The case for behavioral health integration into primary care

In a typical primary care practice, detecting and managing mental health problems competes with other priorities such as treating acute physical illness, monitoring chronic disease, providing preventive health services, and assessing compliance with standards of care.¹ These competing demands for a primary care provider’s time, paired with limited mental health resources in the community, may result in suboptimal behavioral health care.^1-3 Even when referrals are made to mental health care providers, depression is adequately treated only 20% of the time.^2,3 Additionally, individuals with serious mental illness and substance use disorders often do not receive adequate general medical care.^4,5

Approximately 30% of adults with physical disorders also have one or more behavioral health conditions, such as anxiety, panic, mood, or substance use disorders.⁶ Although physical and behavioral health conditions are inextricably linked, their assessment and treatment get separated into different silos.⁷ Given that fewer than 20% of depressed patients are seen by a psychiatrist or psychologist,⁸ the responsibility of providing mental health care often falls on the primary care physician.^8,9

Efforts to improve the treatment of common mental disorders in primary care have traditionally focused on screening for these disorders, educating primary care providers, developing treatment guidelines, and referring patients to mental health specialty care.¹⁰ However, behavioral health integration offers another way forward.

WHAT IS BEHAVIORAL HEALTH INTEGRATION?

Behavioral health integration (BHI) in primary care refers to primary care physicians and behavioral health clinicians working in concert with patients to address their primary care and behavioral health needs.¹¹

Numerous overlapping terms have been used to describe BHI, and this has caused some confusion. In 2013, the Agency for Healthcare Research and Quality (AHRQ) issued a lexicon standardizing the terminology used in BHI.¹¹ The commonly used terms are coordinated care, co-located care, and integrated care (TABLE 1),^11,12 and they may be best understood as part of a BHI continuum. A combined expert panel of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) has developed a conceptual framework defining 6 levels of integrated care spanning the 3 practice structures of coordinated care, co-located care, and integrated care (FIGURE 1).^12,13Reverse co-location is another frequently used term; it refers to primary care providers who work in settings devoted to mental health or chemical dependency treatment.¹¹

COORDINATED CARE AND THE COLLABORATIVE CARE MODEL

BHI at the level of coordinated care has almost exclusively been studied and practiced along the lines of the collaborative care model (CCM).^14-16 This model represents an advanced level of coordinated care in the BHI continuum. The most substantial evidence for CCM lies in the management of depression and anxiety.^14-16

Usual care involves the primary care physician and the patient. CCM adds 2 vital roles—a behavioral health care manager and a psychiatric consultant. A behavioral health care manager is typically a counselor, clinical social worker, psychologist, or psychiatric nurse who performs all care-management tasks including offering psychotherapy when that is part of the treatment plan.

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