In the second episode of "On Your Mind With Erin Crown," a conversational series from Psychiatric Times built around informal, off-the-cuff conversations among clinicians, host Erin Crown, MHS, PA-C, Psych-CAQ, spoke with Laura Melaro, DNP, APRN, FNP-BC, PMHNP-BC, a psychiatric nurse practitioner who practices integrated psychiatry and primary care in West Tennessee. The discussion centered on the current state of behavioral health integration and what still stands in the way of broader adoption.

Melaro, who became a family nurse practitioner (FNP) in 1988 after growing up in a family of primary care physicians, spent a decade in primary care before moving into community mental health and later earning her doctor of nursing practice (DNP) with psychiatric certification in 2008. She now works at a federally qualified health center (FQHC) that uses a collaborative care model, pairing a behavioral health case manager and primary care team with a psychiatric consultant. She said workforce shortages, not preference, drove that choice: her region has only one university training licensed clinical social workers, and few therapists are willing to work at the pace of primary care.

Both clinicians said cross-training across medicine and psychiatry improves care. Crown, who trained as a PA across the broader medical model, noted that physical conditions are sometimes mistaken for psychiatric symptoms, citing patients presenting with low mood and fatigue who instead have mononucleosis. Malaro said clinicians trained only in psychiatry can struggle to recognize physical illness, a gap she addressed while teaching integrated behavioral health courses at the University of Tennessee, where DNP psychiatric and FNP students worked through shared clinical scenarios.

Melaro also described her years in community mental health, where she continued monitoring patients' physical health, including metabolic effects of second-generation antipsychotics, despite being told to focus solely on psychiatric symptoms. 

"I really want the health of patients with severe mental illness to improve," she said, describing the persistent life-expectancy gap for this population as a personal priority.

Crown's practice takes a different approach, combining psychiatry, primary care, and obesity medicine in one setting. She said the model developed in response to data showing up to 80% of people with severe mental illness lack a primary care provider, along with the transportation and scheduling barriers that keep patients from attending separate appointments.

Asked to describe her ideal integrated care model, Melaro said she wants primary care clinicians to buy into treating behavioral health themselves, or at minimum to maintain active communication with a psychiatric partner rather than treating referrals as a one-way handoff. She emphasized that no single integration model works everywhere, given differences in local workforce and resources, from embedded-therapist models to the case-management approach she uses. "We have to recognize the benefit from it and make it work wherever you are," she said.

Crown closed the conversation by thanking Melaro for her contributions to the psychiatric and primary care community.

Erin Crown, MHS, PA-C, Psych-CAQ, in her first installment of "On Your Mind With Erin Crown," sits down with Psychiatric Times Editor in Chief, John J. Miller, MD. Miller identifies "tribalism in psychiatry" as the main topic on his mind, explaining that it has become a significant issue in various fields, including psychiatry. He compares current tribalism to sports rivalries and how it manifests in psychiatry, and is especially concerned about the increasing division and isolation within the field.

Tribalism can take several forms in psychiatry: including academia vs the pharmaceutical industry, different prescribing subspecialties, and the roles of various health care. Both Crown and Miller advocate for a more integrated and supportive system among all health care professionals to address the epidemic of untreated mental illness.

He believes this tribalism leads to a loss of important information and benefits for patients, colleagues, and the field as a whole. Miller recounts his early experiences with pharmaceutical industry collaborations and how they were integrated into academia and organizations like the National Institute of Mental Health. These collaborations help drive innovation and improve patient care. Both Crown and Miller reinforce the importance of continuous learning and innovation in psychiatry, noting the limited tools available when they started and the advancements made since then.

However, there are increasing administrative burdens for frontline prescribers, which reduce the time available for professional development and collaboration. Staying current with the latest scientific and clinical developments ensure clinicians can provide the best possible care for patients. The fragmentation of the psychiatric field makes this difficult; there is a strong need for better integration and collaboration among different stakeholders, including clinicians, academia, and pharma. 

The psychiatric field needs to work together more cohesively, Miller emphasized, sharing that we need a unified approach among psychiatrists, psychiatric nurse practitioners, and physician assistants to address the mental health crisis effectively. The entire conversation underscores the importance of continuous learning and collaboration in psychiatry.

What psychiatric topic is on your mind? Let us know at PTEditor@mmhgroup.com!