(This blog post is a reprint of a piece in the CFHA Blog from January 15th, 2015. Click here for the original post. Reprinted with permission.)
In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.
With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.
PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
Pediatric Symptoms Checklist: The 17-item version is easy to use in family practices for detecting developmental and behavioral problems.
SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.
In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hang to screen for additional conditions, such as:
Geriatric depression
Eating disorders
Postpartum depression
Intimate partner violence
ADHD
Autism
Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these cools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.
“When you look at people holistically and start valuing their mind-body resiliency, I think there is a level of excitement, and better outcomes.”
Larry Fricks
September is Recovery Month. This year’s theme is Join the Voices for Recovery: Together on Pathways to Wellness. It is very fitting that Larry Fricks is our featured Integrated Care Thought Leader this month, as he is one of the nation’s greatest leaders in peer-led services, wellness, and recovery. An amazing individual who has devoted his life to helping others, Mr. Fricks was gracious enough to his insights into the importance of whole health wellness and resiliency and the vital role of engaging with people who have the lived-experience to provide support through the process. He offered insight into the role that a whole health approach plays in improving health outcomes and managing wellness. Drawing from his own experiences, Mr. Fricks identified many factors that contribute to a person’s recovery process. Acknowledging that factors such as race, socioeconomic status, and personal support system play a crucial role: “I don’t think you can underestimate what social determinants do to break somebody down.”
I first met Mr. Fricks in 2000 in Rockford, Illinois. He was the keynote speaker at the Consumer Family Forum, addressing a group who receive behavioral health services, their families, and behavioral health professionals from across the state. His passion resonated among the 300+ attendees as he shared his personal recovery story, urging others to believe that recovery is possible. I vividly recall (and have frequently shared with others) a very moving story that he shared about an initiative that has grown to be The Gardens at Saint Elizabeths: A National Memorial of Recovered Dignity, honoring the hundreds of thousands of people who died and were buried in unmarked graves on the grounds of psychiatric hospitals…and were forgotten:
Larry Fricks:Their graves were decimated and desecrated and they have no markers and people didn’t care about maintaining their graves. They walked the Earth and they had a life. Mothers, husbands and wives, children. They had wonderful things happen, and they saw miracles, and they had heartbreak, and you’re just honoring that experience. I just really believe that the Memorial is drawing people that I never expected to draw…very inspiring.
Through the years, Mr. Fricks has traveled from state to state, providing inspiration to so many, sharing his vision, and leading the way to transforming the way behavioral health organizations provide services. He led the national initiative to include peer-led services as a core feature, and is now working with states to embed Peer Support Specialists and Family Peer Specialists in integrated healthcare efforts as well. He currently divides his time between his work with the Appalachian Consulting Group based in Georgia, and his work in Washington, DC, as Deputy Director with the SAMHSA-HRSA Center for Integrated Health Solutions which has included testifying at Congressional Hearings on Mental Health.
Larry Fricks: We now know that things like a social network and service to others are huge health and resiliency factors. People who are in service to others tend to be healthier and they tend to live longer. Also they tend to be more resilient toward relapse or illness. So my life striving to be in service to others to strengthen their health and maybe strengthen their skills in recovery has had the benefit of strengthening my own recovery.
While his earlier work has focused on the role of Peer Support in the recovery process, Mr. Fricks’s work has broadened the focus to include a whole health approach. With startling reports that people with serious behavioral health conditions are dying decades earlier on average than the general population, he led a team at the SAMHSA-HRSA Center for Integrated Health Solutions to create a training called Whole Health Action Management (WHAM) that is designed to address this disparity though self-management supported by peers. Mr. Fricks has great praise for the effort in Georgia to develop Peer Support, Wellness, and Respite Centers that are reducing hospitalizations.
Larry Fricks:Let me tell you about what excites me. Georgia has three of these Peer Support, Wellness, and Respite Centers and they’re going to open two more. I’m very excited about what’s going on in those centers. Basically, if you feel early warning signs of your illness, or your addiction, you can go to one of these peer respite centers where you have your own bedroom and you can stay up to seven nights, chill out, and you’re surrounded by peers trained holistically to support your wellness. I think it’s really cutting the need for more intense crisis services and hospitalizations. So I had a chance to actually pull a shift in one of them, I answered the warm line and experienced what it was like to provide healing support by simply listening, or maybe just ask a few quetions for deeper reflection like we are trained to do. These peer support wellness centers are returning us to whole health. Removing some of the stigma, giving us a sense of owning our recovery and being proactive, and really engaging peer support to be successful. Georgia is leading the nation. With three we had more than any state, and with five we’ll really be out in front.
What’s next on the horizon?
Larry Fricks: I’m really excited about epigenetics. On April 2 of this year, Time magazine had a cover story on curing cancer, and this whole science on epigenetics basically says DNA does not have the last say. There are mind-body resiliency factors and there’s more and more research on epigenetics. “Epi” means over and the epi is the cell structure over your genome, over the DNA. And what they’re saying here is: Things that you do, like what you eat and managing stress to stay well, it determine which genes switch on and switch off. And so being aware of this thing, if you look at the WHAM training, we include ten health and resiliency factors which we got from Dr. Greg Fricchione who used to run Mrs. Carter’s Mental Health Program [at the Carter Center], and now he’s director of the Benson-Henry Institute for Mind Body Medicine. These prevention doctors are big on something called the Relaxation Response, and so we’re looking at the things you can do to switch on and switch off gene markers; and they can impact the next generation.
And in parting:
I’m aware that there are just people and things that happen in your life that, if you’re open to it, you work on staying connected and having faith, your life can experience great meaning and purpose.
Dr. Martin Luther King, Jr. said “We’re all bound in a mutual destiny and I’m not all I can be until you’re all you can be, and you’re not all you can be until I’m all I can be.” We should be about connection. We should be about cooperation, and there’s a spiritual power to that, and when you’re open to it, positive things just seem to happen. And you’re inspired by it.
Sometimes you want to shake your head and say, “Oh my gosh, why don’t I have more faith?”
“That’s the next direction that [organizations] need to go, bringing substance abuse back into the discussion. We need to go past just the integration of primary care and mental health care to a more Whole Person Care.”
Benjamin Druss, MD, MHP
It has been my pleasure to talk with Dr. Benjamin Druss for this edition of the Integrated Care Thought Leader Series. Having had the privilege to work with Dr. Druss on various integrated care projects over the past few years, I have come to respect not only his keen insight into what’s needed beyond the horizon for the care of people with behavioral health disorders, but the compassion and dedication he brings. His humility and brilliance are evident upon introduction; he’s a true visionary. Dr. Druss, my mentor and my friend, has provided inspiration to me in my work and outlook on the world of healthcare, integration, and beyond.
Dr. Druss, Dr. Silke von Esenwein, and their colleagues at Emory University are currently conducting an exciting NIMH research trial, The Health Outcomes Management and Evaluation (HOME) Study. As described on the website clinicaltrials.gov: There is an urgent need to develop practical, sustainable approaches to improving medical care for persons treated in community mental health settings, this study will test a novel approach for improving mental health consumers based on a partnership model between a Community Mental Health Center and a Community Health Center. When this study is completed, it will provide a model for a medical home for persons with severe mental illness that is clinically robust, and organizationally and financially sustainable.
Dr. Druss received his bachelor’s degree from Swarthmore College in 1985, earned his medical degree from New York University in 1989 and later his master’s in public health from Yale University in 1995.He is also board certified in psychiatry. He trained as a resident in general internal medicine at Rhode Island Hospital and in psychiatry at Yale University School of Medicine. Click here for more information about Dr. Benjamin Druss
Advancement in integrated care through the years
Dr. Druss was one of the first to address the physical health concerns among people with serious mental illness and substance use disorders, particularly among the public sector populations in urban regions. During our discussion on integrated care, he addressed areas of change over the past 18 years that has had the greatest impact on the advancement of healthcare for people with serious mental illness. He described the world of Health Information Technology as a frontier that, over the past 10 years, has resulted in changing policies and procedures in healthcare. These changes have had significant impact on the ability for healthcare organizations to share information, resulting in improved care for patients.
Dr. Druss advises that the next stage needed for healthcare is to begin “broadly looking at other social determinants of health.” The focus should be on an approach to healthcare that is person-centered. The concept of addressing population health and creating a system of care will be a more effective approach to improving health outcomes moving forward. He recommends that substance abuse must be brought back into the discussion, and to go past just the concept of integration of physical health and mental health, toward a more “whole person care” approach.
What do you foresee for the field as we move forward?
Dr. Druss: Clearly there’s going to be major changes in how care is delivered. I think there’s a lot of opportunity moving forward with new public sector models, Medicaid, patients with medical homes, and also the promise of new technologies moving forward as well.
I’m very optimistic; I think things will certainly be very different five years from now. We’re in a period where things are evolving very quickly and we don’t know exactly what the world will look like, but I think we can say that things will look different—and that things will look better.
Research has to change as well. I’m mostly a researcher and lot of what we’ve been doing is slow-paced. The slow-paced process by which we develop a model, and then test it over a five year period. You apply for a grant and then you test it for five years, then it’s another two years before it’s published. So we’re going to have to be looking for more ways for understanding data and evaluating programs. I think the new technologies will help, their more wide-spread availability will help. Just as the health system needs to change—and is changing—health research is going to need to change as well.
The funding agencies still are gradually coming to that point. NIMH has a new program that they are looking to fund that looks at natural experiments out in the community. So I think that’s the sort of research that we’re going to need to see more of in the coming years—good, careful, thoughtful evaluations of some of the demonstration projects going on out in the community.
What barriers to integration to you currently see?
Dr. Druss: I’d say that a lot of community mental health centers are still on this part of the learning curve in terms of learning about integration, such as how potential partner organizations work, [such as] Federally Qualified Health Centers. [CMHC’s] often lack information technology infrastructure that makes it easier to do the work. There are some places, some community clinics, and other organizations that are out in front on these issues, that are early adopters, and there’s some that are trying to figure it out and hopefully will learn from the experience of those organizations that are further ahead.
Thank you, Dr. Druss, for your dedication to improving the health and quality of life of so many who live with serious behavioral health conditions.
Be sure to check back soon for our next Thought Leader, Larry Fricks, pioneer in the Peer Support movement.
A sampling of Dr. Druss’s cutting-edge research and other publications are listed below:
Co-Principal Investigator, Robert Wood Johnson Foundation; Funding Period 9/1/96-1/31/98
“Chronic Illness, Disability, and Managed Care”
Principal Investigator, National Association for Research in Schizophrenia and Affective Disorders (NARSAD); Funding period July 1, 1996 – June 30, 1998
“Work and Health Care Costs associated with Depression Compared with Chronic General Medical Illnesses”
Principal Investigator, Donaghue Medical Research Foundation; Funding period July 1, 1996-Decmeber 31, 1999
“Costs of Depression for an Employed Population”
Principal Investigator, NARSAD; Funding Period July 1999-June 2001
“Treatment of Depression and Medical Illness Under Managed Care: Understanding the Differences”
Principal Investigator, NIMH K08 Mentored Clinical Scientist Award; Funding Period January 1999-December 2004
“Impact of Depressive Disorders in Health and Work Settings”
Principal Investigator, Robert Wood Johnson Foundation; Funding Period October 1, 2004-September 30, 2006
“Evidence-Based Management of Depression in Public-Sector Primary Care”
Principal Investigator: R34MH78583; Funding Period September 1, 2006-August 1, 2010
“Adapting a Medical Self-Management Program for a Community Mental Health Center”
Principal Investigator: K24MH075867; Funding period July 2006-June 2011
“Mending the Safety Net: Improving Linkages between CHCs and CMHCs”
Principal Investigator, AHRQ R18; Funding Period September 2008-September 2012
“An Electronic Personal Health Record for Mental Health Consumers”
Principal Investigator R21HS017649; Funding Period August 1st 2008-April 2010
“Mental Comorbidity and Chronic Illness in the National Medicaid System”
Principal Investigator, NIMH R01; Funding period August 2004-April 2014
“Improving Primary Care for Patients with Mental Disorders”
Principal Investigator NIMH MH090584-01A1; Funding Period 06/15/2011- 03/31/16
“A peer-led, medical disease self-management program for mental health consumers”
“It’s very hard to do integrated care and still think of mental health and physical health.”
Welcome to the first in the Integrated Care Thought Leader Series. This series will focus on the forward-thinking individuals who have had the foresight to envision possibilities in the healthcare industry’s future. I’m pleased to begin the series with a man who has been instrumental in advancing integrated healthcare.
Alexander Blount, EdD
Alexander Blount, EdD, better known to most as “Sandy,” has played a very important role in bringing the integration of behavioral health and primary healthcare to its current prominent focus within the healthcare industry. Dr. Blount is credited with coining the term integrated primary care in his 1994 publication, “Toward a System of Integrated Primary Care,” Blount A, Bayona J. Family Systems Medicine, 1994;12:171-182.
He currently serves as Professor of Clinical Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA and Director of Behavioral Science in the Department of Family Medicine and Community Health. He teaches resident physicians the psychosocial skills of primary care practice and founded the post-doctoral Fellowship in Clinical Health Psychology in Primary Care. He was previously Director of the Family Center of the Berkshires in Pittsfield, MA and a faculty member at the Ackerman Institute for the Family in New York. He has more than thirty-seven years experience as a therapist, teacher of physicians and therapists, administrator and lecturer in the US and abroad. He is a member of the National Integration Academy Council and has had a leadership role in state and national efforts developing healthcare policy. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration published by W. W. Norton and Knowledge Acquisition, written with James Brule’, published by McGraw-Hill. Click here for more information about Dr. Blount.
It’s an honor to talk with Dr. Blount about the integration of behavioral health and primary care. Yes, he admits that he is optimistic about the direction in which the field is moving! His enthusiasm is almost palpable, with a freshness that belies the number of years he has devoted to the advancement of this revolutionary approach to healthcare. It’s apparent that this enthusiasm easily holds the attention of the students he teaches at UMASS.
Dr. Blount is a visionary whose diligent efforts and perseverance have made great strides toward bringing attention to the widespread failure to address the individual patient as a whole. He graciously agreed to provide insights for Behavioral Health Integration Blog:
What do you see as being the greatest barriers for successful integration of behavioral health and primary care services?
Dr. Blount: I see two things:
First are the barriers that have always been there: regulatory barriers that are built on the idea that mental health and medical services have to be kept separate, financial barriers that only pay fee for service and define services as what is delivered in specialty mental health, and cultural barriers on the part of both medical and mental health people that make working together difficult without some cultural broker who can make the connections and translations necessary. These have been our problems historically, and happily with the ACA and the PCMH movement, these are reducing.
The second area is the barriers caused by our own success. Because integrated care is becoming more possible and is proving itself, there is pressure to start programs in settings where there is little understanding of what it entails and little time and resources to prepare for the change. People are getting put into integrated programs or co-located, who aren’t trained for it and didn’t pick it. They don’t know what to do. They go in and do specialty mental health. They do what they’ve been trained to do…and it doesn’t work. Then administrators, who may have been skeptical initially, thought this was a fad, see this failure and think “oh yeah, I was right,” it was more inconvenient than useful. We felt we had to develop a training program at UMass Medical School available to these folks to prevent just this form of failure.
Also because there is sometimes a faddishness about integration, you get some administrators who become “true believers” who really don’t know how to do this. They see a presentation, and they say this is what we are going to do–and they start it without any depth of understanding. It’s sort of the administrative version of the clinician that doesn’t work. We need clinicians who are fully oriented to integrated primary care and leaders who are aware of the difficulties of making these changes and who can develop the buy-in from the whole practice. Integrated pilot programs are often funded on three year cycles. Places like the DIAMOND Project in Minnesota, where they’ve had some real time to make it work, say that it’s more like a five year cycle from beginning to fully transformed practice. I fear that federal and private funders will think it will happen faster than it does and will turn away.
Another barrier to our success is the workforce crisis we are facing. All of the government projections of what will be needed for behavioral health workforce, when compared to the number of people who are being trained, say we will have a terrible deficit, and those projections were made without any calculation of the workforce that has proved to be needed in mature integrated settings. When word gets out that we will need a four-fold increase over 2010 levels in behavioral health clinicians in Federally Qualified Health Centers alone, not to mention the rest of the health system, the true magnitude of the problem will become clearer.
What excites you about the field today?
Dr. Blount:One, is absolutely the transition in payment models that may make a great leap forward happen. Essentially those models let us implement the clinical routines of integrated care. Up to now the payment models have dictated routines that weren’t very integrated. Paying for health, rather than for services allows us to deliver evidence based care by the clinician best able to do it at the point that it is most sensible and acceptable to the patient. Having it actually knitted into the flow of care makes a big difference.
And the other thing that I see happening is a transformation in how we conceptualize mind and body, illness and health. It’s very hard to do integrated care and still think of “mental health” and “physical health”. The categories just begin to break down because they don’t describe the way people present. They don’t describe how problems form over the years. We’ve had science now for a good while on the plasticity of brain and the way that experience changes the brain and the brain changes experience. The current science even describes the way that experience changes what genes are expressed at various points in a person’s development. In other words, the science of the brain has been there but the way of thinking in our day-to-day clinical lives has not because we have been enacting models build on conceptions of separate domains. As we enact integrated clinical routines, we will begin to think differently. We create the likelihood that the science of the brain will be mirrored in the unity of our conceptions about people and how we try to help them.
So I think, at least in the places that are more developed, the places that integrated care gets to be mature, you begin to see different forms of conceptualization and hopefully we’ll be documenting those, writing about those, helping to pull others along. There aren’t many places where integrated care is really mature. The places that are mature are very different in numerous ways that don’t initially seem to be connected to integration. The question of “isn’t integration interesting, how do we work on it?” just goes away and the questions are about new ways of helping patients, new groups of patients we can understand better, and new ways of involving patients on their care teams. How we involve people in their own care, how we get past the doctor as leader and authority to doctor and the team as teachers and facilitators, that’s really the next piece. And when that is going well, I think that integrated care will sort of already be there.
Will you look into your crystal ball for us and tell us what you foresee in the future for integration?
Dr. Blount: Let’s imagine that we get it right in terms of mature programming, mature routines of integration as far as our workforce allows. Then we begin to be able to think about health and illness differently, and the whole set of concepts, the models that we have of understanding health and illness and how to influence those begin to move. I foresee the time when there’s a foundation of mature integrated care that we will be looking at great leaps forward in theory or great research leaps forward with greater understanding of what and how we should be researching. That’s one optimistic thing.
And when I look in my crystal ball I think we are going to have states that begin to have whole-state programs that are starting to be implemented and organized so that we can begin to look at the impact of integration on a really big scale.
Thanks so much to Dr. Blount for sharing his insights in the premiere of the Integrated Care Thought Leader series!
Check back soon for a conversation on integrated care with Benjamin Druss, MD, MPH, Rosalynn Carter Mental Health Chair and Department of Health Policy and Management Professor at Emory University.
The poll generated a tremendous amount of interest, both in voting on the poll and in comments. Much has happened in the healthcare industry in the past twelve months, changes that have an impact on the way behavioral health and primary care will be delivered in the future.
The greatest impact has come from the Patient Protection and Affordable Care Act (ACA) that was upheld by the Supreme Court of the United States on June 28, 2012. Though passed in 2010, the flurry of activity toward implementing began after the Supreme Court ruling. As states prepare for the 2014 implementation of the new health laws, more and more are agreeing to participation in the Medicaid Health Home plan.
Poll Results
As we near the end of the first quarter 2013, time is running out quickly for implementation. With integrated care playing a crucial role in health reform, the challenges for integrating healthcare services are more and more apparent. Revisiting the below results of the poll conducted one year ago, one has to wonder whether the perceived challenges remain the same among healthcare providers.
Poll results from LinkedIn group, Behavioral Health Integration 3/5/2012 – 3/5/2013
Finance and Billing
Poll responses indicated that sustainability issues related to finance and billing were the greatest challenge for integration efforts. While many providers have successfully overcome this barrier, it is no easy feat to develop a financially sustainable integrated services delivery system. Fortunately, the ACA created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with chronic conditions who receive Medicaid benefits. While only a handful signed on initially, there are currently 24 states and the District of Columbia who have elected to participate in the Medicaid Expansion. Fourteen states have elected not to participate; and 12 states remain undecided. (Click here for more information on where each state stands on ACA’s Medicaid expansion.)
States that are moving forward with Medicaid Health Homes are in the process of making adjustments to policies, billing, and service delivery to enable service providers to integrate behavioral health and primary care services, a requirement of Health Homes:
Regular visitors to this blog know that much has been published here about the partnership between behavioral health and primary care providers. This was ranked as second most challenging in the poll.
Why do so many people find partnership issues as challenging? It’s counterintuitive. Most providers approach the integration of behavioral health and primary care with a blind eye to the process of partnership development. It is assumed that the interpersonal aspects will fall into place. Unfortunately, it is far more likely that an integration effort will fail due to partnership issues than financial ones. They are not unlike other partnerships, requiring attention to building a strong foundation from the onset.
All healthcare administrators acknowledge the importance of operations for successful service delivery. That’s why 15% of respondents to the poll indicated that this area is the greatest challenge. Once a smooth-running clinic takes on an entirely new service-line, a degree of disruption is inevitable. The workflow will likely be drastically different than the service providers and support staff have grown accustomed to. Of course, taking on a new service also means addressing the organization’s policies, regulatory requirements, physical space requirements, etc.
With a little careful planning and a LOT of patience, your new integrated clinic will be operating smoothly in no time. Click here for a useful integration planning checklist.
Workforce Issues
Seven percent of the respondents indicated that workforce is the greatest challenge. With the current shortage of primary care providers, nurses, and psychiatrists, it’s no wonder that this is of concern. Fortunately, programs for training about integrated care delivery are available, such as the University of Massachusetts Medical School’s Center for Integrated Primary Care, which offers three programs aimed at training healthcare providers for providing integrated services:
Despite concerns over the dilemma of sharing health records for integrating behavioral health and primary care, health information technology garnered 5% of the responses. Fortunately vendors of electronic health records are working earnestly to develop products that allow for the seamless sharing of behavioral health and primary care records. (Click here for more information on the role of HIT in integrated healthcare.)
One Year Later
What are the greatest challenges to integrating behavioral health and primary care in 2013? What will be the challenges next year? Dare we suggest that in the near future there will no longer be challenges?
Behavioral health advocacy groups are expressing concern over recent media attention about people who may or may not be suffering from mental illness.
And they should be.
The horrendous acts committed in the recent past in Connecticut, Oregon, Colorado, etc. are tragic acts of violence. However, make no mistake that these atrocities are NOT synonymous with mental illness.
The fear of advocacy groups, such as the National Alliance on Mental Illness, A New PATH, and Mental Health America, is that the association between behavioral health and these violent acts will result in increased stigma. These and other groups have worked diligently for many years to reduce/eliminate the negative stereotypes associated with mental illness and substance use disorders.
However, the grain of truth to be derived is that behavioral health services need to be more accessible. Ongoing cuts to behavioral health budgets by states over the past few years have resulted in inadequate coverage (click here for NAMI’s chart: State Mental Health Budgets FY2009-FY2012).
Community Behavioral Health Safety Net
Community behavioral health providers are mandated to serve more people with funding that is steadily decreasing and with no hope in sight. The safety net is nearly frayed beyond repair.
Health Reform has spawned a wide array of innovative approaches to healthcare delivery. The integration of behavioral health and primary care is one such alternative that holds great promise for mental health and substance use services.
When primary care providers integrate behavioral health services, there is a dramatic increase in access to services. When behavioral health is included in routine screenings, the stigma of seeking behavioral health services is removed and opportunity for early detection is dramatically increased. Depression, anxiety, and substance use screenings are normalized through inclusion with height, weight, and blood pressure.
Research shows that depression impacts such chronic health conditions as heart disease. Concurrent treatment of behavioral health and physical health conditions results in improved health outcomes. In addition, integrated behavioral health and primary care services results in reduced healthcare costs.
Integrating behavioral health and primary care is a win-win for patients and providers.
Healthcare providers across the US and in many other countries are integrating services in order to improve service delivery. As individuals, we can do our part by reporting both behavioral health and physical health symptoms to our healthcare providers. Remember, healthcare is a partnership. You are a vital member of your healthcare team.
As readers of this blog are well aware, depression and anxiety “are a major cause of disease burden and disability with depression projected to become one of the three leading causes of burden of disease by 2030.” It is estimated that 90% of people who suffer from depression and anxiety are treated solely by their primary care physician, and the majority of these interventions are exclusively pharmacological. Many people also report being unsatisfied with the level of care they receive. While these facts point toward collaborative care being a logical and effective treatment model for depression and anxiety, there was not enough research that provided conclusive evidence to support recommending collaborative care for those with depression and anxiety problems until this year.
*Collaborative Family Healthcare Association (CFHA) promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities. CFHA achieves this mission through education, training, partnering, consultation, research and advocacy.
If psychiatrists want to be more effective and help a much larger number of people, they need to work in a model of integrated care where they can collaborate closely with primary care physicians, said psychiatrist Jürgen Unützer, M.D., M.P.H., at APA’s 2012 Institute on Psychiatric Services in New York last month.
In the US the first week of October has been recognized as Mental Illness Awareness Week since 1990 when it was established by Congress in recognition of the National Alliance for Mental Illness’s efforts to increase public awareness about mental illness. Mental Illness Awareness Week also coincides with similar organizational campaigns:
There is no doubt that this campaign has been a successful one, raising awareness, encouraging people to screen for depression, and chipping away at the negativity surrounding mental illness. This theme is aligned with the philosophy of behavioral health integration. Therefore, perhaps a day can be designated for recognizing the importance of integrating behavioral health and primary care services. When physical health and behavioral health are addressed concurrently, people have better health outcomes and are better satisfied with their healthcare services. Integrated healthcare also offers improved access to services and reduces healthcare costs.
Integration has been referred to as the neck; a means of reconnecting the mind and body. In integrated healthcare, the mind and body are addressed as a whole, rather than compartmentalized. There is a focus on prevention and wellness that promotes improved health outcomes. Across the United States and around the world, behavioral health and primary care providers are transitioning service delivery to a more collaborative approach. The United States Department of Health and Human Services‘ Substance Abuse and Mental Health Services Administration has invested in nearly 100 initiatives in their Primary and Behavioral Healthcare Integration grants. This commitment demonstrates the importance placed on integrated healthcare by the United States.
Perhaps we can designate each Friday of Mental Illness Awareness Week as National Behavioral Health and Primary Care Integration Awareness Day.
Cardiometabolic syndrome (diabetes, hypertension, obesity, and dyslipidemia) is prevalent among people living with serious behavioral health conditions resulting in their dying decades prematurely. The integration of behavioral health and primary care holds great promise for improving health outcomes. Not only are comorbid conditions treated concurrently, the focus on wellness/prevention allows for learning healthy habits.
Focus on Wellness
The following video, Be One in a Million, was created by Intecovery Cobb CSB and the Peer Support Program at Cobb/Douglas CSB as part of the Million Hearts initiative. It provides a look at the prevalence of preventable health conditions and the contributing factors. This inspiring video features individuals who self-identify as living with behavioral health disorders and thought-leaders in healthcare integration. It provides suggestions of ways to adopt a healthier lifestyle.
Enjoy…after watching you may decide to take the pledge, too!
Behavioral Health Integration 