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Office of the Surgeon General (US). Report of a Surgeon General's Working Meeting on The Integration of Mental Health Services and Primary Health Care: Held on November 30-December 1, 2000, at the Carter Center: Atlanta, Georgia. Rockville (MD): Office of the Surgeon General (US); 2001.

Cover of Report of a Surgeon General's Working Meeting on The Integration of Mental Health Services and Primary Health Care

Report of a Surgeon General's Working Meeting on The Integration of Mental Health Services and Primary Health Care: Held on November 30-December 1, 2000, at the Carter Center: Atlanta, Georgia.

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Meeting Highlights

Nature of the Problem

Every year, about 20 percent of U.S. adults and children have a mental disorder. Despite an array of effective known treatments, the majority of those with mental disorders do not receive treatment and thus needlessly suffer from distress and disability. Mental disorders are highly disabling, ranking second only to cardiovascular conditions as a leading cause of worldwide disability by the World Health Organization (Murray & Lopez, 1996). Moreover, these disorders impose substantial cost burden to patients, their families, and communities at large. That burden is reflected in lost productivity and premature death and in the amount of medical and community resources expended.

The prevalence of mental disorders in primary care is somewhat higher than that in the population. About 25 percent of people receiving primary care have a diagnosable mental disorder (Olfson et al., 1997), most commonly anxiety and depression. Depression occurs in about 6 to 10 percent of primary care patients (Katon & Schulberg, 1992). Older adults are particularly vulnerable in an unintegrated system because many of them are treated in primary care for a variety of health conditions, and depression may go undiagnosed and untreated. Low-income minority populations face similar identification barriers because primary care services are often cost prohibitive and difficult for them to access.

Major depression is one of the more prevalent conditions observed in the primary care setting afflicting an estimated 5 to 9 percent of presenting patients. Such prevalence coupled with evidence that most depressed patients receive mental health care from primary care physicians Coyne et al., 1994; Reiger et al., 1993; Rost et al., 1998 has prompted much attention in the field.

Mental disorders frequently co-occur with other mental or somatic (physical) disorders. Estimates of this "comorbidity" range from about 20 to 80 percent of primary care patients Sherbourne et al., 1996; Olfson et al., 1997. Comorbidity adds to disability and contributes to morbidity and mortality.

There are a number of barriers to effective diagnosis and treatment of mental illness in primary care. Overwhelming societal stigma is partly to blame for patients resisting diagnosis, resisting treatment altogether, or not adhering to treatment recommendations (DHHS, 1999). Primary care providers vary in their capacity to recognize and diagnose disorders, and, if they do so correctly, they may not adequately treat or monitor patients. Some estimates are that about half of those with mental disorders go undiagnosed in primary care (Higgins, 1994). Finally, mental health services in either primary care or through referral to specialty care are often difficult to access, fragmented, or poorly financed. Thus, the integration of mental health services and primary health care faces broad-sweeping attitudinal, educational, organizational and financing problems. These problems stem in part from the historical separation of mental health from the mainstream of medicine (DHHS, 1999).

Opportunities

Primary care holds a myriad of opportunities to engage patients in need of mental health care. These opportunities range from health promotion to disease prevention and treatment.

As a first point of patient contact with the health care system, primary care is often closer to home or work and more affordable than specialty care. It offers the possibility of cost-effective treatment, particularly with less severe mental disorders. Primary care also has the potential for early identification of symptoms and for coordination and continuity of care for both mental and somatic disorders. This is highly important given the frequency of comorbidity and the long-term nature of many mental disorders. Further, a focus on mental health within primary care underscores a message of the Surgeon General's report: Mental health is fundamental to overall health.

Primary care is not only where individuals receive care; it is where family members do too. By establishing relationships with the family, primary care providers have the advantage of tapping the family as a source of support. These relationships with the family are key for children and older people with mental disorders.

Perhaps most importantly, primary care is where many consumers prefer to receive mental health services (Annexure et al., 1997). Primary care is often perceived by consumers as less stigmatizing than the specialty mental health sector.

Most of these opportunities for integrating mental health care have yet to be realized, with the exception of one mental disorder: depression. Research and practice on prevention, diagnosis, and treatment of depression in primary care have been proceeding for more than a decade (Schulberg et al., 1999). A special subgroup of meeting participants met to explore depression as a model for service integration.

There are many possible ways to organize and staff mental health services in primary care, for integration does not exclusively rely on a single setting or type of professional. Some programs described at the meeting use a psychiatric social worker to deliver mental health services and to "bridge" primary care and specialty mental health care, with patients seen in either setting. Other programs use multidisciplinary teams, including mental health care, to furnish care in the context of routine health visits and follow-up within the primary care setting. Regardless of the variation, a central feature of many programs is enhanced training of primary care providers in the detection of mental health problems.

Obstacles and Challenges

As is true for any new approach to health care, an array of obstacles stand in the way of attaining the promise of integrated and collaborative care. The nature of the problem is compelling, and the opportunities plentiful. Our Nation's health care system is a highly complex and diverse system serving the interests of consumers, professionals and providers, hospitals, insurers, employers, and government. The rationale for integration of care, according to meeting participants, needs to be made for each of these stakeholder groups and bolstered by empirical research on cost, efficacy, quality, and consumer satisfaction.

And beyond these traditional stakeholders are many vulnerable populations who are uninsured and thus left out of public or privately funded systems of care. The obstacles and challenges described by meeting participants are highlighted below.

Design

A major design challenge to the integration of mental health services and primary health care is the lack of motivation on the part of consumers, providers, and payors.

  • Consumers are hesitant to accept and follow through on mental health services.
  • Primary care providers are overwhelmed by limited time to attend to each patient's needs. Visits last on average 13 to 16 minutes, and patients have an average of six problems to address with their provider (Williams et al., 1999).
  • Partnerships between primary care providers and mental health professionals have been stymied by different cultures of care, including styles of communication and duration of office visits.
  • Payors have limited motivation to offer integrated programs owing to what they see as high start-up costs, lack of consumer demand, and limited evidence for cost neutrality or cost offsets (in terms of lower overall health care costs, lower disability costs, or improved worker productivity) (Malek, 1999).
  • Other major design challenges include delegation of roles and responsibilities of primary care physicians and other professionals (e.g., mental health specialists, nurses, health educators) and the need for common integrated information technologies for medical records, scheduling, billing, and reporting.

Training and Practice Guidelines

There are few training programs and practice guidelines that emphasize the integration of mental health services and primary care.

  • Primary care providers generally have little formal training in the diagnosis and treatment of mental disorders and even less in promoting mental health wellness and disease prevention.
  • Primary care providers have sparse guidance about decision support, i.e., what disorders (alone or in combination) and at what level of severity can be treated effectively in primary care versus being referred to mental health specialty care.
  • There are few incentives for educational institutions and professional organizations to step beyond existing training and practice programs to embrace integrated and collaborative approaches.
  • If demand for services expands, integrated programs may be unable to keep apace because of an insufficient supply of well-trained mental health professionals in rural areas and many other parts of the country (Peterson et al., 1998).

Economics

There are many economic barriers to the creation and implementation of integrated care.

  • The funding of mental health services is generally separate from the funding of general medical services.
  • There is lack of parity, i.e., the level of funding of mental health services is more restrictive than and not on an equal footing with that for general health services. Further, over the past decade, spending for mental health services has decreased as a percentage of overall spending for health care (DHHS, 1999).
  • An increasing number of health plans are moving to "carved-out" mental health services, i.e., separate systems of financing, delivering, and managing specialty mental health services. Carved-out mental health plans have little economic incentive to offer, or to participate in, integrated treatment because these plans cannot recoup cost offsets (reductions in overall health care utilization/costs as a result of treatment of mental disorders).
  • There is little, if any, economic incentive for mental health and primary care providers to collaborate across disciplinary lines and develop a team approach to care.

Quality

There are few explicit programs for measuring quality of services that integrate mental health care and primary health care. One step forward has been the development of quality improvement programs for treating a single mental disorder-depression-in primary care (Wells et al., 2000).

  • The development and continued monitoring of quality-improvement programs rests on a foundation of skills and knowledge concerning staffing and treatment of mental disorders in primary care, yet such knowledge has yet to be developed beyond that for depression.
  • Greater attention to quality improvement is likely needed for vulnerable populations. For example, research has found that patients at greatest risk of having their mental health problems go undetected in primary care include African Americans, men, and younger patients (Borowsky et al., 2000).

Research

With the exception of depression, research is sparse on the development or evaluation of programs for the integration of mental health services and primary care.

  • Research funds are generally limited to the conduct of research and thus cannot be used to sustain research programs found successful.
  • Programs with strong efficacy based on research are difficult to translate into the "real world" of practice owing to heterogeneity and diversity of patient populations, comorbidity, and less monitoring of outcomes by providers (DHHS, 1999).
  • Little research has been directed to integrating primary care and mental health services for people with severe mental illness.
  • There has been a paucity of investigator-initiated research applications in this area.

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