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3
II
BACKGROUND AND OVERVIEW
The recognition of benefits from a strengthening of the relation-
ship between general medicine and psychiatry in hospitals has stimulated
interest in extending the coordination of medical and mental health
care to ambulatory primary care. Better coordination of mental health
services with primary care holds a promise of better treatment for
disturbed individuals in the general health care system who are not
referred for specialized mental health care.
The potential benefit of the general health care system to the
delivery of mental health care is illustrated by recent epidemiologi-
cal findings: (l) at any one time, 15 percent of the American popu-
lation suffers from some form of mental disorder; (2) 21 percent of
identifiably disordered individuals receive specialty mental health
services; (3) 54 percent of identifiably disordered individuals are
seen only in the ambulatory general health care sector, 3 percent are
in nursing homes or general hospitals, and 20 percent are in contact
with-no recognized health care providers of any kind. 1/
In addition to those with identifiable mental disorders, a great
many patients seen in primary care settings have significant emotional
or behavioral problems expressed as somatic symptoms or personal
distress. The onset of physical illness often is precipitated by
psychosocial stress or elicits maladaptive behavioral responses.
Failure to recognize a correlation of physical and behavioral factors
can impair the restoration of the patient to health. The limitations
of specialty mental health resources, however, would make it difficult
for the mental health sector to absorb high numbers of patients with
mental disorders being seen in the primary care sector. To provide
appropriate care to those who need it, closer ties between mental
health services and general health care should be effected in the
organization of health care delivery, the training of both health
professionals and mental health professionals, and the financing
of health care.
The 1966 Report of the Citizens Commission on Graduate Medical
Education stated the shortage of physicians delivering general medical
care was the leading deficiency of the U.S. medical care system. The
Commission promoted the concept of the "primary physician" who would
"serve as the primary medical resource and counselor to an individual
or family." 2/ In the more than ten years since the publication
of the report, training of more primary care physicians has been
advanced by legislation and other health policy decisions. In 1976,
the Health Professions Education Assistance Act (Public Law 94-484)
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encouraged development of training programs for ambulatory care-based
primary care physicians in order to increase their number and thereby
accomplish certain improvements in health care for the American
people. It was expected that elimination of certain deficiencies
in the health care system (such as limited comprehensiveness of treat-
ment, disrupted continuity of care, maldistribution of physicians,
high costs, and overly technical focus of the medical profession)
would be accomplished by the implementation of this legislation.
Other developments in medical education have indicated a growing
appreciation of the need to train physicians to recognize the role of
psychosocial factors in illness, and of the impossibility of separating
the mental and physical aspects of health care. There are increased
emphases on social and behavioral sciences in medical curricula, pro-
motion of primary care residency training programs with psychiatrists
and other mental health specialists helping in the design and collabor-
ative teaching arrangements, and development of neighborhood health
centers and pre-paid health plans with psychiatric components.
The President's Commission on Mental Health in its report sub-
mitted to the White House in April, 1978, emphasized a need to strengthen
the working alliance between mental health and the general health care
system:
General health care settings represent an important
resource for the mental health care in the community.
There is ample evidence that emotional stress is
often related to physical illness and that many physical
disorders coexist with psychological disorders. While
general health care settings frequently serve as an
entry point to the mental health care system, many
millions of persons with some level of mental disorder
are never referred to mental health specialists. They
are cared for by office-based practitioners, in in-
dustrial health care settings, in homes, in general
hospital outpatient clinics and emergency rooms.
While the interdependence of the mental health
and general health system is evident, cooperative
working arrangements between health care settings
and community mental health service programs are
rare. If we are to develop a truly comprehensive
system of mental health services at the community
level, greater attention must be paid to the
relationship between health and mental health.
As initial steps toward coordinating the working alliance between
the health and mental health systems, the Commission recommended
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o Funding by the Department of Health, Education, and
Welfare of a limited number of research projects to
assess integrated general health care and mental
health care services.
o Requiring community mental health centers and
community mental health service programs, where
appropriate, to establish cooperative working
arrangements with health care settings.
These arrangements should allow for:
c)
a) mental health personnel to provide direct care
and treatment in the health care setting to
patients with emotional disorders whose problems
exceed the skills of non-psychiatric health
care practitioners;
b) consultation directed toward altering behavioral
patterns that increase the risk of physical
illness;
collaborative treatment with non-psychiatric
health care practitioners for those patients
with combined physical and mental illness; and
d) training non-psychiatric physicians and other
health rare personnel to enhance their skills in
the treatment of patients with relatively mild
emotional disorders. 3/
Strategies for implementing these recommendations of the President's
Commission on Mental Health have been developed on the agency policy
level and at the legislative level. The Department of Health, Education,
and Welfare has supported a number of activities to encourage linkages
between health services and alcohol, drug abuse, and mental health ser-
vices to promote a comprehensive health system. Notable among these is
an agreement between the Alcohol, Drug Abuse, and Mental Health Adminis-
tration and the Health Services Administration to spend $1.5 million of
Community Health Center funds to provide on-site mental health personnel,
and encourage linkages of community health centers with a nearby mental
health center. Fifty-seven linkage grants were approved for funding
in fiscal year 1979. The Mental Health Systems Act (S.1177) introduced
in the Senate in May, 1979 is the Carter Administration's proposal for
reform of the nations mental health program. Title IV' Section 404,
would authorize grants to assist ambulatory health care centers to
participate in provision of mental health services to their patients.
An Institute of Medicine conference, which this report summarizes
was convened to examine some of the underlying concepts and long
range implications of these "linkage" efforts. Major themes of the
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conference were developed by individual speakers and in workshop
sessions. These themes are outlined briefly in the pages that follow.
Definitions of Primary Health Care and Mental Health Services
In the 1978 Institute of Medicine report, "A Manpower Policy for
Primary Health Care," primary care is defined as "accessible, compre-
prehensive, coordinated, and continual care provided by accountable
providers of health services." _/ The five essential attributes of
primary care as it should and could be practiced in the United States
today were described as follows:
(1) Accessibility of care refers to the provider's responsibility
to assist patients or potential patients to overcome temporal,
spatial, economic, and psychologic barriers to health care;
i.e., to promote the availability, attainability, and
acceptability of services provided.
(2) Comprehensiveness of care refers to the willingness and
en.
ability of providers to handle the great majority of
health problems arising in the populations served (which
may be limited to a given age group or sex). While the
primary care practitioner may have an area of special medi-
cal interest, his or her services are not restricted by
concentration on that specialty.
(3) Coordination of care denotes the primary care practitioner's
role as ombudsman, coordinating the total care -- including
that provided by specialists -- of his or her patients.
This role presupposes awareness of patients' financial
capabilities and personal desires.
(4) Continuity of care depends largely on the first three
attributes of primary care, requiring active commitment
on the practitioner's part to maintaining an ongoing
relationship with each patients Record-keeping is an
important aspect of continuity.
(5) Accountability requires that primary care providers review
-
regularly both the process and outcomes of care with
attention to potential improvement, and also entails
commitment to ensuring that patients are informed deci-
sion-makers. Providers also should respect their obliga-
tion to maintain appropriate financial accountability,
including adequate professional liability coverage.
Primary care generally is recognized as the first level of personal
health services, in which initial professional attention is paid to
current or potential health problems. Primary care frequently is
associated with care of the "whole person" as opposed to care for an
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illness. Primary care is distinguished from other levels of personal
health services by the scope, character, and integration of the services,
and is not necessarily limited to provision by any particular type of
practitioner or practice setting.
Mental health services (primary mental health services) are de-
fined in terms of direct and indirect care to patients with mental dis-
orders in ambulatory settings. 5/ Direct services consists of diagnostic
and problem evaluation, crisis intervention, individual, group and family
psychotherapies, supportive counselling, prescription of psychoactive
medication, and post-hospital care for the chronically mentally ill in
the community. Indirect and preventive services are provided through
consultative and collaborative arrangements with schools, welfare agencies,
police, and a wide range of other community organizations. In some se-t-
tings the provision of these mental health services is almost exclusively
in the domain of specialty mental health professionals: psychiatrists,
psychiatric social workers, psychologists, or psychiatric nurses. In
other settings, these services are provided by the primary health care
provider trained in mental health skills.
Nature and Scope of Mental Health Problems in Primary Care
Epidemiologic and health services utilization studies suggest that
the number of patients with psychiatric disorders seen in primary care
settings is higher than indicated by current data. It cannot be deter-
mined, however, whether the majority of the mentally ill have always -
been treated by the general health practitioner or whether these patients
have become more numerous in the past few years. In the absence of com-
pletely objective criteria, researchers have used a variety of techniques
to identify the rates of psychiatric morbidity in primary care settings.
The reported rates of mental disorder vary with its definition, with the
method of case identification, and with the setting and the sampling
method.
An increase in the medical treatment of mental disorders, speci-
fically pharmacotherapy, and in outpatient treatment make it not sur-
prising that the majority of the mentally ill already are being cared
for by primary care practitioners. Several studies have suggested
factors that act as barriers to the use of specialized mental health
services, including 1) patient fear of stigma associated with psychiatric
treatment; 2) the generally high cost of psychiatric treatment, limited
private insurance coverage, and the major portion of public funds spent
on inpatient care, particularly long-term institutionalization; and
3) the patient's lack of knowledge about the availability and nature
of specialized mental health services. Advocates of integrated mental
health and general health services in prepaid plans or community health
centers contend that those arrangements improve access to mental health
professionals. Such health care models, typically report relatively
high utilization rates of mental health services.
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The distribution of mental illness by health care models is
important to note. Of research conducted to date, eighteen studies
from fee-for-service settings indicate prevalence rates ranging from
4 to 39.6 percent; studies from prepaid practices indicate a range
of prevalence for mental illness from 1.2 to 14.6 percent; and studies
from community health centers indicate a range of 15.6 to 50 percent.
Finding the lowest rates of disorder in prepaid practices may reflect
particular incentives in such plans to under-diagnose.
Some data suggest that referral rates among health care delivery
models are highest in prepaid settings, perhaps because of a physical
proximity of health and mental health professionals in those and
certain community health center settings. Proximity encourages close
relationships, making referral more feasible and attractive both to
the patient and the referring physician.
Models for Coordinated Mental Health and Primary Care Services
There is general agreement that implementing the linkage of the
mental health system and the general health service system in the
United States requires the development of many conceptual and organiza-
tional models for health care. There are at present three principal
types of health care delivery in this country: fee-for-service, prepaid,
and community health centers.
Fee-for-service health care is the predominant type of health
care in the United States for both general medical services and mental
health services. The distinguishing feature of fee-for-service health
care is that physician services are purchased on an individual basis.
Availability of non-specialty mental health care from a fee-for-service
primary care practice-appears to depend largely on the individual pri-
mary care physician's training, skills, personal interest, and individ-
ual practice style. Economic incentives or disincentives also are
likely to have significant effect an the kind and extent of mental
health service in this setting.
Prepaid health care, typified by health maintenance organizations
(HMOs), is a system in which subscribers pay a prearranged amount for
an established set of medical services, which may or may not include
mental health care. Physicians delivering prepaid health care are
usually salaried. Prepaid health care plans currently cover only about
3 percent of the American population, mostly middle-income families.
Federally-funded EMOs are required to provide enrollees with
up to 20 visits per year to mental health clinicians, along with
unlimited visits to primary physicians for treatment of emotional
problems. In keeping with the traditional separation of health and
mental health services in this country, HMO s typically have set up
separate psychiatric clinics for referrals within their organizations
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or have purchased specialized psychiatric services outside of the
plan.
Community health centers are much like prepaid health plans in
that a geographically defined population is provided a comprehensive
set of medical services. Almost all employ salaried physicians.
These centers are largely subsidized by public funds and provide
free or low-cost services to disadvantaged persons.
Identification and Management of Mental Health
Problems in Primary Care Settings
Although many patients with disorders that are both distressing
and disabling seek primary care, it appears that primary care providers
identify only a limited number of such patients who could benefit
from specialty mental health care. A small segment of the adult primary
care population may be utilizing medical services at high levels in
an effort to remedy their undetected chronic psychiatric disorders.
Studies have shown that primary care case identification improved
where mental health and primary care services are integrated profes-
sionally, administratively, and structurally -- particularly when the
physical setting is shared and when training takes place in the
primary care setting. Formal hospital consultation liaison applied
to ambulatory care settings may also improve case identification.
However, case detection does not guarantee successful, or even feasi-
ble, treatment.
A lack of uniformly applied diagnostic criteria is documented
by many surveys of mental disorders among patients attending primary
care physicians. These studies have shown wide variations among
individual practitioners' estimates of the frequency of such conditions,
although psychiatric screening tests used during the surveys typically
show less variation between various practice populations than indicated
by the physician assessments. It has been suggested that differences
in physician assessments may reside not in the patients but in the
physicians' concepts of psychiatric disorder and the threshholds
adopted for case identification.
There is general agreement that high priority needs to be given
to developing more effective screening and evaluation of psychiatric
illness in primary care settings. Further study is needed of the
interaction of the three dimensions - syndromes, functional status,
and socially unacceptable behavior -- that furnish the basis for the
widely used Research Diagnostic Criteria (RDC) evaluation. Improved
detection of psychiatric illness by primary care providers could
promote more appropriate therapeutic interventions and decrease the
financial burden on the ambulatory medical care system.
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Little is known of the treatments provided to patients with
mental disorders or other emotional or behavioral problems who remain
in the general health care sector. Referrals for mental health services
usually are low; even when primary care physicians identify patients
as emotionally disturbed, they are likely to make a referral for
specialized mental health care for only one in 10 to 20 such patients.
In terms of treatments received by emotionally disturbed patients
from family physicians, evidence suggests that drug therapy is more
common than other psychotherapeutic help, including counseling and
referral to specialists. Evidence on the appropriateness of drug
prescriptions, however, is not encouraging, and suggests a need for
further research on the utilization of psychotropic drugs in the
management of emotionally ill patients by primary care physicians.
Unresolved questions include: 1) When are such prescriptions appro-
priate? 2) Are psychotropic drugs efficacious when used alone, or
should they always be combined with psychotherapy? 3) Is management
of psychiatric patients with psychotropic drugs cost-effective rela-
tive to other alternatives? 4) What is the quality of psychothera-
peutic prescribing by primary care physicians? 5) When should
patients be referred to psychiatrists for drug therapy?
Although definitions of psychotherapy vary, 60 to 80 percent
of patients with recognized mental disorder reportedly receive such
therapy in some form from their primary care physicians. However,
such therapy occurs in only 22 percent of the patient visits, and
the difficulty of conducting formal psychotherapy due to time con-
straints in primary care settings are cited frequently. Although
short-term life crisis therapy seems to be emphasized, with more
than half of the patients receiving Psychotherapy in one to four
visits, there is little data on the intensity and nature of psycho-
therapy in general.~ Studies on psychotherapy outcomes among primary
care patients are almost nonexistent.
Unanswered questions about psychotherapy by primary care physi-
cians include: 1) For which patients is primary care psychotherapy
indicated, rather than psychiatric referral? 2) Which psychothera-
peutic techniques are most successful for a specific diagnosis?
3) Is psychotherapy cost-effective in this setting?
Education and Training
The relationship between general health and mental health has
important implications for the training of both health professionals
and mental health professionals. Given the substantial amount of
mental illness identified and treated in general medical practice,
there was agreement at this conference that general health profes-
sionals should receive adequate training in the psychological aspects
of patient care, and should demonstrate competence in when and how
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to treat patients, when and how to refer patients to mental health
professionals, and how to collaborate with mental health professionals.
Three broad categories of skills required by primary care physi-
cians to work effectively in mental health are: 1) sensitivity skills,
including physicians' awareness of their own reactions and the effects
on treatment, understanding of a life cycle context, and understanding
of both the psychosocial factors involved in illness and community
resources for treatment; 2) therapeutic skills for counseling, based
on a psychosomatic approach to history taking and interviewing, minor
psychotherapy, and recognition and management of anxiety and depression
related to illness; and 3) referral skills, which involve learning
to recognize serious psychiatric disorders that can best be treated
by mental health specialists.
Conversely, there is agreement that mental health professionals
should be better trained to understand the relationships between
medical and mental illness. They should be required to demonstrate
competence in collaborating with health professionals. One educational
opportunity that could benefit both professional groups is experience
in integrative health care settings that could provide a model for
future collaboration and sensitize professionals to the needs and
issues of the other members of the health care team.
Issues of Financing and Cost-Offset
If efforts to link services are to be successful, the financing
of health care must take into account the integral relationship between
general health and mental health. Recent increases in insurance coverage
notwithstanding, mental health services typically are covered to a
lesser extent than general health services in private health insurance
plans. Mental health insurance also more frequently includes deductible
and co-insurance requirements than do plans for medical illness. Some
evidence suggests that adequate coverage for treatment of mental dis-
orders within primary care settings and by primary care physicians as
well as mental health professionals may lead to increased utilization
of mental health services and a decrease in the utilization of general
medical services. Whether the change in the locus of care will be
cost-saving is not yet clear. It may, however, be an important step
toward assuring the quality and appropriateness of care.
There appear to be both conceptual and methodological problems
in studying the effects of providing mental health services at the
primary care level. It was suggested that the following conceptual
issues be considered: 1) The assumption that the cost of mental
health care should offset the cost of physical health care may be
valid when physical health care has been misused as a substitute
for needed mental health care. However, there are mentally ill
patients, who, with treatment, should have utilization of general
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medical services that increases to more optimal levels as they become
less likely to neglect their overall health. 2) Cost-effectiveness
may not be an appropriate indicator of effective mental health care.
Other outcome indicators such as improved ability to function may
be more reasonable. 3) The common assumption that mental health
care and physical health care services can be evaluated separately
may be inaccurate if they are as integrally related as are mental
and physical illness in the individual. 4) Medical utilization is
often used as an indicator of health status. Accordingly, persons
discharged from the medical care system are assumed to have improved
health. In fact, nothing may be known about their subsequent health
status or utilization of other service.
There was consensus at the conference that methods should be
developed to assure adequate reimbursement for consultation and
collaboration between health and mental health professionals. These
services, along with the cost of such preventive services as be-
havioral therapy for smoking or obesity are unlikely now to be covered
by any private insurance plan or proposed models of national health
insurance .
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REFERENCES
1. Regier, D.A., Goldberg, I.D., Taube, C.A., The DeFacto Mental Health
Services System, Archives of General Psychiatry, Vol 35, June, 197B,
pp. 685-693.
2. Report of the Citizens Commission on Graduate Medical Education.
.
American Medical Association, Chicago, 1966.
3. Report to the President from the President's Commission on Mental
. .
Health submitted April, 1978, p. 20.
4. National Academy of Sciences, Institute of Medicine.
Policy for Primary Care. Report of a Study. Washington, D.C..
1978.
A Manpower
J. Borus, B. Burns' A. Jacobson, L. Macht, R. Merrill, E. Wilson'
Coordinated Mental Health Care in Neighborhood Health Centers,
Vol. II Mental Health Services in General Health Care, National
Academy of Sciences, Institute of Medicine, Washington, D.C., 1979
.
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Representative terms from entire chapter:
care settings
