Special Article| Volume 31, ISSUE 3, P222-231, March 2023

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Integrated Care for Complicated Patients: A Role for Combined Training and Practice

  • Gregg A. Robbins-Welty
    Send correspondence and reprint requests to Gregg Alan Robbins-Welty, M.D., M.S., Combined Internal Medicine & Psychiatry Residency Program, Duke University Hospital, Box 3837, 2301 Erwin Rd., Durham, NC 27710
    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center (GAR-W, JPG), Durham, NC

    Department of Medicine, Duke University Medical Center (GAR-W, JPG), Durham, NC
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  • Jane P. Gagliardi
    Department of Psychiatry and Behavioral Sciences, Duke University Medical Center (GAR-W, JPG), Durham, NC

    Department of Medicine, Duke University Medical Center (GAR-W, JPG), Durham, NC
    Search for articles by this author
Published:November 05, 2022DOI:


      • What is the primary question addressed by this study?
        Patients with comorbid medical and psychiatric illness suffer poorer outcomes due to a siloed healthcare system in the United States and new models of care, but do integrated behavioral models, combined medicine-psychiatry services, or complexity intervention units better serve these patients?
      • What is the main finding of this study?
        Integrated behavioral models of healthcare are designed to provide whole-patient care, addressing health disparities, and reducing barriers for patients with comorbid psychiatric illness. We describe integrated behavioral healthcare models with an emphasis on the combined medicine-psychiatry (med-psych) service at Duke University Hospital as well as detail the Duke University combined internal medicine-psychiatry residency training program.
      • What is the meaning of the finding?
        The Duke University Hospital med-psych service and residency training program may serve as an archetype for those interested in developing combined services or training programs elsewhere as a means providing integrated care for complex patients with comorbid illness.


      Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.


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        • Kessler RC
        • Demler O
        • Frank RG
        • et al.
        Prevalence and treatment of mental disorders, 1990 to 2003.
        N Engl J Med. 2005; 352: 2515-2523
        • Wang PS
        • Aguilar-Gaxiola S
        • Alonso J
        • et al.
        Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.
        Lancet. 2007; 370: 841-850
        • Manderscheid R
        • Kathol R.
        Fostering sustainable, integrated medical and behavioral health services in medical settings.
        Ann Intern Med. 2014; 160: 61-66
        • Grembowski DE
        • Martin D
        • Diehr P
        • et al.
        Managed care, access to specialists, and outcomes among primary care patients with pain.
        Health Serv Res. 2003; 38: 1-19
        • Cunningham PJ.
        Beyond parity: primary care physicians’ perspectives on access to mental health care.
        Health Aff. 2009; 28: 490-501
        • Simon GE
        • Ludman EJ.
        Predictors of early dropout from psychotherapy for depression in community practice.
        Psychiatr Serv. 2010; 61: 684-689
        • Bradford D
        • Kim M
        • Braxton L
        • et al.
        Access to medical care among persons with psychotic and major affective disorders.
        Psychiatr Serv. 2008; 59: 847-852
        • Wang PS
        • Lane M
        • Olfson M
        • et al.
        Twelve-month use of mental health services in the United States.
        Arch Gen Psychiatry. 2005; 62: 629
        • Jansen L
        • Van Schijndel M
        • Van Waarde J
        • et al.
        Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: a systematic review and meta-analysis.
        PLoS One. 2018; 13: 1-19
        • Huang H
        • Meller W
        • Kishi Y
        • et al.
        What is integrated care?.
        Int Rev Psychiatry. 2015; 0261: 620-628
        • Kathol RG
        • McAlpine D
        • Kishi Y
        • et al.
        General medical and pharmacy claims expenditures in users of behavioral health services.
        J Gen Intern Med. 2005; 20: 160-167
        • Katon WJ
        • Seelig M.
        Population-based care of depression: team care approaches to improving outcomes.
        J Occup Environ Med. 2008; 50: 459-467
        • Seelig MD
        • Katon W.
        Gaps in depression care: why primary care physicians should hone their depression screening, diagnosis, and management skills.
        J Occup Environ Med. 2008; 50: 451-458
        • Jansen L
        • Ellison A
        • Nguyen F
        • et al.
        Complexity interventions units in the United States : organization and dispersion.
        Psychsomatic Med. 2020; 82: 805-807
        • Gater RA
        • Goldberg DP
        • Evanson JM
        • et al.
        Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis.
        J Psychosom Res. 1998; 45: 437-448
        • Huyse FJ
        • Herzog T
        • Lobo A
        • et al.
        Consultation-liaison psychiatric service delivery: results from a European study.
        Gen Hosp Psychiatry. 2001; 23: 124-132
        • Rossiter F
        • Hamer M
        • Levenson L
        • et al.
        A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients.
        Am J Psychiatry. 1992; 149: 631-637
        • Bartels SJ.
        Improving the United States’ system of care for older adults with mental illness: findings and recommendations for the president's new freedom commission on mental health.
        Am J Geriatr Psychiatry. 2003; 11: 486-497
      1. Anderson C. Geriatric mental health workforce faces a growing shortage. Healthcare Finance. 2012.∼:text= Currently there are about 1%2C700,65 and older b.

        • Colton CW
        • Manderscheid RW.
        Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states.
        Prev Chronic Dis. 2006; 3: 1-14
        • Druss BG
        • Zhao L
        • Von Esenwein S
        • et al.
        Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey.
        Med Care. 2011; 49: 599-604
        • Lobo E
        • Ventura T
        • Navio M
        • et al.
        Identification of components of health complexity on internal medicine units by means of the INTERMED method.
        Int J Clin Pract. 2015; 69: 1377-1386
        • Kroenke K
        • Unutzer J.
        Closing the false divide: sustainable approaches to integrating mental health services into primary care.
        J Gen Intern Med. 2017; 32: 404-410
        • Kroenke K
        • Cheville A.
        Canons of collaborative care.
        J Gen Intern Med. 2022; 37: 456-458
        • Herrman H
        • Patel V
        • Kieling C
        • et al.
        Time for united action on depression: a Lancet–World Psychiatric Association Commission.
        Lancet. 2022; 399: 957-1022
      2. Medicine in Psychiatry (MIPS) - strong recovery - mental health & wellness - University of Rochester Medical Center. Available at: Accessed June 9, 2022.

      3. Inpatient Medicine in Psychiatry (IMIP) Unit 19200 - adult services - mental health & wellness - University of Rochester Medical Center. Available at: 2022. Accessed June 9, 2022.

        • Wittink MN
        • Cross W
        • Goodman J
        • et al.
        Taking the long view in an inpatient medical unit: a person-centered, integrated team approach for patients with severe mental illnesses.
        Psychiatr Serv. 2020; 71: 885-892
      4. The Association of Medicine and Psychiatry Medical-Psychiatry Unit Consortium. Available at: Accessed June 9, 2022.

      5. Cartesian solutions. Available at: 2022. Accessed June 9, 2022.

        • Kathol RG
        • Butler M
        • Mcalpine D
        • et al.
        Barriers to physical and mental condition integrated service delivery.
        Psychosom Med. 2010; 72: 511-518
        • Kathol R
        • Kathol M.
        The need for biomedically and contextually sound care plans in complex patients.
        Ann Intern Med. 2009; 153: 2009-2011
        • Stuart S
        • Wright JH
        • Thase ME
        • et al.
        Cognitive therapy with inpatients.
        Gen Hosp Psychiatry. 1997; 19: 42-50
        • Nawaz RF
        • Reen G
        • Bloodworth N
        • et al.
        Interventions to reduce self-harm on in-patient wards: systematic review.
        BJPsych Open. 2021; 7: 1-9
        • Camp ME
        • Gagliardi J
        • Jacobson S
        • et al.
        Combined residency programs in psychiatry.
        Acad Psychiatry. 2021; 46: 369-374
      6. Accreditation Council for Graduate Medical Education (ACGME) Public. Available at: Accessed June 1, 2022.

        • Bogner H
        • Morales K
        • Post E
        • et al.
        Diabetes, depression and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT).
        Diabetes Care. 2007; 30: 3005-3010
        • Doebbeling CC
        • Pitkin AK
        • Malis R
        • et al.
        Combined internal medicine—psychiatry and family medicine—psychiatry training programs, 1999–2000 : program directors’ perspectives.
        Acad Med. 2001; 76: 1247-1252
        • Robbins-Welty GA.
        A scientific autobiography of an early career physician: at the intersection of geriatrics, psychiatry, palliative care and bluegrass banjo.
        Am J Geriatr Psychiatry. 2020; 28: 683-689
      7. National Resident Matching Program. Available at: 2022. Accessed June 16, 2022.

      8. American Board of Psychiatry and Neurology. Available at: Accessed June 16, 2022.

      9. American Board of Psychiatry and Neurology. Combined programs and alternative pathways. Available at: Accessed June 8, 2022.

        • Jain G
        • Dzara K
        • Gagliardi J
        • et al.
        Assessing the practices and perceptions of dually-trained physicians : a pilot study.
        Acad Psychiatry. 2012; 36: 71-73
        • Warner CH
        • Morganstein J
        • Rachal J
        • et al.
        Perceptions and practices of graduates of combined family medicine-psychiatry residency programs: a nationwide survey.
        Acad Psychiatry. 2007; 31: 297-303
        • McClellan C
        • Flottemesch TJ
        • Ali MM
        • et al.
        Behavioral health's integration within a care network and health care utilization.
        Health Serv Res. 2018; 53: 4543-4564
        • Bruce ML
        • Ten Have TR
        • Reynolds CF
        • et al.
        Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.
        JAMA. 2004; 291: 1081-1091
        • Gallo JJ
        • Morales KH
        • Bogner HR
        • et al.
        Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care.
        BMJ. 2013; 346: f2570