Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Journal of General Internal Medicine, Feb 2017

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, measurement-based 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.

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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)


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Kurt Kroenke MD, Jurgen Unutzer MD. Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care, Journal of General Internal Medicine, 2017, pp. 404-410, Volume 32, Issue 4, DOI: 10.1007/s11606-016-3967-9