Collaborative Care for Mental Health: A Scalable, Team-Based Model for Primary Care

In the interview above, Matthew Press, MD, discusses the principles behind the collaborative care model, a proven and practical approach to integrating mental health services into primary care. As he explains, this team-based, measurement-driven model not only improves outcomes for patients with depression, anxiety, and other common mental health conditions, but also supports primary care clinicians by distributing care responsibilities. Dr Press outlines how the model works, who is involved, and how proactive monitoring and short-term treatment cycles can lead to remission for half of participants—all while extending the reach of limited psychiatric resources.

Dr Press is an associate professor of medicine in the division of general internal medicine in the department of medicine at Perelman School of Medicine at the University of Pennsylvania, in Wynnewood, PA.

The following transcript has been edited for clarity, style, and length.

Patient Care: Can you explain the core principles of the collaborative care model and how it differs from traditional models of mental health care?

Matthew Press, MD: Sure. The collaborative care model is a disease management approach that applies the same principles we use for chronic conditions like diabetes or hypertension to common mental health conditions such as depression, anxiety, and some substance use disorders.

There are a few key elements. First, it’s team-based care, which is one reason primary care clinicians tend to appreciate the model once it’s in place—it actually helps reduce their burden by bringing in additional support. The core team includes three members:

1. A behavioral health care manager—someone with mental health training who serves as the central coordinator of the model.
2. The primary care clinician.
3. A psychiatric consultant—typically a psychiatrist or psychiatric advanced practice provider—who doesn’t see patients directly but supports the team behind the scenes. They meet with the care manager weekly and are available to consult with the primary care clinician.

By doing this, we extend the reach of a scarce resource—psychiatrists—by having them provide expertise across a larger population instead of seeing individual patients directly.

The second principle is measurement-based care. In many settings, mental health treatment often proceeds without measuring symptoms, which is unlike how we manage other conditions. We would never treat diabetes without tracking blood sugar or hypertension without measuring blood pressure. Collaborative care requires regular measurement of symptoms at the start and throughout the treatment, so we can assess whether the treatment is effective and make adjustments as needed.

The third principle is to be proactive. In the traditional model, patients might receive a referral for mental health care and then we don't know what happens next. Collaborative care changes that. Patients are enrolled in a registry—this could be a simple Excel sheet or integrated into the electronic medical record. That registry tracks symptom scores and helps the care team follow each patient’s progress. The care manager regularly reviews these scores and coordinates adjustments when a patient isn’t improving, often with input from the psychiatric consultant.

This model is usually a short-term intervention, lasting around 3 to 4 months. By 6 months, if a patient hasn’t improved, they typically need to be referred to specialty mental health care. But in our experience—and in many health systems—about 50% of patients experience remission of depression or anxiety during their collaborative care episode.

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