Attending to Mind and Body Together with Collaborative Care
An interview with UCSF’s Dr. Maga Jackson-Triche about integration at the point of care
Psychiatrist Maga E. Jackson-Triche is a pioneer in behavioral health. Over the past three decades, she’s been involved in researching and implementing new strategies to improve access to behavioral health care, particularly for populations with poor access to that care. A Massachusetts native, Jackson-Triche earned her medical degree at the University of Chicago’s Pritzker School of Medicine. As a medical student, she worked with rural populations in Rwanda and Zaire (now known as the Democratic Republic of Congo). After a residency in internal medicine at Los Angeles County’s Martin Luther King Jr. General Hospital, she completed a second residency in psychiatry at the UCLA School of Public Health.
She held leadership roles at the US Department of Veterans Affairs (VA) health care network in Los Angeles, Southeast Louisiana, Northern California, and Washington, DC. She has written journal articles and was coauthor of a book, Beating Depression: The Journey to Hope.
Jackson-Triche joined UCSF in 2016 to lead an expansion of clinically integrated mental health services. She is the UCSF Health executive advisor for diversity, equity, and inclusion and assistant vice chancellor. She has championed the evidence-based care model known as collaborative care, which was recently added as a benefit in Medi-Cal and is the focus of Concert Health, an investee of the CHCF Innovation Fund. My interview with Jackson-Triche was conducted over Zoom, and this transcript has been lightly edited and condensed for clarity.
Q: You’ve accomplished a lot in your career in behavioral health. What drew you to the field?
A: I’ve been interested in emotional well-being since high school. I used to do a lot of reading about psychology. When I was a Girl Scout, one of my candy-striping assignments was in the hospital. I got to do rounds with physicians, and I got interested in medicine.
My first residency was internal medicine, but I found that I really liked spending time talking with patients about their behavioral and emotional concerns. So I applied for a psychiatry residency at UCLA. I saw that emotional well-being is really the foundation of health. People who were able to successfully deal with things like anxiety and distress seemed to have better outcomes.
Q: You’ve worked all over the country in both urban and rural areas. Are there different challenges to providing behavioral health depending on where you are?
A: Access to behavioral health care is not great anywhere, but it’s really bad in rural areas that have very few mental health professionals, where figuring out how to get services to people is very challenging. Also, the poverty level in Louisiana and Southern Mississippi was unlike anything I’d seen, and it was compounded by systemic anti-Black racism. Many people were struggling to get food. I was there during Hurricane Katrina, which revealed a lot about the poverty and disparities there. Since then, many people have been working to address those issues. In the more urban settings such as San Francisco and Sacramento, there’s a big homelessness problem, and this type of poverty is much more noticeable to the public. I didn’t witness as much homelessness in the South, mostly, I think, because rural housing costs are a lot less, and many times families have been living together in the same properties for generations.
Q: You’re known for your research and efforts to improve access to mental health care, particularly through what’s called “behavioral health integration” and a model called “collaborative care.” What do those terms mean, and what sparked your interest in this model?
A: In the early ’90s, Kenneth Wells mentored me in looking at disparities around treatment for depression care. Colleagues and I found that people with behavioral health conditions were going to their primary care doctor or to emergency rooms, not to behavioral health practitioners. We thought that there’s got to be a way to move mental health clinicians closer to where the patients are going.
At the UCLA San Fernando Valley Program, I helped integrate mental health services into a VA medical clinic by adding a psychiatrist to each of three clinical care teams that included general practitioners. This is one example of what is called “behavioral health integration,” because you have the behavioral health person integrated into the team at the primary care clinic.
An approach developed by Wayne Katon and Jürgen Unützer at the University of Washington used a model that included a behavioral health care manager and a psychiatrist providing consultation. Those years marked the beginning of what’s now called “collaborative care.” Collaborative care basically means that psychiatrists and other behavioral health experts collaborate with primary care doctors in an evidence-based way to treat patients and use validated screening tools and a registry to standardize care and track outcomes over time. We are developing this approach at UCSF.
Q: How does that differ from traditional behavioral health care?
A: In the traditional model, someone would typically come into a primary care clinic feeling depressed, and they might or might not disclose this to their clinician. People often suffered in silence. Also, they might come in with a lot of medical complaints related to the depression but have no physical findings. If the depression did get diagnosed, the patient might not want to go see a behavioral health specialist because of stigma, or they tried but had trouble getting an appointment. Many primary care doctors became adept at addressing these problems, perhaps offering advice on coping skills or prescribing medications. However, many also worried that this was not the optimal way to provide care, and the worry was that many depressed patients were falling through the cracks.
Q: How does collaborative care benefit patients?
A: Having access to collaborative care is often the difference between getting treatment and getting no treatment. Also, patients have the opportunity to get earlier treatment, so they don’t fall into despair and suffer consequences such as job loss or even becoming suicidal. If they have an addiction, which can complicate depression, it can get recognized and treated early. Patients like the integrated care / collaborative care model because they can go to a central place for all their care. It’s very patient friendly. Finding and sticking with treatment can be hard, especially for a patient experiencing depression. Collaborative care, by providing screening, enables timely treatment for patients who screen positive for symptoms. Preliminary studies show this model to be cost effective, because when people get treatment early, they’re able to work, to parent better, and to have a better overall well-being.
Q: Studies show that African Americans, Latinx, and Asian Americans don’t access behavioral health care as much as White people. Does collaborative care help address those disparities?
A: It certainly has the potential to address these known disparities. We don’t yet have studies that prove this definitively, but anecdotally we see that people of all ethnicities and races are getting more treatment. The model has been tested and found to be effective with many different populations.
Q: Do you have any stories of patients who’ve benefited from the collaborative care model?
A: There are many. A physician I knew was having trouble getting his mother to go see a mental health clinician, even though she was clearly depressed. But he was able to get her in to see a mental health specialist through her primary care doctor, who diagnosed her and actually got her on treatment. She did very well. We often have people getting treatment through collaborative care say, “If you weren’t in the same office with my primary care doctor, I wouldn’t have gone out of my way to do this.”
Q: Does collaborative care help providers?
A: For primary care doctors, work satisfaction goes up and burnout goes down. An average primary care visit is only 10 to 15 minutes, so it’s hard to cover all the medical conditions and deal with behavioral or emotional issues as well. Doctors are more comfortable asking about those things if they have someone they can refer patients to. For behavioral health clinicians, it’s also very satisfying because you see a lot of people you ordinarily wouldn’t have seen. And you often treat people at an earlier stage of illness, which is very satisfying because you can prevent more serious problems.
Q: What does implementation look like at UCSF?
A: At the department of psychiatry, we hired an associate director for collaborative care. We have embedded psychiatrists and therapists in the primary care clinics, and expanded this to women’s health, particularly in maternity care. These specialists help recognize depression and emotional issues that may come up prebirth and that can impact labor and delivery as well as postpartum care.
Q: What insights into the behavioral health system have you gained from being a psychiatrist of color?
A: Being a woman and being a person of color, it makes me more sensitive to issues of disparity around access to treatment. For a long time, we didn’t have enough female psychiatrists, for example, and we still don’t have enough psychiatrists of color. Although we need to increase representation, doing only that doesn’t solve the problem. We have to get every clinician to provide excellent care to everybody, so that finally, the color or gender of the clinician or the patient doesn’t matter. We want to get to a place where everyone gets the best care available.
Q: What are the hurdles to providing integrated or collaborative behavioral health care?
A: There are so few mental health practitioners. Telehealth could help. The University of Washington has developed a good telehealth network, and the VA has started doing that. I think COVID-19 has moved that at light speed. Figuring out how to cover the salaries of the psychiatrists and behavioral health care managers is a challenge. In the past, you could bill for therapy in the clinic but not for a psychiatric consultation or for warm handoffs or other elements of collaborative care, such as managing an outcome registry or proactively reaching out to patients to check in on them. That’s starting to change. Medicare, most commercial insurers, and several state Medicaid agencies, including California’s, began reimbursing collaborative care. When something’s reimbursed, people are more motivated to try it.
Q: Do you have advice for policymakers or providers interested in expanding access to collaborative care?
A: Visit the AIMS Center website at the University of Washington. It gives detailed information about how to implement it, and they provide consultations. Providers can go to their managers and say, “This model is proven to work clinically and economically, and it could really benefit our patients.”
Q: What’s next for collaborative care, particularly in California?
A: I think people understand that it’s the future, and they’re trying to figure out how to do it in their systems. Sometimes people start with more limited aspects of integration, where the primary care provider has a mental health clinician they consult with by phone or through the electronic health record. Others are moving to the collaborative care model where they have a mental health clinician in the primary care clinic and a psychiatrist either in the clinic or available for consultation. Now that it’s going to be reimbursed, I think the collaborative care model will expand more and will become broadly accessible within 10 years. It’s the future of behavioral health care and the future of medicine in general.