Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care
J Gen Intern Med
Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care
Kurt Kroenke 0 1 2
Jurgen Unutzer 3
0 Regenstrief Institute, Inc , Indianapolis, IN , USA
1 Department of Medicine, Indiana University School of Medicine , Indianapolis, IN , USA
2 VA HSR&D Center for Health information and Communication , Indianapolis, IN , USA
3 Department of Psychiatry and Behavioral Sciences, University of Washington , Seattle, WA , USA
Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurementbased care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care.
PRIMARY CARE INTEGRATION RATIONALE AND BARRIERS
Worldwide, the prevalence of major depression and anxiety
disorders is 5.6% and 4.0%, respectively, and mental disorders
account for nearly 25% of all health-related disability.1
Depression and anxiety are each present in about 10% of primary
care patients in the US2 and are the first and fifth most
common causes of years lived with disability (YLDs) among
all diseases.3 Indeed, depression and anxiety alone account for
as many YLDs in the US as do chronic obstructive pulmonary
disease, diabetes, Alzheimer disease, ischemic heart disease,
stroke, and chronic kidney disease combined.
Of all mental health (MH) visits, more are to primary care
providers (PCPs) than to psychiatrists, and the PCP proportion
has been rapidly increasing. Of the 22 visits per 100 persons in
the US population to psychiatrists and PCPs that resulted in a
mental health diagnosis in 2010, 60% were to a PCP
(compared to 54% in 1995); of the 35 visits per 100 persons that
resulted in a psychotropic medication prescription, 77% were
to a PCP (compared to 67% in 1995).4 A majority of patients
are treated for depression exclusively in primary care (73%)
with fewer patients treated by psychiatrists (24%) or other
mental health professionals (13%).5 Although PCPs provide
the majority of MH visits, these visits only make up a small
proportion of their overall work: 3% and 2% of PCP
encounters are coded for a primary diagnosis of depression and
anxiety compared with 41% and 27% of psychiatrist visits.4
Besides prevalence, other factors mandating a principal role
for PCPs include a shortage of mental health specialists and the
reluctance of some patients to accept a mental health referral.
Fewer than one in four adults with a diagnosable mental
disorder receive care from a mental health professional in
any given year.6 Many patients prefer receiving treatment from
providers with whom they already have an established health
care relationship.7 Barriers include: (1) insufficient training
and/or interest of some PCPs in managing mental disorders;
(2) the brevity of primary care visits; (3) the competing
demands of preventive care and treatment of comorbid medical
conditions; (4) reimbursement systems that carve out mental
health care or constrain payment to PCPs for adequate
treatment of mental disorders; (5) confidentiality concerns of MH
providers or patients that impede sharing of notes; (6)
disagreements among different types of MH specialists on which
providers should be integrated and what roles they should play
KEY COMPONENTS OF EFFECTIVE INTEGRATION
Because most trials of integrated care have tested
multicomponent treatments, the evidence supports these bundled
interventions as a whole rather than their discrete components
(Table 1). The key components outlined in Table 2 are distilled
from more comprehensive reviews.7–17
Table 1 Six Key Components of Integrating Mental Health into
Primary Care
Identify and track all patients with a
particular disorder
Difficult without registry and/or care
manager
Screening and severity assessment
Regular treatment outcome monitoring
Regularly monitor severit (...truncated)