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139
VI
SUMMARIES OF PANEL PRESENTATIONS:
FUTURE DIRECTIONS IN COORDINATION OF MENTAL HEALTH
SERVICES AND PRIMARY CARE
Julius Richmond, M.D.
Assistant Secretary for Health
Department of Health, Education, and Welfare
Discussions at this conference have both theoretic and practical
implications for various aspects of health services delivery beyond
mental health and primary care. Patients must be considered in terms
of their social contexts, whether or not the problems overtly appear
to be mental health concerns, and thus an understanding of emotional
development over the life cycle is important for all physicians.
Pediatrics provides an excellent example of a field in which biosocial
and developmental factors are integrally involved in health.
After years of persistent, largely independent efforts to promote
the integration of mental health concepts and programs with general
health care and with primary health care in particular, it appears
that finally the time is right for broader acceptance of and formal
commitment to this concept. The President's Commission on Mental
Health focused significant attention on this issue, as has the general
trend toward providing comprehensive services in primary health care
settings. This trend also represents movement towards the World
Health Organization (WHO) goal of primary health care for all by the
year 2000.
Clearly, however, the implementation of these policy goals
depends on a practical base of scientific knowledge. The growth
and diversity of programs committed to coordinating health and men-
tal health services has contributed significantly to the necessary
knowledge base. Dr. Richmond believes that sufficient models for
achieving the WHO goal already exist, many of them in the developing
world. He cited as an example the Cuban health care system which
utilizes a primary care system with two levels of organization: in
very rural areas, primary care physicians work individually as part
of required post-graduate social service; at the 'rpolyclinic" level,
primary care teams -- each including a pediatrician, an internist,
an obstetrician-gynecologist, and a psychiatrist and a psychologist
(who are consultants for community social, as well as health, ser-
vices) -- administer ambulatory care. Continued expansion of the
practical knowledge base, especially through more systematic and
sophisticated means of evaluating existing programs, will further
promote progress in this area.
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141
Gerald Klerman, M.D.
Administrator
Alcohol, Drug Abuse, and Mental Health Administration, DREW
The federal commitment to integrating mental health and primary
health care has been shaped by recent advances in both epidemiological
research and organizational research. The development of epidemiological
methods to quantify the extent of mental illness, both in the community
and in the primary care system, has enabled researchers to document the
high degree of prevalence and the diversity of diagnostic considerations
that make this issue particularly important in public policy terms. As
federal efforts to implement mental health services in primary care
settings have expanded, organizational studies which benefit from the
involvement of a range of behavioral and health services sciences have
become increasingly important as well.
Linkage grants initiated by the Bureau of Community Health Ser-
vices and developed on the regional level in cooperation with National
Institute of Mental Health in fiscal year 1978, along with current
budget requests reflect "momentum" within various federal agencies to
increase both the number and plurality of modes for integrating mental
health and primary care. At the same time, the need to incorporate
program evaluation into these efforts has been stressed. Although an
emphasis on evaluation of new programs clearly is warranted, Klerman
suggests that more appropriate measures of both outcome and intervention
are needed. The outcome measures most often used in U.S. studies have
focused on organizational variables -- cost-offset, medical utilization,
and referral patterns -- and have generally neglected less quantifiable
but significant "human" variables such as relative symptom reduction,
improved ability to function, and patient and provider satisfaction.
Intervention variables that continue to merit attention relate to:
1) treatment -- controversies concerning the merits of psychotropic drug
and/or counseling therapies indicate the ongoing need for controlled
clinical research; 2) personnel -- further investigation of appropriate
qualifications for providers of mental health care in primary care
settings is needed to develop adequate training programs; and 3) organ-
izational arrangements -- various modes of integration in addition to
the linkage mechanism currently in vogue should be studied.
Dr. Klerman stated that the next phase of research should attempt
to better evaluate what is known about the determinants and dimensions
of program outcomes. Such studies will have particular relevance in
terms of the current general public policy trend to increase support
for the delivery of a full range of specialty services, including mental
health care, at the primary health care level.
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143
George Lythcott, M.D.
Administrator
Health Services Administration, DREW
Successful coordination of mental health services and primary care
presupposes closer integration of care and caring in medical prevention,
treatment and control, and in medical services, training and research.
"Care" reflects technical knowledge and skill; "caring" reflects deep
personal involvement and commitment. Although the two concepts clearly
should not be mutually exclusive, the current public policy focus on
coordinating care and caring indicates growing recognition that medical
services often do not meet the real needs of patients. If federal
efforts to coordinate these elements in service, training, and research
programs are to succeed, collaboration in terms of actual functions
and activities must be emphasized.
1) Services for both the elderly and children -- particularly
handicapped children -- entail special consideration of care and caring
by both mental health and primary health care providers. In each of
these services areas, the Bureau of Community Health Services (BCHS)
within HSA is working with other federal agencies, including the NIMH,
to develop specific programs of collaboration at the levels of policy-
making, planning, and service provision.
2) Training programs in several states are directed toward
preparing primary care providers to deal sensitively and effectively
with mental health concerns, either directly or through linkages. The
programs also have involved cooperation of ADAMHA and HSA at the
federal level. The recruitment and placement of mental health per-
sonnel within the National Health Service Corps of BCHS is also
part of the overall training effort. Planning with NIMH is currently
underway to expand Corps supportive mental health manpower, specific-
ally to meet the health/mental health needs of patients with chronic
mental illness.
3) Research efforts, such as the planned joint evaluation by
HSA and NIMH of the 1978 health/mental health linkage grants, should
be extended to other areas of common interest to ADAMHA and HSA.
If enacted, the Community Mental Health Systems Act will support
the development of state-based systems of care and caring that would
involve coordination at the federal level and between federal agencies
and the States. -
To effectively integrate mental health services into primary
health care, new dimensions of care and caring at the primary level
also should be considered. Because of the interlocking nature of
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144
of behavior and heal th, self-care and caring should be included
formally as primary health care concerns, especially among under-
served populations to whom access to other level s of care is often
limi ted . Mutual health and f ormal and inf ormal sac ial support
systems al so should be expanded as part of primary care . Advocacy
although a special aspect of care at all levels is particularly
important to ensure the quality of primary care health services and
should be emphasized as well.
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Representative terms from entire chapter:
care settings
