Psychosomatics 44:1-11, February 2003
© 2003 The Academy of Psychosomatic Medicine
The Future of Behavioral Health and Primary Care: Drowning in the Mainstream or Left on the Bank?
Harold Alan Pincus, M.D.
Received Feb. 26, 2002; revision received July 3, 2002; accepted July 24, 2002. From the Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine; and the RAND—University of Pittsburgh Health Institute. Address reprint requests to Dr. Pincus, Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St., Pittsburgh, PA 15213; pincusha{at}msx.upmc.edu (e-mail).
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INTRODUCTION
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It is impossible to practice effective primary medical care without attention to the range of psychological and social issues embedded in the lives of all human beings. While most thinkers, practitioners, patients, and others involved in health care would tend to agree with this axiom, the separation between the mental and the physical has persisted at least since the time of René Descartes in the 17th century and, by means of current organizational and financing strategies, is actually increasing. Moreover, the failure to effectively integrate mind and body persists in the face of
- massive epidemiological evidence on the prevalence of mental disorders in primary care and their personal, family, and societal impact;1
- promulgation of powerful conceptual models (e.g., George Engel's biopsychosocial model2) and treatment frameworks (e.g., behavioral medicine/health psychology3 and consultation-liaison psychiatry4) that integrate these concepts;
- enormous growth in basic and clinical research documenting the linkage and indivisibility of mental and physical processes; and
- exhortations by major governmental (e.g., A Report of the Surgeon General on mental health1) and other national leaders (e.g., Institute of Medicine/National Academy of Science reports.5)
I assume that the readership is reasonably knowledgeable regarding each of these points. I also assume awareness of the persistent problems that have been documented with regard to the adequacy of primary care providers' recognition and treatment of mental and behavioral disorders.5–7 In addition, I assume that the rationale for, and effectiveness of, longitudinal collaborative-care models for these conditions is well accepted.8,9
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SPECIAL FEATURES OF MENTAL/BEHAVIORAL CONDITIONS
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Why then are mental disorders and psychosocial problems perceived as different from the other issues primary care providers routinely encounter? While they are not exclusive to these kinds of problems, a few particulars stand out, especially in this regard.
They Are Seen as Ubiquitous
All humans, at some point in their lives, encounter stress, have problems with or lose friends and relatives, have difficulty concentrating, feel despair or sadness or anxiety, or directly or indirectly feel the hazardous effects of alcohol, tobacco, or illegal drugs.
They Are Perceived as Difficult to Define
The definitional problem is evident from the discomfort I have in using the term "behavioral health" in the title of this article. The term imperfectly includes care of mental disorders, substance use conditions, and a broad range of psychosocial problems as well as behavioral aspects of general medical conditions. Further, as a corollary, not all individuals who encounter these issues consider them problems or illnesses (or are considered by others to have a problem or illness) or have evidence of impairment as a result. Most of these phenomena (but not all) lie on a continuum in which objective means for making distinctions are rare, which is not all that different from most other medical conditions! To complicate matters further, biological, psychological, behavioral, and socioenvironmental interventions are all relevant.
They Are Stigmatized
Whether viewed from the popular media portrayal of a Woody Allen-esque New Yorker cartoon or a grade-B slasher movie, these types of problems are often caricatured by the general public (and by primary care providers). On a more serious and insidious note, there remains extensive bias in insurance, hiring, and other financial and administrative practices. Moreover, perhaps because of their ambiguity and dimensional nature, there is often an expectation that individuals ought to "bootstrap" themselves up and that failure to do so represents a personal or moral weakness.
The Role of Primary Health Care Is Ambiguous
By their very nature, these types of problems lie at the intersection of multiple social institutions or systems, i.e., education, social welfare, criminal justice, and occupational. The precise boundaries and responsibilities of the various sectors are generally not well specified, and even within a given system (e.g., health care), the precise roles of generalists and the various subspecialists (e.g., psychiatrists, psychologists, etc.) are often more subject to local, financial, and organizational factors than to clearly specified empirically based algorithms. This ambiguity is furthered by the tensions between primary care provider interests and predispositions (e.g., action-oriented, algorithmic) and those of behavioral health specialists (e.g., introspective, reflective).
Perhaps more than with any other interface of primary care, these types of problems call into question the foundations and boundaries of all of medicine as well as our concepts of health and disease. At the same time, and probably in more ways than not, these types of conditions are very much like the other types of conditions that are the focus of primary care. In fact, the main theme of this article reflects the view that the conceptual, financial, organizational, and educational approaches to mental and behavioral conditions should be not different from those of other bodily systems. As Frank deGruy put it in his superb and comprehensive review of mental health and primary care for the 1996 Institute of Medicine report on primary care:
Systems of care that force the separation of "mental" from "physical" problems consign the clinicians in each area of this dichotomy to a misconceived and incomplete clinical reality that produces duplications of effort, undermines comprehensiveness of care, hamstrings clinicians with incomplete data, and ensures that the patient cannot be completely understood.5
Thus, in this article I will provide some initial concepts and definitions, briefly summarize the issues and barriers faced at multiple levels in trying to integrate care of these conditions into primary care, and then portray the future—laying out assumptions, population-specific scenarios, and potential risks.
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CONCEPTS AND DEFINITIONS
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One of the major problems in discussing the subject of this article is the difficulty in defining it. Table 1 describes some of the many terms used to characterize this topic. For the purposes of this discussion, I incorporate three main foci (each with its own definitional issues):
- Alcohol, drug, and mental disorders and psychosocial problems in primary care.
- Behavioral and psychosocial interventions in primary care.
- Primary care for individuals with mental disorders.
Alcohol, Drug, and Mental Disorders and Psychosocial Problems
In many ways, the anchor point for defining this group of conditions has been DSM-IV.10 DSM-IV, which is fully linked to ICD-9 CM (the official U.S. classification and coding system) and the ICD-10 (used in other countries), is essentially a descriptive system that attempts to define relatively homogenous categories on the basis of their phenomenologic presentations (i.e., by specific symptoms). A core conceptual feature of DSM-IV is the definition of a mental disorder, which essentially requires that the manifestations meet the specific criteria in DSM-IV (e.g., for major depressive episode, schizophrenia, alcohol abuse) and have "clinically significant distress or impairment (in major social roles)." In addition, in situations in which specific criteria are not met (e.g., atypical or subthreshold cases) but the clinical significance criterion is met, a condition is classified as a disorder by using a not-otherwise-specified category (e.g., depression not otherwise specified).
Unfortunately, DSM-IV is quite inadequate for use in primary care.11 While a comprehensive critique of DSM-IV is beyond the scope of this article, its focus on specialty care (and derivation primarily from data gathered in psychiatric tertiary-care settings), its length, complexity, emphasis on "splitting" rather than "lumping," and particularly its focus on mental disorders compared to psychosocial problems or other subthreshold (but not subclinical) conditions12 make it less useful to, and less used, in primary care.
DSM does actually attend to nondisorders, i.e., psychosocial problems, in a section on "Other Conditions That May Require Clinical Attention" and through its multiaxial system, i.e., axis IV—psychosocial/environmental problem checklist. These components, however, are generally given little attention in clinical or academic use, and as a result, there is a disconnection between primary care providers' and mental health specialists' perspectives on "diagnosis," as depicted in Figure 1.12 While both may agree on the diagnosis of certain conditions manifested by individuals as needing or not needing attention to disorders/ problems, there are also important discrepancies, as represented by boxes 2 and 3. Numerous studies have documented the low rate of recognition of mental disorders by primary care practitioners, as defined by standard psychiatric research diagnostic tools.6,7 At the same time, mental health specialists and the academic and research leadership tend to be uninterested in the "meat and potatoes" of primary care practice—patients with various forms of psychosocial problems or who are distressed or impaired but may not meet formal DSM criteria. Furthermore, even individuals without any disorder or problem may benefit from one or more forms of behavioral or psychosocial intervention. Thus, for the purpose of this article, we include in our purview individuals represented in boxes 1–3 of Figure 1.
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FIGURE 1. Relation of Primary Care Providers' Perspectives on Diagnosis to Those of Mental Health Specialistsa
aBox 1 represents no disagreement regarding diagnosis. Boxes 2 and 3 represent disagreement regarding diagnosis. Box 4 represents no disagreement regarding absence of diagnosis.
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Behavioral and Psychosocial Interventions
While the advances in psychopharmacology have been exceptionally dramatic, a more subtle but in some ways equally important revolution has been occurring within the domain of nondrug interventions. Highly specific, manualized, short-term, evidence-based behavioral technologies have been developed and tested to treat a wide range of conditions.13 Some have been developed for specific mental disorders, e.g., cognitive behavior therapy or interpersonal therapy for depression, dialectical behavior therapy for borderline personality disorder, and cognitive rehabilitation for schizophrenia. Others are aimed specifically at behavioral factors associated with general medical conditions. Still others are chronic disease management protocols that involve psychoeducation or cognitive behavior techniques for particular general medical conditions. Other behavioral and psychosocial interventions might best be considered preventive health interventions, some of which should be available to all individuals in a population (e.g., education about safe sexual practices, tobacco use prevention activities). Many interventions that are commonly labeled complimentary or alternative medicine would fit into this category (e.g., meditation and relaxation techniques).14 Inasmuch as I recommend broader integration of behavioral health specialists into primary care, the skills many of these individuals possess apply to interventions across the range of general medical conditions, which are preventive opportunities as well as treatments for alcohol, drug, and mental disorders and psychosocial problems. In addition, many of these interventions can be implemented by primary care providers.
Primary Care for Individuals With Mental Disorders
Individuals with mental disorders (especially severe conditions such as schizophrenia and Alzheimer's disease) are more likely to suffer from general medical conditions as well as inadequate primary medical care.15 Many factors contribute to these findings. The nature of the mental disorder may make it difficult for individuals to seek out and trust in care. Reimbursement mechanisms and the organization of services are incredibly confusing, with separate systems, personnel, and rules and lessened communication and collaboration. Anyone would be challenged to navigate through that level of complexity, let alone individuals with severe mental illness.
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BARRIERS
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For centuries, mental and physical disorders have been perceived differently, and this is reflected in how institutions for providing care for them have been constructed. The mental health system, especially for care of individuals for more severe disorders, has long been largely based in the public sector, generally as the responsibility of states or counties. The substance abuse treatment system is even more entrenched (and separate from mental health) in an underresourced public auspice that is generally more closely linked to criminal justice and social welfare than to medicine.
The providers have also grown up in largely different worlds; only a minority of mental health specialists are physicians, and even psychiatry has had mixed connections with the rest of medicine (e.g., in the 1970s, psychiatry briefly did away with the medical internship requirement). Various types of psychologists, social workers, substance abuse counselors, and therapists often have little, if any, exposure to primary care—except for their own personal medical care. They are just as likely to be linked to (or placed within) social services systems, educational systems, or criminal justice systems as to primary care.
The separation between the two systems is perhaps most palpable in the lack of parity in insurance coverage provided for mental illness and substance abuse disorders. Various trends in financing and care have further supported this separation—the community mental health movement, psychoanalysis, the 1980s growth of private psychiatric hospitals, and behavioral health carve-out arrangements.
There do exist important links between mental and behavioral health and general medicine (e.g., neuroscience research, consultation-liaison psychiatry, and health psychology). Unfortunately, each has had its limitations in overcoming these barriers. Neurobiological paradigms have tended to replace psychoanalytic concepts in mainstream psychiatry. Unfortunately, despite the linkages to medicine from a physiological perspective, this preoccupation with brain biology and psychopharmacology has evolved in a way that is rather unhelpful to generalists. Primary care clinicians have lost a theoretical framework for understanding the human condition and giving meaning to symptoms. Similarly, health psychology, behavioral medicine, and psychiatric consultation-liaison services have developed outside the realm of primary care. Connections to medicine or to medical concepts in biology or frameworks developed in the context of specialty care are not adequate. The view from within primary care practice is an absolute prerequisite.
Beyond the historical and structural barriers, there are barriers between each level of stakeholder, i.e., patients, providers, practitioners, payers/plans, purchasers, and the population or community.16 For example, at the patient level, stigma, resistance to diagnosis, and health beliefs that tend to emphasize somatic presentations and the very nature of many mental illnesses (e.g., nihilism, pessimism, reduced energy) act as barriers to recognition and treatment in the primary care setting. For primary care providers, limited time as well as limitations in background, training, and the capacity and interest to reflect introspectively may also act as barriers to appropriate treatment in primary care settings. There is also wide variation in how primary care practices are organized to care for people with behavioral health problems, how they allocate resources in this regard, and how they are linked to behavioral health specialty care. Often there is ambiguity about who is responsible for care, and there is limited communication and teamwork between primary care and mental health practices. Typically, primary care practices focus on acute management and referral for what are often chronic or recurrent conditions. (Of course, ambiguity in responsibility and lack of communication between specialists and generalists is not unique to behavioral health, and systematic structures for orchestrating care along a longitudinal perspective of a chronic illness are as rare for such illnesses as depression as they are for asthma or diabetes.)
The presence of an impaired connection between behavioral health and primary care is illustrated and propelled by modern day health care financing and organizational arrangements in the United States. While managed behavioral health organizations have focused on the most resource-intensive mental health cases, one result has been a misalignment of incentives for coordination and communication between primary care and specialty practices and providers. While public purchasers (e.g., Medicare and Medicaid) and private purchasers (e.g., employers) wield insufficiently tapped power in the design of the health care system, they are generally afflicted by many of the same biases as the general population. They also may be uninformed about the substantial indirect costs of mental illnesses, such as depression, from absenteeism and disability.
On the positive side, approaches for improving primary care for depression and anxiety disorders in both integrated and network managed care plans have been developed and tested.9,17,18 Unfortunately, these collaborative arrangements are unlikely to remain in place after a demonstration is concluded unless a sustainable strategy is built in from the beginning. Moreover, depression places enormous burdens at the population level or community level, especially among socially disadvantaged and vulnerable groups. However, there have not been efforts to more broadly link public health approaches with customized community development models in the service of improving depression recognition, management, and outcomes.19
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THE FUTURE
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Trends and Assumptions
These barriers are quite formidable, and it is unlikely that they will crumble in the near future. Nonetheless, important current trends with regard to the health care system and its evidence base portend immense changes in the relationship between primary care and mental/behavioral health. These trends (and their associated assumptions) are likely to result in the following:
- More effective and targeted medications with fewer side effects and risks. The development of selective serotonin reuptake inhibitors and other newer and safer antidepressants have already revolutionized the treatment of depression in primary care.20 Since the door has been already opened quite wide in getting primary care providers to feel comfortable in prescribing psychotherapeutic agents, future drug development may be less revolutionary in shifting primary care practice. However, the clear trend is toward developing more compounds tied to more specific indications that are so safe and easy to dose that the threshold for prescribing by primary care providers will be quite low.
- More targeted, effective, and efficient psychosocial/behavioral treatments for specific mental illnesses/substance use disorders and for prevention and treatment of general medical conditions. Parallel to the development of medications, new psychosocial technologies will be developed, refined, and formally tested. Targeting specific clinical and practical needs may alter our current conception of psychotherapy as only occurring in a series of 45–50 minute face-to-face weekly or more frequent sessions. Some will be limited from one to 12 sessions, of variable length (from 5 minutes to 90 minutes), and administered face-to-face, through broadband video, the Internet, or DVD in the primary care provider's or behavioral health specialist's office or in the patient's home or work environment. Of importance, these technologies will be packaged for specific target situations, e.g., panic disorder with or without agoraphobia, marital discord, or nonadherent adolescent diabetes.
- Diagnostic categorization schemes with more relevance for primary care. As noted, there is a significant disconnection between the mental health specialty diagnostic system (DSM-IV) and the needs of primary care providers. Moreover, the existing instruments and screening tools have not been largely geared toward primary care practice. Primary-care-oriented screening and assessment tools such as PRIME-MD21 and similar tools are important in moving toward linking the two perspectives, but they remain somewhat cumbersome and tied to specialist concepts. New conceptual approaches will be needed to better bridge psychiatry, primary care, and other behavioral sciences (e.g., psychology), especially with regard to classifying and studying the psychological problems that primary care providers identify that do not fit into the DSM/ICD framework (i.e., box 3 in Figure 1). Ultimately, better and more relevant diagnostic systems and tools will enhance the identification of problems and the targeting of specific management strategies.
- Clinical information systems that enable effective tracking and provide decision support. The electronic medical record is fast approaching, but there remain significant potential technical and financial impediments to its widespread implementation. While it is assumed that the field will find effective ways to maintain needed record keeping and communication in the face of the Health Insurance Portability and Accountability Act of 1996 and its children, maintaining an effective bridge between general medical and mental health and substance abuse information will remain complex and controversial. While lessened stigma and a broader acceptance of understanding of mental health issues will help, society and the field are likely to expect a different standard with regard to privacy, confidentiality, and the sharing of behavioral health records. With greater primary care provider involvement in mental health and a broader presence of behavioral health specialists in primary care, mechanisms will need to be established that balance these concerns.
- Financing and practice arrangements for primary care and behavioral health that are more integrated. This may be the most problematic assumption since it envisions the elimination (or drastic reinvention) of carve-out arrangements, which thus far have been quite attractive to purchasers. It would also require full parity for mental health and substance-related conditions—another assumption with significant political hurdles. An alternative scenario might be an even more isolated behavioral health system that operates separately from primary care much as the criminal justice and educational systems do now. I view this scenario as less likely because 1) more resources for behavioral health are likely to be available under the health care umbrella than as a totally independent system (and acceptance of that strategy, i.e., parity, is moving forward), 2) primary care providers will demand a closer connection because their needs are increasingly not being met, 3) purchasers will see more value in such integration, 4) patients will increasingly demand behavioral health services (including complementary and alternative medicine), and 5) the low-hanging fruit of cost savings from carve outs has already been harvested.
Population-Specific Scenarios
A somewhat simplistic and outmoded notion of the potential pathway of primary care involvement in behavioral health/psychological care has primary care providers screening and either treating or referring individuals with specific mental disorders. A more variegated list of functions is presented in the vertical axis of Table 2, which demonstrates the broad potential roles and capacities of primary care.
Table 2 is a matrix providing a sample description of the underlying assumptions regarding the relevant roles of primary care providers and behavioral specialists (psychiatrists and nonpsychiatrists) for particular conditions. With respect to each condition, the specific provider roles, functions, and locations (both in primary care and specialty settings) are depicted. This type of analysis forms the basis for pictorial descriptions in Figure 2 and Figure 3. Implicit in this broader notion of primary care involvement is an expanding role of behavioral health specialists located in primary care settings, as also displayed in Figure 2 (providing a picture of the relative roles of primary care providers and behavioral health specialists for different subgroups). Figure 3 depicts the overall framework for care delivery in which specific populations defined by diagnosis or by need for particular behavioral health/psychosocial interventions (i.e., only d and e) are linked to particular service providers and settings (as depicted by various levels of shading).
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FIGURE 2. Relative Degree of Involvement of Primary Care Providers and Behavioral Health Specialists in the Treatment of Mental Health Disorders
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FIGURE 3. Overall Framework for Mental Health Care Deliverya
aSpecific populations defined by diagnosis or need for particular behavioral health/psychosocial interventions are linked to particular service providers and settings.
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Care for severe/complex mental illnesses/substance use disorders
Most of the time, we think of primary care/ mental health integration from the perspective of integrating behavioral health care into primary care; however, there is a compelling need to simultaneously consider a reverse perspective. Individuals with severe mental and addictive disorders (i.e., schizophrenia, substance dependence, bipolar disorder, and more debilitating forms of chronic anxiety, depressive, and personality disorders) (in Figure 3a) are known to have higher mortality rates than the general population. While some of the excess mortality is due to direct mental health outcomes (i.e., suicide), a substantial proportion is due to general medical conditions (e.g., cardiovascular disease, infectious disease, respiratory problems, etc.). Individuals with these disorders are also likely to have less access to care because of the barriers described. It has also been well documented that general medical conditions are often unrecognized and inadequately treated in this population. For many of these individuals, especially those treated in the public sector, specialty clinics (e.g., community mental health centers, addiction treatment programs) are likely to be the principal or only points of contact with the health care system.22 While there have been exhortations over the past several decades for psychiatrists to officially take on responsibility for the primary care of individuals with severe mental disorders, primary activities are a tiny portion of psychiatrists' focus.
Thus, to improve primary care for these individuals, it will be necessary to go where they are, i.e., the specialty mental health system, and bring primary care providers on-site, i.e., and not rely on psychiatrists and other mental health specialists. Such an approach would also allow for better integration across other levels of specialty behavioral care (which these patients often require) and other systems (e.g., vocational, welfare, criminal justice) since these connections are better established on the mental health side than in primary care. While the barriers to integrating primary care into the specialty behavioral health settings treating these populations are formidable, on-site integrated models providing primary care and case management that incorporate preventive care, patient education, and close collaboration with mental health professionals have been tested and found effective. Making use of a nurse practitioner and a part-time family practitioner, one randomized controlled study documented significant improvement in the quality and outcomes of care without any increase in costs.22 It will, however, be essential to develop financing mechanisms that encourage such integration.
Care for less severe/complex alcohol, drug, and mental disorders or psychosocial problems/subthreshold conditions
In this instance, I am referring not only to the "bread and butter" of mental and behavioral disorders currently in primary care, i.e., individuals with undifferentiated depressive and anxiety disorders, but to those with varieties of psychosocial problems and subthreshold conditions including problem drinking, tobacco use, etc. (circles b and c in Figure 3). I also believe that there will be an important role for the primary care sector in caring for individuals with more complicated and severe conditions (e.g., panic disorder, substance abuse) that afflict large numbers of individuals. Thus, the following scenario is likely to be present:
- Longitudinal care management will be integrated into primary care in a strategic/planned manner.
- Primary care providers and care managers will have enhanced skills in psychopharmacological and psychosocial interventions.
- Behavioral health specialists will be on site for more complex treatments (both psychosocial and pharmacological).
- Psychiatrists will be more accessible, primarily for informal and formal (primarily but not exclusively psychopharmacological) consultation.
As Table 2 indicates, primary care providers will continue to have responsibility for general medical care (obviously), but they will also be expected to have in place a systematic capacity for limited assessment of psychosocial problems and strengths and to conduct screenings for both lesser and more severe disorders. In addition, for all psychiatric conditions initially detected or encountered in primary care settings, the primary care provider will be expected to maintain an ongoing monitoring capacity: for example, is the patient still seeing his or her therapist, is the patient continuing to take his or her medication, did he or she follow through with the referral, etc. The primary care provider will maintain ongoing communication links (even via an electronic medical record) with any behavioral specialist involved.
In most cases, for lesser severity or uncomplicated conditions (e.g., initial treatment of major depression, early nonadherence to hypertension regimens), the primary care provider will have responsibility for a more extensive assessment and initial treatment (through both medications and limited psychosocial interventions, e.g., psychoeducation).
Perhaps most important, for a large proportion of the patients who are currently being treated in the behavioral health specialty area (with more complex cases of depressive and anxiety disorders and substance-related problems and abuse), behavioral health specialists located in primary care settings will be the mainstay of care. There are many advantages to such arrangements. The dropoff resulting from referral to a separate, more distant (and stigmatized) consultant will be reduced. Communication will be enhanced between primary care and behavioral health, both with regard to individual patients and, more important, on a general level. Propinquity will allow easy, informal "curbside" consultation and an ongoing educational presence that will raise primary care providers' skills in, and awareness of, these issues. Also, the presence of behavioral health specialists establishes a more effective behavioral health quality improvement capacity in the practice. Furthermore, the new, short-term, more targeted psychosocial interventions are well suited for primary care environments. In any case, the behavioral health specialists will be there because they will be providing interventions for individuals described in the next section.
Individuals needing psychosocial/behavioral intervention
As noted earlier, new behavioral technologies will be developed and be made applicable to populations well beyond those traditionally considered to have mental disorders (circles d, e, and f in Figure 3). Specific interventions to promote healthy habits and prevent illness (both physical and mental) will be widely available and applied universally (circle f) as well as to targeted populations profiled to be at a higher risk for specific conditions (circle e). While many of the universal interventions will be applied by community organizations or by means of broad population initiatives (e.g., advertising, the Internet, etc.), primary care settings will be an important site, especially for targeted interventions.
The standard of care for virtually all chronic medical conditions (both physical and mental) will include the application of disease-specific psychosocial/behavioral interventions, ranging from psychoeducation to adherence enhancement to specific cognitive rehabilitation techniques that alter the course of the disease. Primary care settings, with responsibility for the bulk of longitudinal chronic illness care, will also have the responsibility for implementing these interventions and maintaining the necessary staff and expertise to do so. Thus disease-specific psychosocial behavioral interventions will be routinely incorporated into chronic disease management systems within primary care by primary care providers, care managers, and in many cases (for more complex or technical interventions) by behavioral health specialists in primary care settings. The training and personnel implications for primary care are profound.
Risks, Dangers, Caveats
Prognostication, in and of itself, has uncertainties and risks, and the assumptions and picture of the future presented could have untoward outcomes that might include the following:
Segregation of individuals with severe/complex alcohol, drug, and mental disorders—"left on the banks"
To the extent that these conditions are seen as separate from the rest of medicine, with different organizational and financing arrangements, as we have seen for centuries, they are likely to be increasingly stigmatized and underfunded. Moreover, while access to quality primary care may increase, more specialized medical/surgical services may become less accessible for individuals with mental disorders. To avoid this scenario, it is critical that academic and professional organizations in behavioral health link to (and establish leadership in) mainstream medicine.
Limited attention of primary care providers to alcohol, drug, and mental disorders and psychosocial behavioral problems—"drowning in the mainstream"
Primary care providers are overwhelmed by the exponentially rising set of expectations and responsibilities placed on them. The human capacity to attend to the myriad of conditions and attendant protocols and guidelines is limited. Unless primary care providers' accrediting and credentialing organizations recognize the importance of behavioral health conditions and place them at high priority, history again suggests that they will be ignored. This means that behavioral health will need to be in the forefront of accreditation and credentialing requirements and the development of quality monitoring systems, electronic medical records, and decision support technologies. Of course, there will also be pressure for imperfect or partial integration of mental health and behavioral issues. The growth of newer medications along with the enormous power of industry marketing may result in hypertrophy of pharmacological approaches and a stunting of the behavioral components.
Failure of financing mechanisms to facilitate integrated care—"On beyond parity"
Ultimately, dollars drive the health care system. As noted earlier, the historic separation, organizationally and financially, of primary care and behavioral health creates enormous financial barriers and disincentives for effective coordinated care. Overall, the level of health care resources devoted to behavioral health (with the exception of pharmacy costs) has significantly dropped over the past decade. Thus, not only will there need to be clever approaches developed to realign these incentives, but there will need to be an enhancement of resources targeted toward behavioral conditions (especially substance abuse). To achieve this goal, a better understanding of how to influence the levels of decision making, i.e., private and public purchasers (e.g., employers, state Medicaid programs) will be needed.
Returning to a narrow definition of medicine, health, and health care—"policy reductionism"
It may be that the challenges presented are too overwhelming, the scope of health care envisioned too broad. Conceivably, given the conceptual, financial, and practical complexities, society (and medicine) may choose to conform to the pressures of stigma and historical antecedents and narrow the focus of health care to the treatment of "physical" diseases. Such a reaction, while unlikely, would be extremely unfortunate. Powerful and sophisticated advocacy efforts will be needed to avert this outcome.
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CONCLUSIONS
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The definitions and issues pertaining to the subject of this article are quite complex. Enhanced comprehensive primary care for individuals that incorporates attention to alcohol, drug, and mental disorders, psychosocial problems, and behavioral interventions will require overcoming an array of barriers at multiple levels. Nonetheless, the future is likely to see enhanced integration of primary care providers into specialty mental health and of behavioral health into primary care. A major strategy will be the incorporation of behavioral health specialists within primary care settings. While there are potential risks in such a future scenario, the quality of care and health outcomes for individuals should improve substantially. Of course, all this is dependent on ensuring adequate access to and financing of health care (primary, specialty, and behavioral health) for all Americans.
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ACKNOWLEDGMENTS
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Supported by a grant from The Robert Wood Johnson Foundation.
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