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139 VI SUMMARIES OF PANEL PRESENTATIONS: FUTURE DIRECTIONS IN COORDINATION OF MENTAL HEALTH SERVICES AND PRIMARY CARE Julius Richmond, M.D. Assistant Secretary for Health Department of Health, Education, and Welfare Discussions at this conference have both theoretic and practical implications for various aspects of health services delivery beyond mental health and primary care. Patients must be considered in terms of their social contexts, whether or not the problems overtly appear to be mental health concerns, and thus an understanding of emotional development over the life cycle is important for all physicians. Pediatrics provides an excellent example of a field in which biosocial and developmental factors are integrally involved in health. After years of persistent, largely independent efforts to promote the integration of mental health concepts and programs with general health care and with primary health care in particular, it appears that finally the time is right for broader acceptance of and formal commitment to this concept. The President's Commission on Mental Health focused significant attention on this issue, as has the general trend toward providing comprehensive services in primary health care settings. This trend also represents movement towards the World Health Organization (WHO) goal of primary health care for all by the year 2000. Clearly, however, the implementation of these policy goals depends on a practical base of scientific knowledge. The growth and diversity of programs committed to coordinating health and men- tal health services has contributed significantly to the necessary knowledge base. Dr. Richmond believes that sufficient models for achieving the WHO goal already exist, many of them in the developing world. He cited as an example the Cuban health care system which utilizes a primary care system with two levels of organization: in very rural areas, primary care physicians work individually as part of required post-graduate social service; at the 'rpolyclinic" level, primary care teams -- each including a pediatrician, an internist, an obstetrician-gynecologist, and a psychiatrist and a psychologist (who are consultants for community social, as well as health, ser- vices) -- administer ambulatory care. Continued expansion of the practical knowledge base, especially through more systematic and sophisticated means of evaluating existing programs, will further promote progress in this area.

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141 Gerald Klerman, M.D. Administrator Alcohol, Drug Abuse, and Mental Health Administration, DREW The federal commitment to integrating mental health and primary health care has been shaped by recent advances in both epidemiological research and organizational research. The development of epidemiological methods to quantify the extent of mental illness, both in the community and in the primary care system, has enabled researchers to document the high degree of prevalence and the diversity of diagnostic considerations that make this issue particularly important in public policy terms. As federal efforts to implement mental health services in primary care settings have expanded, organizational studies which benefit from the involvement of a range of behavioral and health services sciences have become increasingly important as well. Linkage grants initiated by the Bureau of Community Health Ser- vices and developed on the regional level in cooperation with National Institute of Mental Health in fiscal year 1978, along with current budget requests reflect "momentum" within various federal agencies to increase both the number and plurality of modes for integrating mental health and primary care. At the same time, the need to incorporate program evaluation into these efforts has been stressed. Although an emphasis on evaluation of new programs clearly is warranted, Klerman suggests that more appropriate measures of both outcome and intervention are needed. The outcome measures most often used in U.S. studies have focused on organizational variables -- cost-offset, medical utilization, and referral patterns -- and have generally neglected less quantifiable but significant "human" variables such as relative symptom reduction, improved ability to function, and patient and provider satisfaction. Intervention variables that continue to merit attention relate to: 1) treatment -- controversies concerning the merits of psychotropic drug and/or counseling therapies indicate the ongoing need for controlled clinical research; 2) personnel -- further investigation of appropriate qualifications for providers of mental health care in primary care settings is needed to develop adequate training programs; and 3) organ- izational arrangements -- various modes of integration in addition to the linkage mechanism currently in vogue should be studied. Dr. Klerman stated that the next phase of research should attempt to better evaluate what is known about the determinants and dimensions of program outcomes. Such studies will have particular relevance in terms of the current general public policy trend to increase support for the delivery of a full range of specialty services, including mental health care, at the primary health care level.

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143 George Lythcott, M.D. Administrator Health Services Administration, DREW Successful coordination of mental health services and primary care presupposes closer integration of care and caring in medical prevention, treatment and control, and in medical services, training and research. "Care" reflects technical knowledge and skill; "caring" reflects deep personal involvement and commitment. Although the two concepts clearly should not be mutually exclusive, the current public policy focus on coordinating care and caring indicates growing recognition that medical services often do not meet the real needs of patients. If federal efforts to coordinate these elements in service, training, and research programs are to succeed, collaboration in terms of actual functions and activities must be emphasized. 1) Services for both the elderly and children -- particularly handicapped children -- entail special consideration of care and caring by both mental health and primary health care providers. In each of these services areas, the Bureau of Community Health Services (BCHS) within HSA is working with other federal agencies, including the NIMH, to develop specific programs of collaboration at the levels of policy- making, planning, and service provision. 2) Training programs in several states are directed toward preparing primary care providers to deal sensitively and effectively with mental health concerns, either directly or through linkages. The programs also have involved cooperation of ADAMHA and HSA at the federal level. The recruitment and placement of mental health per- sonnel within the National Health Service Corps of BCHS is also part of the overall training effort. Planning with NIMH is currently underway to expand Corps supportive mental health manpower, specific- ally to meet the health/mental health needs of patients with chronic mental illness. 3) Research efforts, such as the planned joint evaluation by HSA and NIMH of the 1978 health/mental health linkage grants, should be extended to other areas of common interest to ADAMHA and HSA. If enacted, the Community Mental Health Systems Act will support the development of state-based systems of care and caring that would involve coordination at the federal level and between federal agencies and the States. - To effectively integrate mental health services into primary health care, new dimensions of care and caring at the primary level also should be considered. Because of the interlocking nature of

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144 of behavior and heal th, self-care and caring should be included formally as primary health care concerns, especially among under- served populations to whom access to other level s of care is often limi ted . Mutual health and f ormal and inf ormal sac ial support systems al so should be expanded as part of primary care . Advocacy although a special aspect of care at all levels is particularly important to ensure the quality of primary care health services and should be emphasized as well. __