psychiatry. 2022 May-Jun;63(3):189-197.