Putting mental health tools in the hands of primary care physicians

Access psychopharmacology clinical support with The Waco Guide

By Zach Sartor, MD
May 15, 2023

We are living amid a mental health epidemic. One in five people experience mental illness yearly, and the volume of mental and behavioral health disorders will increase in the future as we fully recover from the COVID-19 pandemic.

Primary care is the de facto mental health system in the United States. Primary care clinicians serve most patients receiving treatment for mental illness, prescribing a majority of psychotropic medications in the process. However, two-thirds of family medicine physicians cannot connect their patients with essential mental health support services. Therefore, most behavioral health care services occur in the primary care office. Although the situation is dire, this challenge represents an opportunity to provide high-value mental health care in the primary care context. Family medicine can lead the way forward.

The Waco Family Medicine Residency faculty recognized the discrepancy between mental health needs and primary care’s capacity to manage this need. Therefore, we aimed to bring expert-level knowledge into the context of primary care, focusing specifically on integrating psychopharmacology guidelines into the fabric of clinical practice.

Putting evidence into action

To accomplish this goal, the Waco Family Medicine Residency faculty developed a robust library of clinical decision support tools for the psychopharmacologic treatment of routine and complex mental and behavioral health disorders. These tools complement clinical practice by providing busy primary care clinicians with the best available evidence to make effective treatment decisions at the point of care. Collectively, these tools have been curated in The Waco Guide to Psychopharmacology in Primary Care.

The Waco Family Medicine Residency faculty developed The Waco Guide in consultation with the Massachusetts General Hospital Psychiatry Academy using a pragmatic, consensus-building methodology. We prioritized developing tools for the mental and behavioral disorders most commonly seen in the primary care setting, including depressive disorders, anxiety and trauma-related disorders, bipolar disorder, substance use disorders, and psychotic disorders. We focused primarily on psychopharmacology for these disorders, with informed recommendations for evidence-based psychotherapy when indicated. Additionally, we developed alterations to these recommendations to account for critical comorbid medical conditions, such as kidney, liver, or heart disease. These changes — designated as special populations — ensure effective and safe treatment in an individualistic, patient-centered context.

The Waco Guide to Psychopharmacology

The product of this process is The Waco Guide to Psychopharmacology in Primary Care, or simply The Waco Guide. We believe all primary care clinicians should have equal access to The Waco Guide; therefore, it is available at no cost for clinicians and health care systems. The Guide is accessible online at wacoguide.org and includes more than 100 decision support tools for psychiatric and behavioral health diagnoses. You can also download the guide as an app for iOS, free of charge. We plan to have an app in the Google Play store later this summer.

Using the guide is easy and fast, explicitly tailored to the needs of busy primary care clinicians. Each decision support tool consists of an algorithm for clinicians to use during the medical decision-making process and a dosing guide fr practical and efficient prescribing. Notably, the algorithms account for behavioral health comorbidities or disease related symptomatology in the decision-making process. For example, the generalized anxiety disorder tool will guide the clinicians toward SSRI or SNRI prescribing rather than buspirone when a patient has comorbid depression. The dosing guide includes information on starting doses, side effects, titration schedules, and crucial monitoring parameters. The information is organized into an easy-to-follow format intended to empower clinician prescribing. The Waco Guide provides added value not just for the routine cases but for complex behavioral health disorders and conditions that have been refractory to prior treatment. The tools offer guidance on the second, third, sometimes even fourth step in treating a psychiatric disorder yet highlight the times when treatment of a given condition requires specialty support.

There is a crucial need for high-quality mental health care. Primary care clinicians are uniquely positioned to provide critical services for mental and behavioral health. The Waco Guide will empower clinicians to apply evidence-based psychopharmacologic treatment in their practices.

About Waco Family Medicine Residency

Waco Family Medicine Residency is one of the nation's premier family medicine training programs. Our unique culture cultivates compassionate care to the underserved, and our uncompromising rigor forms exemplary family physicians. We boast an award-winning integrated behavioral health program. Waco Family Medicine graduates practice nationally and globally in diverse settings, with a high proportion serving in health professional shortage areas.