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SECTION V
AN INTEGRATED S _ Y OF INVITATIONAL
WORKSHOP DISCUSSIONS
Each conferee and observer participated in one of three workshop
sessions on the second day of the conference. The discussions, con-
ducted simultaneously and ranging across the entire subject matter
of the conference, are summarized here under five major topics.
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123
PROVIDER ROLES AND FUNCTIONS
A discussion of appropriate functions and roles for primary care
and mental health care providers in general health settings brought
out two points of view. One, more implied than stated, foresaw a very
limited role for psychiatry in primary care settings, and that primary
care practitioners could, with, training in the requisite diagnostic
and case management skills, largely absorb the functions of the mental
health specialists The second point of view was that mental health
care in the primary care context would revise and perhaps increase the
role for psychiatrists. Increasing the diagnostic skills of primary
care physicians was expected to increase the cases of mental disorders
recognized, making it likely that more cases would be referred to the
mental health specialty sector.
In the second view, psychiatrists would be needed: (1) to assist
primary care providers in acquiring and maintaining skills necessary for
diagnosis of mental disorders and management of emotional complaints;
(2) to collaborate with primary care practitioners both (a) to facilitate
their coping with the anxieties and frustrations of caring for patients
with psychiatric disorders, (b) to provide direct service to patients;
and (3) to serve as referral resources. Close collaboration between
psychiatrists and primary care physicians was seen as a promising oppor-
tunity for ensuring appropriateness of patient care and minimizing dis-
ruption of the continuity of care, which is a hazard in the process
of referral.
There was consensus among the participants that a widely recog-
nized and acceptable concept for the division of labor in mental health
treatment does not exist. The range in complexity and severity of pro-
blems for which patients seek care precludes facile distinctions of the
roles and functions of providers. A useful framework for defining
roles and functions of providers should be developed in future research.
There are recurrent difficulties in delineating the kinds, complexity,
and severity of the problems that should be in the purview of various
primary care providers, as well as the complexity and severity of the
problems that are likely to require secondary or tertiary specialized
care by mental health professionals. Difficulties with these distinc-
tions seem to occur more frequently in the ambulatory primary care
setting, where the relationship between mental health specialists and
primary care practitioners is less clearly defined, than in the hospi-
tal, where the roles and functions of "liaison psychiatry" and general
health care seem fairly well circumscribed.
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124
In a discussion of how best to determine the appropriate match
of patients to providers for optimal care of mental health problems,
it was agreed that not all persons with emotional disturbances would
be treated appropriately by psychiatrists, and that the goal for the
primary care practitioner should not simply be to sort out the emo-
tionally disturbed and refer them to specialty practice. It was
suggested that such activities as counseling with parents on child
development, psychological preparation for surgery, or counseling
the post-myocardial infarct patient by primary care practitioners,
are to be expected in the course of general health care. However,
criteria have not been established to determine which non-psychotic
but identifiably mentally disordered persons could be served opti-
mally by primary care providers.
In the matter of defining the general skills required of provid-
ers of mental health care in non-specialty settings, it was emphasized
that mental health care begins with diagnosis. The gamut of mental
disorders in patients who present to general health care providers
makes it essential that the primary physician have a system with fairly
broad applicability to make appropriate diagnoses. Especially in
ambulatory settings, primary care providers should be able to discern
both the patient's underlying disorder and the more immediate reasons
for seeking care.
Several participants noted that -- with some exceptions -- com-
plex cases and chronic mental illness requiring long-term care are
best treated by mental health specialists. Thus, primary providers
should be skilled at referring their patients, when diagnosis so
indicates, to mental health specialists or to other social support
systems. The general health care providers can then focus on counsel-
ing, which serves the functions of interim, crisis-type support and
preventive mental health care.
Although the need for primary care providers to give attention to
patients' mental health needs was mentioned repeatedly, a cautionary
question was raised: Is there a risk, in trying to make primary care
providers more sensitive and better therapists in the psychiatric
sense, of weakening their skills and abilities to manage the medical
problems with appropriate attention? A balance is required between
the medical and mental health skills of providers of general health
care.
Although there was agreement on some of the general skills neces-
sary for providing mental health care in general health care settings,
the "turf" issues remained controversial. A number of participants
cited role differentiation as the principal policy issue to be faced,
and the discussions of an appropriate "division of labor" focused on
the discrete functions of three types of providers: (1) primary care
physicians, (2) psychiatrists, and (3) non-physician mental health
professionals.
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125
Primary Care Physicians
Whether or not it is theoretically optimal, a large part of
mental health care is and will continue to be provided by physicians
who are not mental health specialists, it was conceded. In rural
areas, where approximately one-quarter of the U.S. population lives,
the general practitioner often is the sole provider of health care
in any form, including mental health care. Emphasis on the pragmatic
issues of how to help those who are providing care to deliver better
care was seen preferable to continued debate about who is best quali-
fied to provide mental health care. It was proposed that the basic
mental health skills required by most general health care providers
are relatively simple: warm, humane interests in the patient and the
patient's problems, and a willingness to use psychotherapeutic and
crisis intervention as well as pharmacological intervention to help
people through acute crises. Beyond these basic skills, the general
health care practitioner needs to obtain knowledge from social and
behavioral sciences. This knowledge can promote a more humanistic
approach to patients, increase skills in recognition and diagnosis
of mental disorders and determining their severity, and encourage
use of specialty resources in collaboration and consultation.
Although physicians recognize that much of their practice has a
psychological framework, it was suggested that many tend to be dubi-
ous about the usefulness of collaborating with mental health special-
ists. In addition, some primary care physicians fail to collaborate
or consult with mental health professionals for much the same reason
their patients do not seek care from that specialty sector: they do
not know enough about what the mental health specialist does.
There was consensus that collaboration in some form must be estab-
lished. One promising approach to productive interaction between health
and mental health practitioners is the interdisciplinary team, in ambu-
latory medical settings such as those found in some primary care and
psychiatric training programs. These programs have shown psychiatry and
primary care are not incompatible because of differing approaches to the
multiplicity of patient problems. It was also pointed out that the
whole primary care team, especially in the absence of other contacts,
may become essential parts of the coping mechanisms of patients.
Psychiatrists
An increasing involvement of the general health care sector
in providing mental health care has raised a need to redefine some
aspects of psychiatry~s role. Conferees noted that some health
policy-makers had presumed that increasing the numbers and quality
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of training of primary care physicians would result in their caring
for a greater proportion of the population with mental disorders and
a concomitant reduction in the need for mental health specialists.
But it was agreed that experience to date does not support the pre-
sumption.
Private practice and hospital-based liaison psychiatrists are
expected to continue to provide specialty care for severe psychopatho-
logy, and to fulfill the traditional function of handling mental health
referrals from the general health care sector. There is, however, a
growing need for psychiatrists as consultants in ambulatory health care
settings. Consultation or liaison psychiatry, in addition to promoting
the improved management of a broad range of mental disorders can be a
valuable means of continuing education for both general health care
physicians and psychiatrists.
The role of psychiatrists as educators in residency training pro-
grams may represent the current most effective linkage between psychia-
try and the general health care sector, given the still relatively
limited opportunities for direct collaboration in the actual delivery
of care in established settings. Important contributions of psychiatry
to the training and practice of primary care practitioners include
teaching diagnostic, therapeutic, and preventive skills, along with
guidelines for appropriate referral for specialty care, and explaining
the new emphasis on the biopsychosocial or holistic approach to patient
care.
The practice of psychiatry in the primary health care setting
was seen as an opportunity to revise and broaden the perspective of
the psychiatrist on formats for therapeutic intervention. In contrast
to specialty mental health services, in which patients are ordinarily
seen for prolonged episodes over a relatively brief span of time (such
as two or three visits a week over an eighteen-month period), primary
health care providers generally follow patients in brief episodes of
care over long periods of time (such as two or three visits a year
over the course of several years). A successful outcome of specialty
mental health service typically has been based on the expectation
that the patient will not return-after the completion of psychothera-
peutic intervention. The definition of successful outcome in primary
care is quite the opposite: the primary health care provider assumes
that patients will continue to return for health care as needed.
It was suggested that psychiatrists in primary health care settings
might employ a "string of beads" approach, in which the patient would
work on a theme in a succession of crisis episodes for which he or she
would return to the same therapists to pick up the treatment. The
treatment course in this approach is not terminated but is considered
to have do ant phases. This course could be a workable alternative
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for patients who previously deemed psychotherapeutic intervention
unacceptable because of the prolonged and costly involvement. Most
psychiatrists, however, have not been trained in this kind of task-
centered modality, and psychiatric training programs would have
to be modified for it to become a part of the psychiatrist's thera-
peutic resources. This kind of approach may not be feasible for
some patients, such as the chronically mentally ill who may need
consistent and continuous care.
Non-physician Providers of Mental Health Care
Variability in the type and severity of mental disorders pre-
sented by patients seeking help in the primary health care sector has
implications for employment of a variety of non-physician providers
of mental health care, such as social workers, nurse-practitioners,
psychologists, and physician assistants. Conferees noted that for
the less differentiated states of mental morbidity, which may often
require extensive time and attention, non-physicians in fact may be
the most appropriate providers. A number of participants pointed
out that non-physician mental health professionals are particularly
skilled at assessing and managing psychosocial problems e Examples
were cited of several British primary health care settings where the
use of medical social workers has achieved some positive results in
the economy and efficiency of care for psychosocial problems. It
was suggested that perhaps the most important role of these social
workers was a coordinative one between the health, mental health,
and social service sectors.
The participation of non-physician mental health specialists
in general health care settings, both as primary care providers and
as consultants, can encourage preventive health programs and patient
involvement. The non-physicians also can be effective educators of
medical residents.
The economic benefits of employing non-physician mental health
personnel also were discussed. There was agreement on the potential
advantages of this mode of care, but several participants expressed
concern that the quality of care could be compromised to save money.
The observation also was made that the training in some of these
fields may not necessarily provide adequate skills for many psycho-
logists and social workers, to step into a primary care setting
and be helpful.
EDUCATION AND TRAINING
The discussion of education and training focused principally
on the needs of non-psychiatrist providers of mental health care
in general health settings. The development of adequate programs,
workshop participants agreed, probably will require fundamental
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shifts in-the traditional attitudes and orientation of medical educators.
At present, there is great variation in the mental health knowledge,
skills, and attitudes of practicing primary care professionals and wide
diversity in the mental health training available in medical schools and
residency training programs.
The implications for the training of psychiatrists of the growing
emphasis on integrated health and mental health care also were discussed.
Departments of psychiatry are beginning to consider alternative roles for
psychiatrists in relation to the general health care sector, and training
programs are likely to place increased emphasis on skills in indirect care
and consultation in many kinds of practice settings.
The inadequacy of current programs in medical education and training
at a number of levels was discussed. It was suggested that premedical
undergraduate education generally pays insufficient attention to the be-
havioral and social aspects of human biology, and that selection of medi-
cal school applicants tends to downplay or disregard "whatever it is
that would indicate that they would like to take care of people's needs
beyond a purely physical ailment level." There was general agreement
that medical school curricula tend to neglect the behavioral sciences.
Perhaps the strongest criticism of the current system, however, concerned
the limited opportunities for appropriate practical experience in inte-
grated health/mental health care facilities during residency training.
Opportunities for health care personnel to get continuing education also
were observed to be limited.
Suggested ways to improve medical education and training programs
primarily were: (1) revising the content of the standard medical school
curriculum, in terms of both orientation and instruction in specific
skills; (2) offering more appropriate clinical training experiences to
prepare medical students and residents for the practice of integrated
health/mental health care; (3) providing appropriate and effective role
models throughout the educational and training process; and (4) upgrading
continuing education for practicing physicians. Funding and other fac-
tors in making such changes also were discussed.
(1) Content Education and training of general health care prac-
titioners should include knowledge from many disciplines that are not
necessarily considered "medical," including psychiatry. Fields such
as anthropology, economics, and particularly the behavioral sciences
and sociology, should contribute to both premedical and medical school
curricula; greater emphasis on behavioral medicine should be reflected
in the National Board Examinations. A developmental life cycle approach
to studying health in relation to mental health was endorsed by several
participants. There was general agreement that awareness of patients'
social contexts is an important component of integrated health care.
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Although promoting a less "biotechnical" orientation and approach
among health care providers is essential, the teaching of behavioral
medicine also must include instruction in the specific mental health
skills that enable physicians to deal effectively with the behavioral
aspects of their patients' problems. Three related types of skills
were emphasized: detection of mental health problems; accurate assess-
ment and diagnosis of those problems; and appropriate management of
them, which requires both an understanding of psychotherapeutic tech-
niques--counseling and medication--and when to make appropriate refer-
rals.
(2) Clinical training Effective application of the skills men-
tioned above requires practical experience. Several participants
observed that, even when students are motivated to become providers
of integrated health and mental health care, most training programs
do not furnish adequate clinical preparation for the practice of
mental health care in general health care settings. For most medical
students who do not choose to specialize in psychiatry, practical ex-
perience in applying mental health skills under supervision is limited
to the psychiatric rotation as a small and discrete part of their medi-
cal education, rather than as an ongoing process.
There was general agreement that, to promote effective integra-
tion of mental health and general health care, residency training of
all potential primary care providers -- including those specializing
in psychiatry -- should be available and encouraged in integrated care
settings, such as neighborhood health centers, continuing clinics, and
other primary care settings that include mental health services. Resi-
dents should be integrated into primary care teams with psychiatric
social workers, nurse practitioners, staff physicians, and the like
to encourage sharing of skills and responsibilities. Traditional
hospital-based residencies tend to train physicians to interact episod-
ically with their patients, providing limited opportunities to establish
the longer-term relationships in which health and mental health care
most successfully are combined. Linking such academic centers with
various community care systems was suggested as an effective way to
provide training in integrated care.
Appropriate practical training will become increasingly necessary,
several participants commented, as more physicians are required to ful-
fill "payback" obligations in underserved areas in return for financial
support of medical education. Health care in such areas characteris-
tically lacks the backup support resources associated with better served
communities.
(3) Continuing education Concern was expressed that some primary
care physicians tend to ignore or minimize the mental health needs of
their patients. Another view was that primary care physicians recognize
that there are psychosocial components of patient care, but also are
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aware of the inadequacy of their training in mental health skills.
There was general agreement that improved programs in continuing
education are needed. Most participants felt that collaboration
among specialist and non-specialist providers of mental health care
is the most effective forum for continuing education.
Programs in collaborative postgraduate training for providers
who practice in more traditional, non-integrated settings also were
described. One model that has been fairly successful on a regional
basis involved psychiatrists working with pediatricians in regular
collaborative arrangements. "Balint" groups also were mentioned; in
these, the consulting psychiatrist does not see patients but helps
primary care providers as a group to explore their own sensitivities
and feelings related to patient care.
(4) Role models The point was made that there are not enough
role models for practitioners of the type of integrated care discussed
at the conference. Even with models, learning in this area is difficult
because the concepts are complex and exhausting psychological effort
is involved in applying them. The prevailing disease-oriented medical
models discourage attempts to integrate health and mental health care.
It was suggested that role models must be sufficiently numerous to
form a "critical mass" of professionals who believe in and can practice
integrated care in order to demonstrate commitment to health/mental
health linkages at all levels of care. Participants also emphasized
the importance of engaging medical faculty with additional background
in psychiatric skills, and psychiatrists and other mental health
professionals who have experience working with nonpsychiatric physi-
cians, in the training of primary care residents in mental health
skills.
Policies for Education and Training
Although training health professionals to provide integrated
care apparently is a major objective of both educators and federal
policymakers, current strategies to improve education and training
often are not realistic, a number of conferees indicated. State and
federal funding policies for medical education and training were
particularly questioned.
An increasing proportion of federal funds for psychiatric train-
ing is being moved from the psychiatric specialties to primary care
programs. Although the purpose of this shift is to improve mental
health training in more general programs, the quality of such training
was questioned, both in terms of the qualifications of the trainers
(low levels of funding necessitate hiring faculty at junior levels)
and in terms of available training settings. One educator observed
that ambulatory care training for psychiatrists and primary care
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providers, in which experience with collaboration in patient care or
appropriate referral would be meaningful, is not now funded to any real
extent. Training in general medicine is hospital-based and has relative-
ly little emphasis on ambulatory care. Similarly, liaison psychiatry in
academic medical centers and general hospitals is largely focused on
care of hospitalized patients. There also was concern that the policy
emphasis on mental health as part of primary care will downgrade psychia-
tric programs and discourage the practice of specialty mental health
care. Such a trend, it was noted, ultimately would erode the quality
of overall integrated care.
The issue of state and federal requirements for payback service by
new physicians whose medical education was paid for by the government
also was discussed. Several participants expressed concern about in-
appropriate placements of both general care providers and mental health
specialists, and urged that a variety of eligible service settings
be considered by policymakers.
REIMBURSEMENT
Workshop participants registered a strong consensus that current
patterns of financing do not support an optimal, integrated health/
mental health care system in this country. Insurance benefits for
treatment of mental disorders are sharply limited, compared with re-
imbursement offered for the care of other kinds of illnesses. Often
there is no provision for out-patient treatment, either by general
health care providers or by mental health specialists. Furthermore,
the partial reimbursement benefits for mental health care provided
by various public and private health insurance programs are so incon-
sistent as to be viewed as deterrents to the coordination of primary
care and mental health care.
The variety of sources of reimbursement for mental health care
was discussed: (1) some federal Title XIX and Title XX Social Security
Act monies ? although limited primarily to direct services provided in
federally-funded care settings; (2) Medicare and Medicaid, which again
are limited; (3) prepaid health plans, such as offered by health main-
tenance organizations; and (4) private third-party insurance coverage,
which varies in scope among different plans. Obtaining adequate reim-
bursement for one patient, particularly in comprehensive programs that
include mental health care, can entail a complex administrative process
of getting funds from several sources. A more uniform national health
insurance mechanism of reimbursement, as a prospective plan for the
United States and as currently practiced in Great Britain and Canada,
was considered a possible solution to problems of funding coordinated
health/mental health services.
Conferees highlighted several situations which further compli-
cate reimbursement: (1) a lack of uniform criteria for standard types
of care, providers, and provider settings; (2) reimbursement for
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mental health care typically is restricted to specialty care and direct
services; (3) counseling, especially when provided as preventive care
in general health care settings, usually is not reimbursable; (4) in-
direct services, such as the consultation and coordinating activities
that are crucial for providing integrated health/mental health care,
almost always are excluded frog reimbursement coverage as well. Limited
sources of reimbursement also appear to discourage the development and
support of ambulatory care, preventive care, outreach, case management,
health education, and certain social support services.
It was emphasized that lack of reimbursement deters the involvement
both of psychiatrists and primary care practitioners in efforts to inte-
grate health and mental health care. Although there increasingly is
coverage for specialty care of mental health disorders by psychiatrists
in private practice or specialty inpatient settings, there are minimal
financial incentives for spending time in important consulting and am-
bulatory liaison psychiatry. Also, there is a general lack of reimburse-
ment for mental health care provided by nonpsychiatrists in general health
settings. Determining appropriate rates of compensation for such care
further complicates the issue: simply equalizing the hourly rates for men-
tal health care by primary care physicians and psychiatrists still will
entail a loss for the "ordinary general practitioner who needs to gen-
erate more income per hour . . . because of very greatly increased over-
head." Care by nonphysician mental health professionals is even less
likely to qualify for reimbursement, except in certain prepaid medical
plans.
Several participants expressed concern about the effects of cur-
rent patterns of reimbursement on the quality of mental health care,
particularly in the general health care sector. Incentives to diagnose
in terms of what is reimbursable, it was felt, has led to widespread
masking of mental health problems in this country. Because psychiatric
illness typically remains a "non-reimbursable disease" the use of reim-
bursable labels for mental health problems and treatments is thought
to be common.
There is increasing awareness of the value of humanistic approaches
to general medical care, but inadequate reimbursement continues to dis-
courage many primary care physicians from investing the time required
to care for their patients' emotional and mental health needs. In prac-
tical terms, often "it is the time clock that runs the system," one par-
ticipant said.
The tendency to under-diagnose and under-treat mental health
problems, particularly under the financial disincentives of some health
maintenance organizations and other prepaid plans, was recognized as
having implications for the quality of care.
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Reimbursement presupposes quantification of the care process to
some extent. But thus far, the input factors of mental health care
are more easily defined, measured, and regulated than are patient out-
comes. Some caution was expressed regarding reimbursement for services
that have not been proven effective. Most participants also criticized
the "body count" and "corporate" mentalities they considered to be
associated with current policies of accountability and reimbursement.
Participants discussed a number of alternatives to the current
system of reimbursement for mental health care: (1) A proposal that has
been considered by DREW would permit federally-funded reimbursement only
for mental health services provided after referral from primary care pro-
viders, thus establishing a triage function for the primary care system
to control mental health services. In view both of the longstanding
tradition of direct consumer access to specialty care and the lack of a
uniformly well-developed primary care system in this country, this pro-
posal generally has been considered inappropriate. (2) Further support
of prepaid health plans that include in-house mental health care was
suggested by several participants, although they recognized the need to
examine potential trade-offs between adequate care and incentives for
cost-containment in such plans. (3) Several participants saw a possi-
bility for including a broader range of mental health services in
hospital-based primary care settings; they urged more systematic ex-
ploration of "piggy-backing" the costs of currently nonreimbursable
activities, such as consultation and care by nonmedical personnel, on
services that are reimbursed. (4) Grants to link primary care settings
and federally-funded community mental health centers were mentioned
as a means of tapping existing mental health care resources without,
as one speaker put it, "worrying so much about the larger issue of
third-party payments."
Several participants suggested that studies be planned for future
consequences of increased availability of reimbursement for mental
health care in the general health care sector. Changes in utilization
and probably increases in costs will result from a reduced need for
masking of mental health care by primary care providers. Assuming
that limited reimbursement represents a current means of rationing
scarce mental health resources, one participant suggested that lessen-
ed restrictions on reimbursement will require tighter definitions of
need for mental health care.
There was general agreement that reimbursement issues should be
a policy concern, but it was suggested that revised reimbursement
practices alone may not have a major impact on the success of efforts
to integrate health and mental health care. For consumers in the
United States, quality of care may be the ultimate criterion in utiliz-
ing mental health services, as suggested by evidence that enrollees
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134
in prepaid medical plans seek such care in other settings and pay sepa-
rately for them. Greater commitment to quality of care, rather than
reduced concern about reimbursement, among providers may be the force
that moves mental health care into general health practices.
SOC IAL SUPPORT SYSTEMS
A number of workshop participants urged more effective use of
social support systems in health/mental health care. The linkage of
formal health care systems with both formal and informal social support
systems was seen as essential for care to be integrated at all levels.
Such linkages could aid physicians in providing appropriate health and
mental health care to their patients and also would promote use of a
broader range of non-medical care resources.
There was general agreement that understanding of patients' social
contexts at various levels is an essential component of integrated care
For diagnosis, knowledge both of individual and epidemiological factors
is necessary. For therapy, the patient's own closest social supports
of family and friends often can work effectively with the care provider
while such community resources as social agencies, churches, or schools
can be involved to promote continued care. Although social support is
clearly an important function of the physician - especially in inte-
grated health and mental health care settings -- it was suggested that
the problems of many patients may be managed as effectively or even
more effectively by schools, welfare departments, clergymen, and other
non-medical service systems. Health care providers should be trained
to make referrals to other settings when appropriate, and opportunities
for such linkages through referral should be explored more completely.
Community support systems are particularly important when mental
health care under medical auspices is impractical or infeasible. This
often is the case in inner city areas, and presents a particular problem
for persons with chronic mental disorder who are no longer likely to
receive institutionalized care. If primary care physicians are not
available or accessible, the community and the entire social welfare
system could absorb and maintain individuals who need mental health care.
Two models of collaboration between health care providers and
social support systems were described by one conferee. In the first,
primary care providers work with their patients' immediate social
supports; in the instance of a black extended family, to promote com-
pliance with hypertension medication. The second model is a "cultural
specialty" program being developed in a cross-cultural care setting
in Newark, New Jersey. During the past year, five social scientists
have worked in a psychiatric reception center and crisis unit on
an extensive assessment of patients' natural community support
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135
systems. The program was designed to examine how those support
systems -- extended families, churches, indigenous healers -- function
as coping resources for patients within the community.
The point was made that other outside of the traditional health
and mental health care systems also provide mental health services.
In Virginia during 1977, for example, $3 million was spent under
Title XX of the Social Security Act to fund mental health services
in welfare departments, as compared with $500,000 in Title XIX funding
for mental health services in mental health centers.
The British system, with a single integrated Department of Health
and Social Services, was discussed as a model for organizing linkages
between the health care and social welfare systems in this country.
Although some states have organized human services under single depart-
ments, separation of federal support for social service and health
have discouraged most attempts to establish comprehensive health/mental
health care facilities. Some of the more fortunate and entrepreneurial
neighborhood health centers, including several represented at this
conference, have been able to provide multiservice, comprehensive
care. However, as funding decreases for the indirect patient services
that constitute a large part of mental health care, one participant
foresaw major difficulties for these centers as well.
There was general agreement that the provision of appropriate
mental health care to the entire population in need will require more
than formal linkages of health and mental health. It was pointed out
that a wide variety of community institutions that are not labeled or
identified in our society as health institutions, should be considered
in the design of a truly comprehensive health care system. Knowledge
relevant to the involvement of social support systems in integrated
care programs at all levels is already well-developed in traditionally
non-medical disciplines.* Several participants urged systematic and
useful application of that knowledge.
RESEARCH
Many participants expressed concern that major policy decisions
about health manpower development, organization of the health/mental
health system, and methods and extent of financing both for training
and service delivery are being made on the basis of inadequate re-
search data. There was agreement that health services research,
*See President's Commission on Mental Health, Report of the Task
Panel on Community Support Systems, Vol. II, pp. 139-235. Washington,
D.C.: U.S. Government Printing Office, 1978.
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136
epidemiological studies' and studies combining behavioral and health
services research are needed for systematic development of knowledge
that can contribute to assuring the quality and comprehensiveness of
health care.*
More knowledge also is needed for the development of standardized
mental health indices, such as levels of distress and levels of psycho-
social dysfunction that could be used: (1) by primary care physicians
in diagnosing the gravity of patients' complaints; (2) by health and
mental health service planners and policymakers; and (3) to determine
the incidence of mental illness. Many participants thought that extend-
ing treatment assessment from the specialty mental health sector to pri-
mary care practice will require all forms of health services research
clinically-oriented, institutionally-oriented, and systemic studies.
Clinically-oriented studies could be designed to determine how con-
ditions of practice influence effectiveness of both health and mental
health services and develop a broad range of outcome criteria including
patient satisfaction and the cost of care as well as effectiveness of
treatment, specifically: (1) collect more data on mental disorders that
primary care providers may identify, misidentify, treat, not treat, or
refer; (2) focus on the natural history of mental disorders in general
practice populations; (3) examine the treatment methods employed by
general health care providers for patients whom they identify as men-
tally disordered; (4) determine characteristics of providers and patients
and the combinations of resources that are employed in various practice
settings in which health and mental health care are provided and that
affect the processes and outcomes of care.
Institutionally-oriented studies would bear on such issues as
determinants of utilization patterns of various providers of mental
health services, or the organizational and administrative features of
primary care settings in which health and mental health services are
delivered. There was debate whether an assumption is warranted that
average medical utilization Is proper medical utilization, or that a
reduction in medical utilization is a measure of effectiveness. Re-
search was urged for human as well as economic factors, such as inter-
professional working arrangements, including clinical team organization
and functioning, practitioner training, and competency. Some issues of
the organization of services could be resolved by comparing a number
of setting for their effectiveness. Other questions are how staff time
is spent, who is being served, what services are provided, accessibility
of those services, client satisfaction and level of functioning before
and after services.
*Note: No attempt has been made to prioritize the areas identified by
conference participants as needing futher research.
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137
Systemic studies would concentrate on such issues as the influences
of various financing mechanisms on the delivery of services. Of parti-
cular importance is examination of the economic incentives and disincen-
tives in primary care settings as they differ among fee-for-service,
prepaid health plans, neighborhood health centers, and so forth.
Evaluation research is need on training methods for primary care
physicians who require modified forms of mental health specialty skills
to provide appropriate mental health care. An example of this kind of
study would be one in which "Balint" groups are evaluated as a training
modality and as a mechanism for- improving provider satisfaction, particu-
larly in settings such as HMOs or clinics, where there is considerable
turnover of professional staff.
Epidemiological research was suggested by a number of participants
who saw a lack of precision in definition, identification, and classifi-
cation of mental disorders as a major problem. More accurate data on in-
cidence and prevalence of disorders, identification of risk factors, and
the range and natural history of emotional difficulties of patients seen
in primary care settings were mentioned as other areas for investigation.
There is a need for better outcome studies to determine criteria
for the effectiveness of different kinds of mental health interventions
as they vary among kinds of providers and kinds of patients. Development
of better ways to measure outcome was seen as a necessary first step.
Research on outcome is made difficult by the many definitions of positive
outcome. The observation was made that certain types of interventions
may have a beneficial effect on the system for instance in efficiency
and the cost of the process and not do anything meaningful to the patient.
Quality assurance research was emphasized by many participants.
Studies should develop both definitions of quality care and techniques
to measure it.
Discussion in this conference did not take into account the role
of specialist physicians such as obstetricians/gynecologists, cardiolo-
gists, allergists, and gastroenterologists who have been called part
of a "hidden system" for delivering general care in the United States.
Recent data from two national studies have indicated that "one of every
five Americans now receives continuing general medical care from a
specialist physician." 1/ It would appear appropriate to investigate
(1) to what extent physician specialists are able to identify mental
disturbances in their patients; (2) the incidence of specific disorders;
(3) the kinds of mental health interventions medical specialists are
most inclined to adopt; (4) mental health skills of specialist physi-
cians; and (5) mental health content of medical specialty training
programs.
1/ Linda H. Aiken, et al. "The Contribution of Specialists to the
Delivery of Primary Care: A New Perspective." New England
Journal of Medicine. Vol. 300, No. 24 pp. 1363-1370.
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Representative terms from entire chapter:
care physicians
