A Multifaceted Outpatient Treatment Model for Mood and Anxiety Disorders Designed to Optimize Both Treatment Outcomes and Access to Care

Abstract

Despite the availability of evidence-based psychosocial and pharmacologic interventions for mental health concerns, access to care remains suboptimal. We present a time-efficient mental health treatment program designed to improve overall community access to evidence-based care. Quality of care within the time-efficient model was prioritized by focusing on a multifaceted program of evidence-based interventions and facilitating connections to long-term care when needed. We present the results of a proof-of-concept open trial that indicates that access to care can be improved while maintaining quality mental health services. The Time-Efficient, Evidence-Based, Accessible, Multidisciplinary approach includes time-limited care provided by a team of psychotherapists, psychiatrists, nurse practitioners, and case managers working in pods, supported by measurement-based care, to develop individualized treatment plans. We used data from the electronic health record to evaluate (a) access to care, (b) engagement, and (c) treatment outcomes for an initial sample of 1,726 patients. Patients waited on average 17 days to see a therapist and 20 days to see a psychopharmacologist. Patients received on average 10 sessions of psychotherapy and four medication management sessions. Fifty-seven percent remained in treatment for at least 3 months. Patients demonstrated large improvements in depression (d = 1.18) and anxiety (d = 1.20) with small to moderate effects for improvements in functioning (d = 0.40). By capitalizing on a package of evidence-based interventions delivered with equitable time limits, the Time-Efficient, Evidence-Based, Accessible, Multidisciplinary clinic demonstrates initial access while yielding good engagement in services and moderate to large treatment effects.

Great strides have been made over the last 40 years in identifying effective psychotherapeutic, pharmacological, and measurement-based care interventions for mental health disorders. Furthermore, there is now a focus in the research literature on how best to disseminate and implement these evidence-based interventions in naturalistic treatment settings (Proctor et al., 2009). Many studies currently focus on training clinicians in evidence-based approaches and adapting interventions to meet the needs of unique settings to ensure that evidence-based practices are sustained in community settings (see review by Frank et al., 2020).

Unfortunately, even when evidence-based interventions are being used, many individuals seeking mental health services are unable to access them when they need it. One major barrier to care is the long wait times for services that have been documented in the literature for decades (Sturm & Sherbourne, 2001). A recent large-scale survey of practicing psychologists revealed that more than half of practitioners had no openings, and the average wait time for treatment was over 3 months (American Psychological Association, 2023). Similarly, the majority of psychiatrists do not have immediate openings in their caseloads, with wait times for a first session averaging months (Malowney et al., 2015; Sun et al., 2023). This means that many individuals who seek mental health treatment are not receiving the care they need during acute episodes for a substantial period of time. There is now strong evidence that longer wait times for mental health services are associated with symptom exacerbation (Cuijpers et al., 2021), poor engagement in services once available (Krendl & Lorenzo-Luaces, 2022; Reitzel et al., 2006; Swift et al., 2012), and an increase in psychiatric hospitalizations (Williams et al., 2008).

Multiple potential solutions have been proposed to address the long wait times for mental health services. The availability of group therapy has been offered as one solution (Whittingham et al., 2023) that could result in efficient and effective care. Another proposed solution is to offer individuals on a waitlist a low-intensity intervention, such as a single-session intervention, to minimize clinical worsening (Peipert et al., 2022; Sung et al., 2023). Multiple approaches may be needed for different settings to address the intractable problem of poor access to services. Another option for improving access to care while also optimizing outcomes is to implement a multifaceted package of evidence-based interventions using time limits. Most evidence-based psychotherapies have been established in research studies implementing time limits. However, outpatient psychotherapy practice is often open-ended, allowing patients to continue in services as long as they, their clinicians, and their insurance agree. This open-ended treatment model creates an intractable problem for outpatient clinics, namely that experienced clinicians spend the majority of their time with patients who need, choose, or can afford longer term treatments at the expense of the majority of patients who have more episodic disorders requiring shorter treatment durations (P. Cohen & Cohen, 1984; Vessey et al., 1994). With their practice mostly full with “long-term” patients, clinicians over time believe that long-term treatment is the norm. This has been termed the “clinician’s illusion” (P. Cohen & Cohen, 1984), with research demonstrating that although novice therapists have caseloads representative of the population of people seeking psychotherapy services—that is, comprised mostly of shorter term cases—experienced clinicians will have caseloads comprised mostly of longer term cases as short-term cases turn over and are slowly replaced by the minority of patients in long-term care (Vessey et al., 1994).

Since clinics cannot feasibly expand their clinician pool indefinitely, long waitlists for services have become the unfortunate standard of care. This raises a serious ethical consideration for all outpatient clinics: Should they prioritize the minority of patients in long-term care over the majority of patients with more episodic illnesses who may deteriorate while on long waitlists for services? Setting treatment time limits has been a controversial issue. De Geest and Meganck (2019) pointed out that time limits exert a pressure on the therapeutic process that can have both positive and negative consequences. On one hand, brief treatments were first developed to motivate patients and accelerate the therapeutic process (e.g., Malan, 1976; Mann, 1973; Sifneos, 1979). Several studies had shown that clients prefer time-limited treatment (Johnson & Gelso, 1981) and demonstrated lower dropout in time-limited care (Messer, 2001; Sledge et al., 1990). On the other hand, practicing psychologists are currently reporting a significant increase in severity of symptoms and higher comorbidity among their patients (American Psychological Association, 2023). Clinicians may feel that time-limited treatment is more superficial (J. Cohen et al., 2006; Wright et al., 2012) and not appropriate for those increasingly more complex cases.

One solution for general outpatient clinic settings is to offer time-limited, evidence-based interventions for all patients seeking treatment to allow equitable initial access to care, while also being sensitive to facilitating subsequent access to care for those in need of longer term treatment. While improving access to services is a priority, it is also important to optimize treatment quality in terms of both engagement in services and treatment outcomes in this time-limited context. To optimize treatment quality in time-limited care, multifaceted intervention packages comprised of the broad range of evidence-based intervention options currently available may optimize both access to care and outcomes.

To address the problem of access to mental health services, we brought together a team of psychotherapists, psychopharmacologists (psychiatrists and psychiatric nurse practitioners), clinic supervisors, clinic administrators, and treatment researchers to build a multifaceted outpatient treatment approach that is efficient, evidence-based, and feasible in naturalistic settings. The Time-Efficient, Evidence-Based, Accessible, Multidisciplinary (TEAM) approach builds on both the treatment effectiveness and implementation literatures by focusing on time-limited, evidence-based psychotherapies, pharmacotherapy, collaborative care, and measurement-based care, delivered by a multidisciplinary team of psychotherapists, psychiatrists, nurse practitioners, and case managers working together in pods to develop individualized treatment plans.

In constructing the TEAM approach, consideration was given to the diverse strategies that many clinical settings have implemented to improve access to quality mental health services, including training clinicians in evidence-based psychotherapies, instituting measurement-based care, and exploring time-limited treatment options. The TEAM approach was carefully designed to balance the potential limitations of time-limited care by including both a multifaceted treatment approach based on the best available evidence and a focus on facilitating connection to longer term treatment options when needed. The goal of the approach is to provide equitable initial access to mental health services to the community, high-quality multifaceted treatment to optimize outcomes for individuals suffering from episodic problems that can benefit from the time-efficient care, and a high-quality treatment program that can help stabilize individuals who may need longer term treatments while facilitating access to specialty care.

The TEAM approach assumes that both psychotherapy and medication are important treatment options for this time-efficient approach. A recent meta-analysis of 153 trials of combined psychotherapy and pharmacotherapy demonstrated significantly better functioning and quality of life outcomes for combined treatment compared to monotherapy (Kamenov et al., 2017). Craighead and Dunlop (2014) suggested three potential mechanisms that lead to improved outcomes for combined treatments: (a) the treatments are additive with some patients responding to each treatment, (b) pharmacotherapy and psychotherapy can be synergistic allowing both modalities to achieve optimal results that could not be obtained with the monotherapy, and (c) each modality maximizes adherence across both modalities. However, potential disadvantages to combined pharmacotherapy and psychotherapy have been noted. It is possible that the treatments may interfere with each other (Rounsaville et al., 1981). For example, a patient responding quickly to medication may be less motivated to fully engage in the work of psychotherapy. In addition, there may be context learning effects (Barlow et al., 2000), in which skills learned while symptoms are reduced due to effective pharmacotherapy may not be fully accessible when symptoms are high (Bouton et al., 2006). Finally, patient preferences for treatments may influence treatment outcomes. Patients who receive nonpreferred treatments have demonstrated significantly longer treatment durations (Crits-Christoph et al., 2017). The TEAM model was built taking into account the flexibility needed to meet the needs of the broad patient population. While multidisciplinary care is prioritized, care also balances the needs and treatment preferences of individual patients.

The TEAM model has now been implemented in a large general outpatient clinic at an urban university medical center. We present a detailed description of the components of the TEAM model with the considerations that went into the development of each component as well as the results of a naturalistic open pilot trial evaluating: (a) access to care, (b) engagement in services, and (c) the effectiveness of the TEAM approach in terms of both symptom reduction and improved functioning.

Method

Overview

We conducted a retrospective evaluation of access to care, engagement in services, and treatment effectiveness indicators using de-identified data extracted from the TEAM clinic’s electronic health record (EHR). The University of Pennsylvania Institutional Review Board No. 7 deemed this component of our investigation exempt and waived informed consent because data were de-identified and provided to the investigative team via secure transfer.

The TEAM Model Components

Time-Efficient

The treatment package is offered to patients for 3 months with the multidisciplinary team, with the option of extending to 4 months if needed. Although time-limited treatment is prioritized in order to optimize clinic access, the time frame has some flexibility to address the individual needs of patients. Clinical teams work together with the clinic director to evaluate whether treatment should be extended an additional month to provide support, while the patient is transitioning to a longer term treatment option. For example, the clinical team and patient together may identify earlier in care that longer term treatment for trauma-related symptoms is warranted and may facilitate getting the patient on the waitlist for specialty care services. The clinical team may decide that the patient’s safety warrants an additional month of services to stabilize the patient while waiting for the first session of specialty care. To maintain accessibility to care, provision of an additional month of services to an individual patient is based on the clinical decision of the clinical team in conjunction with the clinical director to ensure patient safety.

To optimize engagement and outcome in this time-limited care, treatment is informed by evidence-based psychotherapy approaches. Clinicians are offered training workshops and expert consultation in a variety of short-term evidence-based psychotherapeutic approaches, all including a strong socialization component. The psychotherapy socialization component builds on the socialization interviews first described by Luborsky (1984) and Book (1998) and is adapted for each evidence-based psychotherapeutic approach included in the clinic. The socialization is provided across Sessions 1 and 2 and includes the following: (a) introducing the patient to the components of the TEAM model, (b) specifying the time limits while also explaining that the dyad can explore and facilitate longer term care needs, (c) presenting the rationale for the specific evidence-based therapeutic model, (d) exploring a focused short-term goal for the treatment while also acknowledging longer term goals, (e) detailing the patients’ and therapists’ roles in the treatment process, and (f) encouraging a positive attitude toward change.

Goal setting is considered a central component of the model. Clinicians work with each patient to set specific short-term goals that can be targeted in this time-limited setting. From the start, the clinical team explores any potential needs for longer term care and, when needed, facilitates getting the patient on waitlists for specialty services. In addition, the option of transition to treatment with a primary care physician, local psychiatrist, or psychiatric nurse practitioner following the time-limited care is facilitated for individuals who require continued medication management beyond the proposed timeframe.

Evidence-Based

To optimize short-term outcomes, we designed a multifaceted treatment package including evidence-based psychotherapies, pharmacotherapy, and measurement-based care. Psychotherapy is provided by licensed master’s-level psychotherapists. Psychotherapists hired to work in this setting all have prior education in evidence-based psychotherapeutic models and supervised experience during training. Craighead and Dunlop (2014) pointed out that dissemination of evidence-based psychotherapies is still limited, with some clinicians practicing these interventions without formal training. To enhance the focus on evidence-based psychotherapies, all therapists have the opportunity to participate in training workshops on a variety of evidence-based approaches for mood, anxiety, and trauma-related disorders, including behavioral activation (Martell et al., 2001), cognitive approaches for depression and anxiety (Barlow et al., 2010; Beck, 1979; Clark & Beck, 2011), short-term relationship focused approaches (Connolly Gibbons et al., 2016; Luborsky, 1984), prolonged exposure therapy for post-traumatic stress disorder (Foa et al., 2019; Hembree et al., 2003), cognitive processing therapy for post-traumatic stress disorder (Resick et al., 2016), exposure and response prevention for obsessive–compulsive disorder (Meyer, 1966; Whittal et al., 2005), and general exposure therapy for anxiety disorders (Abramowitz et al., 2019; Craske et al., 2014). In the naturalistic setting, there is no formal assessment of fidelity to evidence-based psychotherapies. Therapists do, however, receive weekly group consultation with licensed clinical psychologists to help clinicians maintain a focus on evidence-based techniques within their practice. The consultation focuses on clinician presentation of cases and consultation to maintain a focus on the evidence-based techniques. The expert consultants can offer individual consultation and additional training materials to clinicians as needed to improve the focus on evidence-based approaches. The goal is to ensure that all therapists are experienced in a variety of evidence-based techniques to address the wide range of patient presenting problems. Psychotherapists are not required to use all evidence-based approaches in their practice and will work with the clinic director to explore their unique training needs. Therapists will further work with the expert consultant to select specific approaches to meet each patient’s needs, taking into account diagnosis, previous treatments, and patient preference.

The option of combined psychotherapy and pharmacotherapy is important for optimizing outcomes in this time-limited approach and is offered and encouraged for all patients seeking treatment at this clinic. All patients are scheduled with a psychopharmacologist (psychiatrist or psychiatric nurse practitioner) for an initial medication evaluation and to identify any nonpsychiatric conditions that may contribute to symptom presentation or limit treatment response (e.g., thyroid disease, obstructive sleep apnea). Although combined medication management plus psychotherapy is recommended for many patients, final decisions regarding combined treatment versus continuation in monotherapy are made by the treatment team taking patient preferences into account. For cases where medication is prescribed, patients are then scheduled for monthly visits regularly with the psychopharmacologist throughout the 3–4 months of treatment. All pharmacotherapy follows the clinical practice guidelines of the American Psychiatric Association (2024). Nurse practitioners have the opportunity to consult with psychiatrists to ensure evidence-based state of the art pharmacotherapy. The goal is to stabilize the patient using pharmacotherapy and then assist the patient in setting up continued medication management when needed through a primary care, community mental health, or specialty provider following the time-limited care. If necessary, the patient continues with medication management alone in the clinic.

Treatment outcomes are further optimized in the TEAMs approach through a focus on measurement-based care. Monitoring outcomes through patient self-report and feeding back data to clinicians to inform treatment is a low-cost intervention that improves treatment outcomes (Barkham et al., 2023). At treatment intake, all patients complete brief assessments of depression, anxiety, functioning, attention deficits and hyperactivity, mania, trauma history, insomnia, and medication history asynchronously with results automatically captured in the EHR. Assessments are automatically sent to patients via an email link 24 hr prior to their first visit at the clinic. Results of the assessments are automatically populated on a dashboard within the EHR and become available to all members of the treatment team prior to the session. Additional optional measures of substance use and suicide risk are available within the EHR for clinician administration in session. The intake dashboard is used by the treatment team to assist with initial diagnosis and the development of individualized treatment plans. In addition, measures of depression, anxiety, functioning, and any optional measures selected by the treatment team are automatically sent to patients monthly throughout treatment 24 hr prior to their scheduled sessions at the clinic. Results are automatically populated in the EHR dashboard including assessment scores, interpretation of scores, and trends over time to support the clinical team in tracking progress and identifying patients who may be in need of treatment adjustments. Finally, the measurement-based care results are used by the treatment team to identify and support patients who might need continued treatment beyond the time-limited treatment. The measurement-based care assessments can also be administered electronically on clinic devices when the patient arrives for a session to address the needs of patients without access to electronic devices and to capture assessments for those who failed to complete the pushed assessments. Once measures are completed in the office, the dashboards are automatically generated so that the treatment team has access during the visits.

Accessible

Accessibility of services is a priority for the TEAM model in terms of enrolling individuals in care initially when they are in need, engaging patients in the treatment process, and facilitating transition to longer term services for those who require long-term care. All patients seeking psychiatry services in the health system call a central call center where they are briefly screened and triaged. The TEAM clinic is considered the entry point for general outpatient services and replaces our previous model that offered open-ended treatment to all patients. Patients in need of specific services such as substance use treatments and untreated psychosis are referred by the call center to subspecialty care with the remainder offered care at the TEAM clinic. The elements of the TEAM model including time limits, multidisciplinary care, and need for regular assessments are described to patients by the call center. Patients may select to not pursue treatment at the TEAM clinic and instead be placed on a waitlist for a specialty care center. Patients who accept referral to the TEAM clinic are scheduled by the screener for an intake at the TEAM clinic, usually within 2–3 weeks. In our previous model, patients interested in care were immediately places on a waitlist and contacted months later, when there was an opening for an intake for open-ended mental health services. By limiting time in the TEAM clinic, waitlists for services are kept to a minimum.

Recognizing that time limits may not be optimal for all patients entering services at the TEAM clinic, the need for longer term services are evaluated by providers from intake session. By working with patients from the start to identify both short-term and longer term goals, clinicians are able to focus on short-term goals with patients while working collaboratively with the patient to customize treatment pathways and facilitate patients proactively getting on waitlists for specialty services if needed. The focus on measurement-based care also allows the TEAM clinicians to identify patients who are not responding optimally to treatment and develop an individualized longer term care plan for the patient.

Multidisciplinary

Although many patients may receive both psychotherapy and medication management in the community, these treatments are rarely highly coordinated in these settings. Collaborative care models that involve psychiatrists, psychotherapists, and other medical doctors are designed to optimize communication and collaboration among multidisciplinary teams, yet these models have been evaluated mostly in primary care settings and specialty medical centers focused on patients with comorbidities (Woltmann et al., 2012). We propose that bringing together and fostering collaboration within multidisciplinary teams in general outpatient psychiatry settings is central to optimizing outcomes especially in time-efficient care. To foster collaboration in our clinic, small groups of psychotherapists, nurse practitioners, psychiatrists, and case managers work together in “pods” to provide coordinated care to a panel of patients. All members of the treatment pod have access to the measurement-based care dashboard and meet together in daily huddles to review the dashboards and plan services.

All patients meet with both a therapist and pharmacotherapist at intake to evaluate patient needs and explore patient preferences. Although combined treatments are offered to most patients to optimize outcomes in this time-efficient care, the model includes flexibility to allow treatments to be adapted to unique patient needs and preferences. Although some patients may select or be referred for only medication management or psychotherapy, the clinicians working within the pods have access to the multidisciplinary team for consult as patients’ needs may change across treatment.

Participants

Patients

The participants in the nonrandomized trial included all patients who engaged in services in the TEAM clinic by attending a new patient visit and completing at least one intake assessment (N = 1,726). Demographic details are presented in Table 1. The majority of patients identified as female (n = 1,057; 63.6%), White (n = 1,143; 66.2%), and non-Hispanic (n = 1,690; 97.9%). The average age of the sample was 38.42 (SD = 15.37) years. The most common diagnoses included major depressive disorder (n = 710; 41.1%) and generalized anxiety disorder (n = 645; 37.4%). More detailed diagnostic information is presented in Table 2.

Table 1.

Patient Demographic Data at the TEAM Clinic

Characteristic	N available	Summary statistic
Sex at birth, n (%)	1,449
Male		494 (34.1)
Female		955 (65.9)
Gender identity, n (%)	1,661
Male		547 (32.9)
Female		1,057 (63.6)
Nonbinary		47 (2.8)
Transgender		10 (0.6)
Age, M (SD)	1,726	38.42 (15.37)
Race, n (%)	1,726
American Indian or Alaska Native		22 (1.3)
Asian		143 (8.3)
Black or African American		296 (17.1)
Native Hawaiian or other Pacific Islander		6 (0.3)
White		1,143 (66.2)
Other		83 (4.8)
I do not wish to answer		52 (3.0)
Hispanic, n (%)	1,726
Yes		36 (2.1)
No		1,690 (97.9)
Treatment type, n (%)	1,726
Medication management only		356 (20.6)
Psychotherapy only		608 (35.2)
Medication management and psychotherapy		762 (44.1)

Note. Total N = 1,726. TEAM = Time-Efficient, Evidence-Based, Accessible, Multidisciplinary.

Table 2.

Patient Diagnosis Data at the TEAM Clinic

Diagnosis	n (%)
Major depressive disorder	710 (41.1)
Bipolar disorder	106 (6.1)
Generalized anxiety disorder	645 (37.4)
Panic disorder	48 (2.8)
Posttraumatic stress disorder	184 (10.7)
Obsessive compulsive disorder	100 (5.8)
Attention-deficit/hyperactivity disorder	147 (8.5)
Substance use disorder	22 (1.3)
Schizophrenia spectrum disorder	7 (0.4)
Adjustment disorder	81 (4.7)
Borderline personality disorder	18 (1.0)
Autism spectrum disorder	5 (0.3)
Prolonged grief disorder	14 (0.8)
Social anxiety disorder	58 (3.4)

Note. Total N = 1,726. The diagnoses include all diagnoses given (i.e., not only primary diagnoses). TEAM = Time-Efficient, Evidence-Based, Accessible, Multidisciplinary.

Providers

The treatment providers for the open trial included psychotherapists, psychiatric nurse practitioners, psychiatrists, and case managers employed by the TEAM clinic. Nine therapists provided treatment for this sample. All psychotherapists were employed full time at the TEAM clinic and were expected to carry a caseload including 40 cases receiving 45-min sessions per week, allowing 2 hr per day for administrative responsibilities, supervision, and huddles with other providers. Therapists were predominantly female (n = 7, 77.8%), White (n = 8, 88.9%), and non-Hispanic (n = 9, 100%). One therapist (11.1%) was Black. Eight therapists (88.9%) were licensed clinical social workers, and one therapist (11.1%) was a licensed professional counselor. Therapists were on average 34.34 (SD = 9.61) years old with 8.33 (SD = 8.00) years of postgraduate clinical experience. Therapists treated between 92 and 220 patients in the current sample (M = 159.67, SD = 37.95) across a 2-year period. Seven psychopharmacologists provided medication management to this sample, including four nurse practitioners (57.1%) and three (42.9%) psychiatrists. Psychopharmacologists were predominantly male (n = 4, 57.1%). Five psychopharmacologists were White (71.4%), one was Asian (14.3%), one was Black/African American (14.3%), and six were not Hispanic (85.7%). Pharmacotherapists were on average 31.60 (SD = 9.09) years old and had on average 8.33 (SD = 6.80) years of postgraduate clinical experience.

Measures

All outcome assessments were administered and captured automatically by the measurement-based care intervention used for all patients receiving services in the TEAM clinic. Indicators of access to care and engagement in service were extracted from the EHR.

Access to Care

Access to care indicators included: (a) the number of days between the initial patient call and the intake appointment with the therapist and (b) the number of days between the initial patient call and the intake with the medication management specialist (i.e., a psychiatric nurse practitioner or psychiatrist).

Engagement in Services

Engagement was operationalized as (a) initial engagement in services following the intake appointment, (b) the number of sessions of therapy and medication management completed, (c) the percentage of patients retained in the full 12 weeks of care, and (d) the percentage of patients retained in a minimally adequate dose of 8 weeks of services.

Treatment Outcome

Outcome was assessed via (a) the Patient Health Questionnaire–9 (PHQ-9), a nine-item self-report questionnaire developed to capture depression severity as defined by the Diagnostic and Statistical Manual of Mental Disorders-IV (Kroenke et al., 2001); (b) the Generalized Anxiety Disorder–7 (GAD-7), a seven-item self-report brief measure used to assess generalized anxiety disorder symptomatology (Spitzer et al., 2006); and (c) the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Form V2.0 Satisfaction with Social Roles and Activities–8a (PROMIS), a brief eight-item self-report of an individual’s satisfaction with their usual roles and activities (Bode et al., 2010; Hahn et al., 2010).

Data Analysis

Descriptive statistics were used to report on engagement and retention in treatment. The primary outcomes for evaluating improvement across services in the TEAM clinic included the PHQ-9, GAD-7, and PROMIS. Analyses include all patients with at least one postbaseline assessment. Analyses of change on the PHQ-9 total score included the subsample of patients who began treatment with moderate symptoms of depression (defined as a baseline PHQ-9 score of ≥10). Similarly, analyses of change on the GAD-7 total score included a subsample of patients who began treatment with moderate symptoms of anxiety (defined as a baseline GAD-7 score ≥10). Evaluation of change in level of function as measured by the PROMIS was conducted using the full sample of patients entering treatment at the TEAM clinic. We evaluated improvement across services using two-level hierarchical linear models including all available baseline and monthly assessments nested within patient. Each model was computed assuming both a random intercept and random slope. Time was operationalized as the log of the number of months from baseline. Baseline outcome scores were included as covariates in each model. Within group effect sizes were computed by comparing the baseline and last observation carried forward values accounting for the intra-individual correlation between measurements.

Our analyses did not include provider as a nesting variable for multiple reasons. First, treatment was not provided by a single provider that could be included in the analytic model. Rather treatment was provided by multidisciplinary teams that included therapists, psychopharmacologists, and case managers. Second, analyses including only therapist as a nesting variable would exclude the patients in our sample who did not participate in psychotherapy, and our goal was to provide an estimate of outcomes across the full population of patients receiving services at the TEAM clinic. To evaluate the accuracy of variance estimates in the two-level models, we did conduct three-level hierarchical models including therapist as a nesting variable for just the subset of patients who participated in psychotherapy. Analyses of three-level hierarchical models including patients nested within therapists failed to converge and estimated variance components for therapist going to zero. These results indicate uncertainty in estimating variance due to therapist but suggest that therapist as a nesting variable provided negligible contribution to the total variance. For estimation of the effects of treatment on symptoms and functioning, there was no appreciable loss of model fit with the simplified two-level model.

To evaluate treatment outcomes, we used response and remission rates. Response rates were defined as a 50% or greater reduction on the PHQ-9 and a 50% or greater reduction on the GAD-7. Remission of depression was defined as obtaining a score on the PHQ-9 ≤ 5. Remission of anxiety was defined as obtaining a score on the GAD-7 ≤ 5.

Results

Access to Care

Our sample included 1,726 patients who had intake sessions with a therapist and/or a psychopharmacologist. Results for access to care and engagement in service indicators are summarized in Table 3. Patients waited on average 17.45 (SD = 13.55) days from the time they contacted the psychiatry call center until their intake appointment with a therapist and 19.80 (SD = 13.11) days for an intake with a psychopharmacologist. Although we did not have access to specific reasons some patients waited longer than average, review of results with clinic administration indicated that cases who waited longer than average were predominantly driven by patient schedule restrictions and session rescheduling by the patient.

Table 3.

Access to Care and Engagement in TEAM Services

Access and engagement indicator	Summary statistic
Access to care
Wait time for therapist in days, M (SD)	17.45 (13.55)
Wait time for psychopharmacologist in days, M (SD)	19.80 (13.11)
Engagement in services
Initial dropout after intake, n (%)	203 (11.8)
Total number of sessions with therapist, M (SD)	9.68 (7.16)
Number of medication management sessions, M (SD)	4.01 (2.81)
Retention 12 weeks of care, n (%)	976 (56.5)
Retention 8 weeks of care, n (%)	1,122 (65.0)

Note. N = 1,726. TEAM = Time-Efficient, Evidence-Based, Accessible, Multidisciplinary.

Engagement in Service

Of patients who completed an initial intake session with a therapist and/or psychopharmacologist, 203 (11.8%) did not continue with psychotherapy or medication management in the TEAM clinic. Patients who had an intake session with a therapist attended on average 9.68 (SD = 7.16, Mdn = 8.00) total sessions with the therapist including both the initial intake session and subsequent therapy sessions. Patients who had an intake session with a psychopharmacologist attended on average 4.01 (SD = 2.81, Mdn = 3.00) total sessions with the psychopharmacologist including both the intake session and the subsequent medication management sessions. Of patients who had an initial intake session with a therapist and/or a psychopharmacologist, 976 (56.5%) completed at least 12 weeks of treatment, and 1,122 (65.0%) completely a minimally adequate dose of treatment defined here as at least 8 weeks of services.

Change in Symptoms and Functioning

Descriptive statistics for outcome assessments by month are presented in Table 4. Six hundred sixty-seven patients (39%) started treatment in the TEAM clinic with moderate levels of depression and had at least one postbaseline assessment of the PHQ-9. For these patients, there was statistically significant log-linear improvement on the PHQ-9, F(1, 1,274.27) = 225.32, p < .001, d = 1.18, across time-limited treatment. Forty-seven percent of patients entering treatment with moderate depression responded (greater or equal to 50% improvement) to treatment and 29.8% achieved remission. Six hundred seven patients (35%) started treatment with moderate levels of anxiety and had at least one postbaseline assessment on the GAD-7. For these patients, there was statistically significant log-linear improvement on the GAD-7, F(1, 2,139.16) = 129.86, p < .001, d = 1.20. Fifty percent of patients demonstrated a clinical response (greater or equal to 50% improvement), and 35.1% achieved remission of anxiety symptoms. For all patients starting treatment at the TEAM clinic, there was statistically significant log-linear improvement in functioning as measured by the PROMIS, F(1, 1,936.03) = 183.54, p < .001, d = .40. These results represent medium to large effects for improvement in symptoms and small to medium effects for improvement in functioning across time-limited care.

Table 4.

Descriptive Statistics for All Outcome Assessments by Time

Assessment	Baseline	Month 1	Month 2	Month 3	Month 4	Month 5	LOCF
PHQ-9
M (SD)	15.79 (4.14)	11.22 (5.33)	9.90 (5.55)	8.64 (5.24)	7.88 (5.14)	9.03 (5.39)	9.08 (5.59)
n	667	526	428	356	294	146	667
GAD-7
M (SD)	14.95 (3.42)	10.03 (5.12)	9.01 (5.23)	7.73 (4.80)	7.08 (4.91)	8.42 (5.06)	8.29 (5.32)
n	607	472	398	331	272	134	607
PROMIS
M (SD)	22.91 (7.71)	23.59 (8.09)	25.00 (7.96)	25.84 (7.58)	26.85 (7.85)	25.81 (8.18)	25.87 (8.10)
n	1,020	778	656	540	442	216	1,020

Note. Only patients who began treatment with moderate symptoms of depression (i.e., a score ≥10 on the PHQ-9 at baseline) were included in analyses of change on the PHQ-9 total score. Similarly, only patients who began treatment with moderate symptoms of anxiety (i.e., a score ≥10 on the GAD-7 at baseline) were included in analyses of change on the GAD-7 total score. The full sample of patients entering treatment was used in analyzing change in PROMIS scores. LOCF = Last Observation Carried Forward; PHQ-9 = Patient Health Questionnaire–9; GAD-7 = Generalized Anxiety Disorder–7; PROMIS = Patient-Reported Outcomes Measurement Information System.

Discussion

The TEAM approach to mental health care in an outpatient clinic offers an alternative to long waitlists that result in many patients deteriorating while waiting for much needed services. By providing time-limited, multidisciplinary assessment and treatment comprised of evidence-based interventions, the model allows all patients to receive timely care that is designed to optimize both initial access to care and treatment outcomes. Patients seeking services for primarily mood and anxiety disorders were able to get a first appointment within 17–20 days of their initial phone call. With time limits discussed from the start of treatment, the clinic is able to offer first sessions within 2–3 weeks, with longer wait times often driven by patient preference or a patient’s need to reschedule appointments.

Our results for wait times for services compare favorably with documented wait times for typical outpatient services. First, our previous general outpatient clinic where time limits were not restricted consistently had a waitlist for the initial intake session of at least 3 months and often longer. Second, our wait times of 17–20 days on average is a vast improvement over the 3+ months patients typically wait to see a therapist (American Psychological Association, 2023) or psychiatrist (Malowney et al., 2015; Sun et al., 2023). Within only weeks, patients are able to engage in effective evidence-based services compared to the alternative of waiting months on a waitlist, while their symptoms may deteriorate. Finally, our results are consistent with the stochastic modeling presented by Vessey et al. (1994) demonstrating the clinician’s illusion. In this demonstration, Vessey and colleagues modeled a general outpatient clinic where the typical patient case mix includes 19% long-term cases. Although initial therapist caseloads would include 19% long-term cases, after 1 year, as longer term cases hold appointment times, 50% of cases would be long-term cases, and eventually, only 4% of treatment slots would be available weekly for new cases. In contrast, they modeled the caseload for a brief therapy clinic that included only 1% longer term cases. After 1 year, therapists would have a case mix including 11% long-term cases, and once the clinic matures, 12% of treatment slots will be available for new cases each week. In our case, by limiting treatment to 3–4 months, our clinic maintained adequate weekly open slots to allow patients to wait on average only 2 weeks for services across 2 years.

Our results for engagement in services using this time-limited multidisciplinary approach also compare favorably with previously reported engagement in care in outpatient services. Although no perfect comparisons exist for this naturalistic sample, we explored the literature for benchmarks to understand the engagement results obtained for this initial sample receiving care in the TEAM clinic. Early attrition from services following an initial intake session has been an intractable problem for mental health services. A review of attrition in psychotherapy efficacy studies reports that between 25% and 40% of patients who complete an intake session refuse further psychotherapy care (Garfield, 1994). A more recent effectiveness study of evidence-based psychotherapies delivered in the community mental health settings report early attrition rates of 27% (Connolly Gibbons et al., 2019). In routine care, one study reported that 33% of patients receive only an initial psychotherapy session and fail to return for further psychotherapy (Hansen et al., 2002). An evaluation of nationally representative sample individuals who received mental health treatment in the past year reported that 22% of patients reported discontinuing treatment early. Seventy percent of these patients, who dropped out prematurely, did so after only one or two sessions. In contrast, only 12% of patients receiving care in the TEAM clinic discontinued treatment after the initial intake appointment when offered time-limited, multidisciplinary care.

Number of treatment sessions completed is also an important indicator of engagement in services. Counting both the initial intake session and all return appointments, patients receiving services in the TEAM clinic attended a median of eight sessions with therapists and three sessions with psychopharmacologists. Potential benchmarks in the literature for the number of psychotherapy sessions attended range from a median of five psychotherapy sessions in community mental health settings (Connolly Gibbons et al., 2011, 2016), to a median of four psychotherapy sessions in a naturalistic sample of patients in routine care at a university counseling center (Hansen et al., 2002), to a median of seven psychotherapy sessions self-reported by patients completing a nationally representative household survey (Olfson et al., 2009). Olfson et al.’s (2009) national survey further indicated that patients report attending a median of three sessions with psychiatrists. It should be noted that Olfson et al.’s (2009) study included patients receiving care in private practice who might vary in terms of demographics and diagnoses from the current sample. Our results indicate that session attendance at the TEAM clinic exceeded what has been reported in community mental health settings and routine care at university counseling settings and at least as good as what has been self-reported by patients responding to a national survey.

Finally, our retention in treatment results compare favorably with the published literature. Fifty-seven percent of patients in the TEAM clinic stayed in treatment for the 12 weeks offered, and 65% completed what we would consider a minimally adequate dose of 8 weeks of mental health services. In comparison, an effectiveness study of evidence-based psychotherapies delivered in community mental health settings demonstrated that only 21% of patients were retained in treatment for 12 sessions (Connolly Gibbons et al., 2019). In another evaluation of psychiatric services, only 27% of patients engaged in psychotherapy and 23% of patients receiving care with a psychiatrist self-report completing their treatment (Olfson et al., 2009). Our engagement results indicating low initial dropout from services, good session attendance relative to routine care, and high retention in this time-limited care are consistent with theoretical models for time-limited psychotherapy that propose that time limits can motivate patients and accelerate the therapeutic process (e.g., Malan, 1976; Mann, 1973; Sifneos, 1979), as well as studies showing lower dropout from time-limited care (Messer, 2001; Sledge et al., 1990) and patient preference for time-limited treatment (Johnson & Gelso, 1981).

Our results for improvement in symptoms and functioning for patients receiving care in the TEAM clinic also indicate promise for this approach to outpatient mental health care. To put the results of this open trial in context, we compared response rates to published response rates for evidence-based interventions across a variety of contexts. We again recognize that there is no perfect benchmark for our results; as published, efficacy and effectiveness trials often include specific diagnostic and symptom severity inclusion criteria. Our goal was to understand the obtained response rates for the TEAM clinic relative to observed response rates for evidence-based interventions across a variety of contexts. To benchmark improvement in depression, an effectiveness trial in a community mental health setting demonstrated a response rate of 22% for community clinicians trained to competence in cognitive behavioral therapy (CBT) in the treatment of major depressive disorder (Connolly Gibbons et al., 2016). In another trial, EHRs were used to evaluate response rates for psychotherapy supported by measurement-based care and pharmacotherapy across two large integrated health systems (Coley et al., 2020; N = 5,554). Like the current sample, cases were selected based on baseline PHQ-9 scores ≥10. This evaluation reported a response rate of 46%, very close to our obtained response rate, yet representing change across open-ended treatment that included assessments up to 6month postbaseline compared to 3–4 months of treatment examined here.

Comparisons of community-based effectiveness results with findings from efficacy trials should be made cautiously given the careful selection (inclusion/exclusion criteria) of patients conducted in efficacy trials. A meta-analysis (N = 228 randomized trials) of response rates of evidence-based psychotherapy (primarily efficacy trials) for depression found an overall response rate at 2 (±1) months after baseline of 41% (95% CI [38, 43]) compared to 17% for usual care, with no significant differences between types of therapy (Cuijpers et al., 2021). One specific efficacy trial of interventions for major depressive disorder (DeRubeis et al., 2005) has demonstrated response rates of 50% for pharmacotherapy and 43% for CBT at Week 8 and response rates of 58% for both modalities at Week 16. Thus, our response rate of 47% in a naturalistic sample is comparable to that found in many efficacy trials for depression, though some studies report higher response rates. Differences in outcome measures, baseline severity, and inclusion/exclusion criteria likely impact such response rates.

Regarding anxiety symptoms, our response rate of 50% also compares favorably to results presented in randomized controlled (primarily efficacy) trials of CBT. A review of 87 published trials of CBT for anxiety disorders demonstrated a 50% response rate, across a range of response definitions, at post-treatment (Loerinc et al., 2015).

Our open trial of a multidisciplinary, time-limited treatment package including measurement-based care delivered in a general outpatient psychiatry setting has demonstrated optimal initial access to care to ensure that patients get the care they need when they need it, while maintaining engagement in services and symptom and functioning outcomes as good as, if not better than, engagement and outcome indices documented in the literature. These results indicate that this treatment approach may be a solution to the intractable problem of long waitlists for services that inevitably lead to symptom deterioration, while patients are waiting for the care they need.

This naturalist trial, although promising, has limitations. Controlled trials comparing the TEAM model to open-ended treatment in naturalistic settings would be needed to confirm that access is improved while maintaining quality of care. Implementation trials will be needed to fully evaluate acceptability of the model across providers. Although providers included in the present study had a range of years of clinical experience, it will be important to evaluate whether the model is equally acceptable to experienced clinicians. It will also be important to evaluate whether the results presented here generalize across outpatient settings. Our setting used the TEAM clinic as the primary entry point for the majority of patients seeking services, but patients had the opportunity to be triaged to alternative specialty care settings. It will be important to evaluate engagement and effectiveness of this model in settings where these alternatives are not an option and in low resource settings. Finally, future dissemination and implementation trials might evaluate the effectiveness of the TEAM approach, as well as other approaches recommended in the literature to address problems accessing to treatment.

Future research will also be needed to evaluate how the psychotherapeutic process is impacted by the time limits, including both negative and positive consequences. This naturalistic data set does not allow us to draw conclusions about the utilization, fidelity, or effectiveness of specific evidence-based psychotherapies in the naturalistic context of the TEAM approach. Future research will need to focus on the nature of the interventions used, the characteristics of the therapists, and how these factors influenced outcomes. This study also does not allow us to draw conclusions regarding the usefulness of combined treatment approaches versus monotherapies in this context. However, this initial proof-of-concept open trial indicates that patients are motivated to engage in this time-limited service and obtain good outcomes across 3–4 months. This model has been well received by patients, clinic providers, and providers across the larger health care system that now have a place to refer patients where they can access care quickly. Future studies will need to explore the acceptability and effectiveness of this multidisciplinary approach in this time-efficient model.

Our naturalistic trial provided treatment to patients with a wide range of presenting problems. Providers and patients worked together to decide which presenting problems would be targeted in this time-limited care and facilitated engagement in follow-up care to address presenting problems that required longer term treatments. We did not have access to data indicating which specific presenting problems were targeted in each case so were only able to evaluate effectiveness across broad indicators of depression, general anxiety, and functioning. The current results do not allow for any conclusions for specific diagnostic groups. Future studies would be needed to evaluate effectiveness of the model for specific diagnostic groups.

Our initial trial also does not provide information about reasons for dropout or the longer term outcomes of this treatment approach. Our goal in the TEAM clinic is to have the multidisciplinary team evaluate the necessity for longer term care and use this time-limited episode of care to help patients get connected with ongoing care and on treatment waitlists for specialty services if needed. Future research will be needed to evaluate why some patients discontinued treatment and whether the approach was successful in connecting patients with subsequent services when needed and patient satisfaction with this overall approach.

Clinical Impact Statement.

Question:

How can an outpatient clinic care system be modified and restructured to optimize patient access to care while optimizing clinical benefit?

Findings:

Time-limited care provided by a multidisciplinary team of psychotherapists, psychopharmacologists, and case managers can improve access to care while maintaining good engagement in services and moderate to large treatment effects.

Meaning:

The Time-Efficient, Evidence-Based, Accessible, Multidisciplinary clinic model has preliminary evidence showing that it may be an effective care package that provides equitable initial patient access to care.

Next Steps:

Further research should explore the impacts of time-limited, evidence-based care on the therapeutic process, access to care, treatment outcomes, and patient satisfaction with services.