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15 III KEYNOTE PRESENTATIONS David A. Hamburg, M.D. President, Institute of Medicine There has been a gradual increase of interest in primary health care in the United States, maybe I should say a revival, after some decades in the doldrums. That revival has been gradually building for a decade or more and has become rather intense in the past few years. We as a nation seem to be groping for ways to develop a national network of primary health care providers. We are on the way toward that objective, but have some distance to go, and all of you, I am sure, are aware of the hauling and tugging and serious analytical work that is going on to try to ascertain how that can be done. Concomitantly, we have been groping for ways to make mental health care more widely available. We have known for many years that a large percentage of the overtly mentally ill were cared for in the general health system, if they received care at all; and only a small percentage of the overtly mentally ill were cared for by mental health specialists. We have argued a bit about what these percentages might be. We have not had the kinds of epidemiological data we should have had to pin down a lot that is important. But it has been a kind of stark and brutal fact, overwhelmingly apparent to anyone reasonably familiar with the subject, that some gravely ill persons were receiving treatment of essentially unknown characteristics and there was reason to be concerned about finding ways to improve the care that they get within the general health system. We have been aware, too, that beyond the overtly mentally ill, a much larger number - though we could not specifically say what the number is -- have problems in living manifested by truly burden- some emotional distress; these individuals are thought to be almost entirely looked after in the general health care system. Again, we have known little about these patients. We knew that there was a certain amount of depreciation of such patients, reference to them as "crocks" and the like, but there was also a good deal of conscientious, decent and responsible care. But what remained largely unknown were the proportions of the different kinds of
16 care and the nature of the process in the general health care system by which these people suffering from formidable emotional distress were looked after. In recent years we have had an additional factor entering the picture, and that is a growing awareness of the behavioral and environmental aspects of health. Some of that falls in the domain of this conference, as well. Some does not. There are major behavioral aspects of health that contribute to the burden of ill- ness in this country -- heavy cigarette Smoking, abuse of alcohol, very risky driving, and the like. Those aspects of the burden of illness in this country which are pre-eminently behavioral in character have, so far as we know, been dealt with in a rather limited and faltering way, both in the general health care system and the mental health care system. These behavioral problems, whether recognized or not, whether treated or not, are present in the general health care system. Indeed they are coming to be seen as a major responsibility of the general health care system, most particularly within the framework of primary health care. Presumably, then, the mental health component in primary health care -- and beyond that in the general health care system altogether -- must now be a major focus for research. Wrong. It is not a major focus for research as far as we have been able to determine. Well, at least it must surely be a major focus for medical education. Wrong. As far as we have been able to determine it is a marginal component of medical education. Surely, it must be a focus of excellent nationwide collaboration between mental health and general health professionals. Right? Wrong. As far as we can see, there are only promising models. There are some valuable efforts to be sure, but it has not been a high priority, high status activity in the health professions. It has been a kind of a lowbrow activity with some stigma attached to it. Well, then, who is irrational? The patients or the profes- sionals? I remember some years ago when a distinguished social scientist studied a health institution over a period of time. I asked him how the study was coming along and he said to me, "Well, the difference between the staff and the patients in that place is that the patients get better." Fortunately, there are notable exceptions. What I have said so far bears on the question why I think this conference is a decade late. We have dimly been aware of these issues for a long time and for a great variety of reasons have been reluctant to face them. But even in the context of this shortfall, there have nevertheless been pioneering people doing research in the area, conducting inno- vative education in the health professions, and innovative service.
17 These innovators and indeed authentic pioneers, are well represented at this conference: and so are those who have seriously undertaken research, education or service at various interfaces between mental health and general health care. We have not tried to be comprehensive within the time frame available and the resources available. It was not feasible to do so. I am sorry that we have undoubtedly left out people who have done excellent work in this country and abroad, but we thought we could quickly get a reasonable sample of people and institutions who have made important advances in this area; and get a sense, above all, of what is possible in the future. We wish now to be future-oriented. me problems are increasing- ly recognized and we are in a different context than we were even a few years ago. We hope that in this conference we can face some of the obstacles in an analytical way, not in a polemical way, in order to clarify the emerging opportunities to understand more about how lack of knowledge has interfered in this field. We will try to understand some of the major obstacles analytically, and how to deal with them more effectively in the future. We have deliberately included in the conference some people who are constructive, searching skeptics about this area of activity. There is no point in wishing away those difficulties. If it is important to move in the directions I have indicated, then we had better know what the difficulties are likely to be. The social context is in some respects distinctly encouraging with respect to the problems on which this conference is focused. On the governmental side, the President's Commission on Mental Health, under Mrs. Carter's leadership, gave the coordination of mental health and primary health care services a distinct emphasis. That has been carried forward vigorously and dynamically by the new leader- ship in NIMH, Dr. Pardes and his colleagues; and by the new leadership in ADAMHA, Dr. Klenman and his collages; indeed, in HEW altogether. Dr. Richmond, who is participating in the conference, Secretary Califano, Undersecretary Champion these are all people who personally and in a determined way have taken cognizance of this issue and are moving ahead to the extent it is within their power to do so. The level of Congressional interest, at least in the health- relevant committees, is reasonably high and encouraging also. In the private sector, there are hopeful stirrings in medical schools, in schools of public health, and in some professional societies. Altogether there is a kind of ferment in the country in reference to the interfaces between primary care and mental health care. The Institute of Medicine has been active in these efforts. Briefly, these are some of the TOM activities pertinent to this topic.
In the primary health care study, 1/ mainly a manpower study, there was some consideration given to the interface with mental health. Emphasis was put upon the educational dimension, the need for more adequate training in behavioral sciences of those who are entering primary care. This subject deserves more extensive treatment than this report was able to give it. We are in an era in which a fairly wide range of specialties wish to be identified with primary care. They have a new vision of what is possible in primary care. The internists want it built on internal medicine, the pediatricians want it built on pediatrics, and so on. These developments in specialty-based primary care must take account of the major mental health component that characterizes actual practice. Otherwise preparation for primary care would be unrealistic and impractical. This situation has been improving in the past few years. But there has been a tendency for this segment of the medical care population to be put in a marginal status, left with a certain amount of stigma. The IOM's recently published study, Health Services Research, 2/ is significant to this issue. We need an upsurge of health services research in general, and particularly in relation to the issues of this conference. In the papers the Institute of Medicine prepared for the President's Commisssion on Mental Health, 3/,4/,5/ much revolved around the various - 1/ A Manpower Policy for Primary Health Care: Report of a Studye Institute of Medicine. Washington, D.C.: National Academy of Sciences, 1975. 2/ Health Services Research: A Report of a Study. Institute of Medicine. Washington, D.C.: National Academy of Sciences, 1979. 3/ J. Borus, B. Burns, A. Jacobson, L. Macht, R. Merrill, E. Wilson. "Neighborhood Health Centers as Providers of Coordinated Mental Health Care," invited paper of the Institute of Medicine Advisory Committee on Mental Health submitted to the President's Commission on Mental Health, February 13, 1978. 4/ J. Houpt, C. Orleans, L. George, K. Brodie. "The Relationship of Mental Health Services to General Health Care," invited paper of the Institute of Medicine Advisory Committee on Mental Health sub- mitted to the President's Commission on Mental Health, February 13, 1978. 5/ M. Parloff, B. Wolfe, S. Hadley, I. Waskow. "Assessment of Psycho- social Treatment of Mental Disorders: Current Status and Prospects," invited paper of the Institute of Medicine Advisory Committee on Mental Health submitted to the President's Commission on Mental Health, February 13, 1978.
1' -9 interfaces between mental health and general health. There was examina- tion of the research evidence regarding effective measures that could be taken, both psychobiological and psychosocial measures. There was also delineation of the practical arrangements by which interdisciplinary cooperation had been elicited and could be strengthened in the future. The ION will shortly be publishing a report called Sleeping Pills, Insomnia and Medical Practice 6/ addressing a large clinical problem. In the course of conducting that study, the internists, the pediatri- cians, and family practitioners who were consulted in our advisory panel, and the Steering Committee, emphasized not only insomnia, but other mental health problems, as a major part of medical practice. This provided a practical reaffirmation that a major portion of medical responsibility in virtually every field has to do with mental health problems. The present conference is intended to clarify what is known about the interface between the mental health system and the primary care system and to delineate some promising approaches to improving the coordination of these systems. Our goal is not to reach firm conclusions as we do in TOM major studies. Our major studies typically make policy recommendations after analyzing various options. We do not generally see conferences as suitable for that kind of function, although sometimes there are recurrent themes that have almost the force of recommendations. Our intention here is that the major facts and options can be clarified in the conference. The format for this meeting provides a very full schedule the first day, reflecting in part the intense interest in the subject. There will be only a little discussion time today. But please be patient, because tomorrow is arranged in such a way that there will be much more time for discussion. We will have three work- shops in order to be sure that everyone present will have an ample opportunity to make what we here in Washington call "input" -- in any case, to say what you want to say and to have that on the record; and, more than that, we have adopted an additional mode for "input" -- the "record will be open" for 30 days after the conference to allow for flashes of insight that may occur to you, for visions of the future that may come in some moment after you have left the conference. We have made a decision that wisdom need not be con- fined to these two days in this great building. The final conference publication will reflect all of the input -- before, during, and after the conference. 6/ Sleeping Pills, Insomnia and Medical Practice. Report of a Study. Institute of Medicine. Washington, D.C.: National Academy of Sciences, 1979.
20 Finally, I want to welcome our guests from abroad. There is a great deal we can learn from their experience. Granted, there are important cultural differences, as Professor Shepherd will no doubt point out, which make a literal transfer difficult. I recall, not on this topic, but on a science policy topic, discussing with some friends in Sweden some activities I thought were highly constructive I asked, "What do you think about the likel ihood of our adopting those procedures?" The response was negative. I asked, "Why not?" "Well ," they said, "we are a small country, we have 8 million people "Well, so?" "And the other thing, we trust each other ." So, I am not proposing that we automatically or literally transfer what we learn from other cultures. But we have much to learn from experience in other countries. I think we are moving beyond parochialism to share information and ideas with colleagues from abroad. We are very fortunate that several people who can help us a great deal have been will ing to make the journey and j o in with us in thi s important endeavor . lo'
21 THE PROVIS ION OF MENTAL HEALl~l SERVICES IN PRIMARY CARE SETTINGS Opening Remarks Herbert Pardes, M.D. Director, National Institute of Mental Health Typically, the task of an opening speaker is to articulate the significance of the conference theme. On some occasions, the dubious import of that theme or topic makes the task difficult, but today the assignment seems relatively easy. Its ease becomes apparent as one reflects on the many forces and developments that repeatedly and with increasing frequency draw our attention to the interaction of mental health and general health. At the present time, increasing national attention is being given to the role of behavior in medicine. In the population at large, the notion that one may improve one's health by modifying behavior has given rise to everything from Weight Watchers and Smokenders to jogging and gymnastic centers for middle-aged adults, and attests to the broad concern about the interlocking nature of behavior and health. Within the health establishment, the awareness is illustrated in such diverse areas as smoking, teenage pregnancy, alcoholism, diabetes, obesity, and treatment compliance. With regard to this last issue, there is increasing recognition of pervasive noncompliance on the part of anywhere from 15 to 50 percent of persons who receive medical advice, and this is emerging as a matter of some considerable concern. In this context, complaints regarding the disappearance of the old style family doctor seem tied particularly to decline of the personal relationship and psychological sensitivity he supposedly offered. The re-energized family practice movement has emphasized its needs for a major mental health component, both in its training and its clinical work. Other elements, too, within the general medical sector are calling for more focus on psychosocial and behavioral issues. Large segments of the mental health and psychiatric sectors are calling for an increasing alliance with medicine and general health. Data provided by the Division of Biometry and Epidemiology of the NIMH shows that in the course of a year, 54 percent of patients with mental health disorders are cared for solely by the primary or general out- patient health care system (Regier, et al, 1978~.
22 The presence of this large number of patients who stay within the general health sector for mental health care is complemented by estimates that indicate a large proportion of people walking into a general health or primary health care office have some mental health or emotional problem. In essence, we are dealing with a major issue within the health care system, as well as an issue of increasing priority among the broad range of society's concerns. Now, acknowledging the topic's significance, I would like to underline several points regarding the scope of the issue. First, accurate reporting of mental health problems is complicated not only by factors typically involved in reporting, but also by factors somewhat more unique to the mental health field. The difficulty of precise diagnosis is well-known. There is, however, further, the pro- blem introduced by the wide spectrum of reactions, both by provider and patient, to the fixing of a mental diagnosis to an individual. Yet, again, there is a very broad range of difference in individual practitioners' sensitivity to and awareness of mental health problems. Mr. Goldberg, Dr. Regier, and others have noted that the recent National Ambulatory Medical Care Survey showed that a diagnosis of mental disorder as a primary or otherwise existing condition was made in about 2 percent of all visits to office-based pediatricians in the United States (Goldberg~et al, 1979~. On the other hand, in their study of outpatient pediatric service use conducted in Monroe County, New York, the authors found that two-and- a-half times that rate, or 5 percent, of the children visiting the sample of pediatricians in that locale had mental health problems. These were defined as emotional or behavioral disorders, including school problems of adjustment or achievement. In the same paper, the authors, while noting methodological variations among studies, cited differences in two separate English studies of children. One indicated that 5.7 percent of children aged 10 to 11 who were surveyed had a "clinically significant psychiatric disorder." A second study estimated that 19.4 percent of the sample of children were judged to be maladjusted. Aside from noting such differences in re- porting data, one must also recognize that sensitizing and educating people in the general and primary health care sectors about mental health issues may result in significantly higher reporting and essentially greater case-finding. In addition to taking note of these problems of precise epidemio- logical data and diagnosis, it is important, also, to recognize that behavioral and mental health components are not only critical in primary health care, but also in secondary and tertiary health care. For those of us in mental health, who are accustomed to meeting col- leagues in general health who may have reservations if not outright
23 disinterest in the behavioral area, an extraordinary development is the phenomenon of highly specialized surgeons and internists active- ly seeking our mental health psychiatric consultation and involvement in their work. Frequently the settings for such requests are intensive care units, burn units, and units for kidney transplants or renal dialysis. Recognition of high suicide rates, for example, among people with chronic renal disorders, as well as significant family and sexual problems that these patients experience, highlights the need that we be aware that our renewed attention to the inter- face of behavioral and mental health issues with general health cannot be confined simply to the primary care setting. Not only providers, but patients, as well, have recognized the important psychological issues arising in these settings. In a most eloquent article, Dr. Henry Kempe, one of the outstanding pediatri- cians in the country, has described his personal experience at the time of his own acute coronary. Noting the extraordinary psychological pressures it produced, he pointed to the sensitivity of the ICU staff who attended to him, and described the profound gratitude he felt when they reassured him about the variety of psychological and emotional experiences he endured (Kempe, 1979~. The burgeoning attention paid to the mental health-health inter- action offers considerable potential for major contributions to the health and general welfare of society. Increased efforts on programs of prevention and promotion in general health presents the possibility of a healthier population. Particular attention to such issues at the earliest stages of life is a significant part of the prevention~strategy, inasmuch as identify- ing high risk children and families and attending to latent disorders as early as possible offers the possibility of early intervention, with resultant decreases in the severity of problems at the point where they finally receive attention. Furthermore, we know now that people who come to primary care and general health care physicians with mental problems usually have a higher rate of organic illness and utilize health services more frequent- ly than do people with other than mental health disorders (Eastwood and Trevelyan, 1972~. These facts suggest that more effective treatment of this population would have important ramifications, both for health care utilization and incidence of organic difficulties. This notion has been elaborated in a variety of so-called offset studies, which lead to the suggestion that appropriate attention to and provision for the mental health needs of a general population of patients coming for health care may be accompanied not only by better quality and more appropriate care, but also by an actual reduction in inappropriate service utilization and, as a result, possibly financial savings (Vischi and Jones, 1979~.
24 Moreover, the problem of patients and their families' acknowledg- ment of mental illness and their reluctance to seek specialized help has dramatically influenced the mental health care system since its inception. Recent data suggest that perhaps larger numbers of people may be willing to seek mental health consultation and help (Taube et al, 1978). Further, the notion that such help is sought primarily by the middle and upper classes of the society may be-being modified, Judging by early additional data that suggests some increasing readiness of people in the lower social classes to seek mental health consultation and treat- ment (Jacobson et al, 1978~. Given these trends, it is apparent that increasing expertise on the part of general health care providers, accompanied by this readier acknowledgment of mental health problems by all classes in the society, can combine to enhance better care for larger numbers of people. Now, while the trends may be important and have considerable potential, there are, however, major problems that require attention as we work at articulating the best way in which this system should function. Inevitably, questions of turf arise, with some people in the mental health sector feeling threatened by the notion that people in the general health care and primary health care sectors may appro- priate some of their roles. Also, there are questions of the appropriate role in mental health care of primary care physicians, given their training, orientation and temperament. The nature of many physicians and others in the general health care system is one of high activism, the need for immediate results, a preoccupation with the tangible and a fascination with technology. The need to listen, the need to allow the patient to play an active role in his or her own treatment program, the need to avoid intruding one's own set of values and principles on one's patients, and the necessity of being comfortable when playing a necessarily passive role, do not come readily to everyone. There were reasons that the mental health care system was sequester- ed, and in our enthusiasm for reintegrating it, we must be aware of those forces still playing critical roles at the present time. The story of separation of the mental health system, and why separation, is addressed, I believe, in one of the papers by Dr. Goldman (Goldman, 1979~. Suffice it to say that because many of the original forces are still active, they require recognition and attention as we focus on the mental health-health system. At a social gathering recently, a general psychiatrist lamented that at the hospital where he worked, he and
25 several psychiatrists had offered their services to the remainder of the medical staff for discussion or consultation about any psychiatric problems but few came to avail themselves of this service. In this example, one senses the perhaps limited interest on the part of nonpsychiatric staff in securing such consultation and inter- action. But one must also wonder about the nature of the product the psychiatrist was offering. Not infrequently, the mental health field has been justifiably criticized for responding to requests for consulta- tions with irrelevant, unrealistically elaborate or highly personalized jargon, or with cryptic if not invisible responses. Additionally, the notion of simply offering one's self up as available for consultation without the active outreach and involve- ment in the other medical and health care services long encouraged by those familiar with liaison work, is almost a certain ingredient for failure of the undertaking. As the health care provider must recognize the needs of his or her patient, the consultant must recognize the need of the person consulting him. The problems of adequate training and its organization for people in primary and general health care are formidable. At the same time, the value of effective training and liaison is critical. It is com- monly recognized, for example, that medical students who have not received instruction in the area of interviewing often become increas- ingly directive and less empathic as their medical training proceeds. The need to educate actively medical students and general and primary health care students has been recognized by the Psychiatry Education Branch of the NIGH, which has placed increasing focus on and devoted a major portion of its budget to development of such programs. The need for such interaction at the service level, too, has been recognized by the Bureau of Community Health Services of the Health Services Administration, as well as by the Division of Mental Health Service Programs at NIMH e The two have collaborated on the development of projects in which mental health practitioners are brought right into general health care settings for active inter- action, consultation, and mutual education. The interaction of the mental health and health system is important. Its scope is considerable, it has enormous potential, and there are many obstacles that require attention. What, then, are some-of the questions that we would put to this group and to conferences of this sort to help us address? Let me suggest some of them. First, what is the appropriate balance between the primary health care system and the mental health care system and the rendering of mental health treatment? How does one discriminate that which the primary health care person should be able to treat, as opposed to that which should be the responsi- bility of the mental health specialist?
26 Dr. Sharfstein has asked how one enters the mainstream without drowning (Sharfstein, 1979~. Perhaps the primary care physician or general health care practitioner is wondering, if he broadens his field of attention to include behavioral and psychosocial issues, will his mother and his medical society still think he is a real doctor? Is the solution one of the general health sector handling both health and mental health care? Do we stay as we are? Should we consider one radical solution I had put to me by a psychologist colleague who suggested that, given the large number of people coming with mental health problems to general emergency rooms, for example, the mental health care people should be the first line people, and then simply refer on those problems which do have physical causes? Second, in addition to these questions of balance, what kinds of studies, what kinds of research, what kinds of data should we be seeking to round out our understanding of the nature of the problem? Third, how can we best get a handle on the notion or the suggestion that appro- priate attention to mental health care problems has an important impact on services, appropriate utilization, and, ultimately, costs of the health care system? I attach substantial significance to this conference, to the work that has led up to it and also to the work that I anticipate will follow. Having come recently to the NIMH, I am concerned about looking broadly at the nation's mental health programs, and certainly the question of the health-mental health linkage is one of the pre- eminent issues. I would, therefore, like to thank you all for offering your time, energy, and thinking in this process, and I look forward to hearing and learning from you and to a continuing dialogue and ferment around this issue. Thank you very much.
27 References Eastwood, M.R. and Trevelyan, M.H. Relationships between physical and psychiatric disorder. Psychological Medicine, 2:363-372, 1972. Goldberg, I.D., Regier, D.A., McInery, T., Pless, I.B., and Roghman, K.J. The role of the pediatrician in the delivery of mental health services to children. Pediatrics, Vol. 63, No. 6, pp. 898- 909, June 1979. Goldman, H.H. The integration of health and mental health: a socio- historical perspective. Unpublished manuscript prepared for the Institute of Medicine conference, "Provision of Mental Health Services in Primary Care Settings," Washington, D.C., April 2-3,1979. Jacobson, A.M., Regier, D.A., and Burns, B.J. Factors relating to the use of mental health services in a neighborhood health center. Public Health Reports, 93:3, pp. 232-239, 1978. Kempe, C.H. Nursing in a coronary care unit: a doctor - patient's view. The Pharos of Alpha Omega Alpha, Vol. 42, No. 6, pp. 18-19, 1979. Regier, D.A., Goldberg, I.D., and Taube, C.A. The de facto U.S. mental health services system. Archives of General Psychiatry 35:685-693, 1978. Sharfstein, S.S. et al. To pull mental health services into the mainstream of health services (without drowning). Report drafted as a component of the DHEW FY 1980 "Health Systems Reform Initiative." Unpublished DHEW manuscript, 1979. Taube, C.A., Regier, D.A., and Rosenfeld, A.H. Mental disorders. In Health - United States, 1978. DHEW Publication No. (PHS) 78- 1232, 1978. U.S. Government Printing Office, Washington, D.C. Vischi, T.R. and Jones, K.R. Impact of alcohol, drug abuse, and mental health treatment on medical care utilization: a review of the literature. Unpublished DHEW manuscript, February 1979.
29 OPENING REMARKS Merle Cunningham, M.D. Bureau of Community Health Services Health Services Administration The Bureau of Community Health Services (BCHS) is committed to the provision of comprehensive, family-oriented primary health care services to Americans in urban and rural medically underserved areas. That commitment comprises three major types of programs: the primary care-oriented neighborhood and community health centers; the National Health Service Corps; and the maternal and child health and family planning programs. BCHS efforts to promote the integration of mental health and · . ~ ~ primary care services reelect a concern originating with the strong mental health component included within the initial comprehensive maternal and child health programs in-1935. Similarly, in the 1960s OEO philosophy emphasized the importance of mental health services when the neighborhood health centers were established. During FY 1978, $1,500,000 in BCHS supplemental funds were spent to develop "linkages" between community-based health centers and community mental health services. Additional supplemental funds have been allocated for FY 1979 to increase the number of linkage grants from the current 57 sites to 120. Among the 57 sites that have received linkage monies thus far, a variety of linkage approaches have been taken. Those approaches are currently being evaluated jointly by BCHS and NIMH. Dr. Cunningham's personal experience as a primary care physi- cian in a community health setting suggests that the new BCHS funding essentially represents formal Federal recognition and support of an ongoing trend in individual communities, where mental health services and primary care services increasingly have been integrated through less formally defined linkages such as staff sharing.
31 POLICY ISSUES ON PROVISION OF MENTAL HEALTH SERVICES IN PRIMARY CARE SETTINGS: A FEDERAL VIEW Gerald L. Klerman, M.D. Administrator, Alcohol, Drug Abuse, and Mental Health Administration I would like to continue the discussion of mental health and primary care, and share with you some aspects of this issue as they are discussed at the policy level within Health, Education, and Welfare. One interesting experience for a mental health person coming into the policy arena at HEW is the pleasant discovery of how accepted, particularly under the leadership of Secretary Califano and Hale Champion, are mental health concerns. If anything, they are impatient that we get on with them more quickly--they are impatient to have every- thing move more quickly in HEW. And, contrary to my experience in other settings, I have not had to defend the importance of the topic or to re-cry the extent of the problem by quoting statistics in terms of the incidence, prevalence or economic burden. Within HEW, and particularly during the course of the President's Commission and interactions between HEW and the White House and the Commission, there is and was seldom any issue as to the importance of the matter or the impact it has where there are policy concerns as to the nature of the service and fiscal mechanisms to be employed in relating mental health to general health. Now, I want to say a few things about both parts of the title of the conference. I want to identify those aspects of the relationship which have to do with general health as distinct from primary care, although recognizing that the majority of the papers and workshops will be on the primary care issue. There are significant issues in policy that occur at levels of the health care delivery system other than primary care, and I will try to place those into context. Psychiatrists and mental health professionals in general tend to shift unknowingly--I will not say unconsciously--fram talking about mental health as, narrowly, mental illness to mental health as a field that includes alcoholism, drug abuse, developmental disabili- ties, retardation and other concerns that at various times have not been at the center of psychiatric thinking. This is a matter of parti- cular concern to me in my current role because of the sensitivity
32 of the alcoholism field as to whether or not it wishes to be seen as part of the mental health field. Part of the response to this has been the establishment, largely with Federal support, of at least three parallel and somewhat isolated delivery systems--not only the mental health delivery system, but also a well-developed, often nonmedical delivery system for alcoholism and a very highly specialized delivery system for drug abuse, particularly for heroin, mostly supported by Federal monies. The interactions, let alone linkages, among these three systems have been, at most, minimal, let alone their interactions with the general health care system. From a public health point of view, the problem is most pressing with regard to alcoholism, since it is likely that the majority of alcoholics are in the primary or general health care system, but are undiagnosed, misdiagnosed and certainly mistreated, particularly overtreated, with the inappropriate use of sedative, hypnotic and minor tranquilizing drugs. This area represents, to my mind, one in which there is a tremen- dous opportunity for research to impact upon policy, because there are not clear answers and because the lack of not only knowledge, but also of adequate conceptualization, creates the opportunity for research to impact at a time when policy in this aspect of health care is in a very fluid state. It is also of interest that the research areas that have the greatest potential for impact on policy are in the health sciences and behavioral sciences areas. Most important, of course, is epidemi- ology, which is well represented here by Darrel Regier and his col- leagues. But health services research also ranks high, not only because the very conceptualization of primary care grew out of the work of people like Kerr White and others, but also because of the importance of cross-cultural studies. Now, we can, in effect, do a comparative analysis of experiments of administrative nature by comparing the consequences of our dissolution of general practice, an inadvertent experiment of administration, perhaps, with the British experience, where they not only did not allow that to happen, but purposely strengthened the general practice network as their major mode of contact with patients with mental illness. I think it is significant that the organizers of this conference have invited Michael Shepherd, and that David Goldberg is here in the United States on sabbatical from England, continuing this work. Three other types of sciences with potential relevance for policy are not represented here, but might be the focus of future conferences. They are medical anthropology, medical sociology, and economics, both macroeconomics and macroeconomics. Now let me put the policy issues into a certain context.
33 One of the main contributions of recent epidemiologic work, high- lighted by the papers prepared for the President's Commission, is a fairly clear definition of the quantitative extent of the problem, as presented by Darrel Regier of the National Institute of Mental Health. A rough consensus of epidemiologic evidence indicates a yearly pre- valence of discernible disorder in about 15 percent of the population. It is not to be presumed from this that all the remaining 85 per- cent are without symptoms. One of the important things that also has emerged from the epidemiologic research is that in addition to those individuals with such definable disorders as neurotic depression or clear-cut alcoholism, who constitute this 15 percent, there are signi- ficant additional numbers, perhaps as many, with transient symptoms, perhaps stress reactions, periods of insomnia, weight change, and backaches, and the people experiencing these use the health care system to a great extent. While people may argue whether or not it is legitimate to do so, one of the main functions of the health care system, in the United States or in any other country, is to provide a buffer and a means of auxiliary coping for these stressful responses, these symptom states, which may not reach the level of the DSM-3, the St. Louis Criteria, or the Research Diagnostic Criteria, but nevertheless cause misery and distress, and promote individuals to come into the system. One of the unmet diagnostic and epidemiologic needs is to get a better handle on the extent of this matter and to define the prevalence of this group without disorder, but with distress. Next, we have attempted a quantitative compilation of the main disorders within the 15 percent. (Figure 1) Although one can make very crude estimates about children and about the aged, the status of clinical epidemiology for those two important populations is, by my estimate, crude. The absence of good data for the nature of children's disorders, particularly in the community, and the overlap with develop- mental disabilities hinder policy and planning, particularly on the interface with education. Similarly, in the aged, the lack of good data as to the number of demented individuals or the overlap between dementia and depression, once again hinders planning for the extent to which nursing home care is really required, and for alternatives. The best data are for those people in the adult age range, and here, as I read the data from the epidemiologic studies, there is fair convergence, again. Almost all the prevalence is accounted for by three disorders: 1) depression and the affective disorders, up to 8 percent of the population within one year; 2) alcoholism, between 2.5 for alcoholic dependence and up to 8 percent for people with alco- hol problems, such as intoxication episodes and accident involvement, domestic violence, child abuse, homicide, suicide; and 3) anxiety, phobia, and other neuroses, about the same amount.
34 Figure 1 ESTIMATED PREVALENCE OF SELECTED ALCOHOL, DRUG AND MENTAL DISORDERS Disorders by Age Category Point Prevalence (rate per 100 persons) Children (under 18) Adults (18-65) Depression and Affective Disorders Anxiety, Phobia, and Other Neuroses Alcoholism and Alcohol Problems Drug Dependence Schizophrenia Aged (over 65) 8-10% 10-15% 4.5-8% 4.0-7% 2.5-8% 0.5-1% 0.5-1% 10% These three groups of disorders are widely prevalent in the general health care system, particularly in the primary care component, often unrecognized and probably poorly treated. Two disorders which get much attention from psychiatrists and the public are actually of low prevalence, but high social cost. They are drug dependence, particularly heroin, which seldom goes above one percent, and schizophrenia, whose prevalence at best is one percent and lifetime prevalence, with the most broad definition, three percent. Yet it is this disorder with low prevalence, but with such high social cost, that eats up the resources of the long-term care system. I will not dwell on this, except to acknowledge the softness of the data, but also to note that even with better data from more elaborate studies now underway in this country, or others such as the Camberwell Registry and the registry in Iceland, the trend seems to be that almost all the adult prevalence is accounted for by depressions, anxiety states and alcoholism. Now, to return to the Regier analysis. Fifteen percent of the population comes to 31 million. That might seem like a staggering amount, but, again from the point of view of current thinking, it is not an insurmountable problem. Let me point out to you that hyper- tension has about the same prevalence throughout the population, and yet the Public Health Service has seen fit to mount a nationwide campaign on the detection and treatment of hypertension with discerni- ble results on the death rate from cardiovascular disease.
35 We may not yet have the technology as well-established for diagnosis and treatment as in the hypertension field, and I am not advocating as comprehensive a program for mental illness as for hypertension, but I use the hypertension comparison to indicate that the magnitude of the problem, 20 to 30 million people, is not in itself one which need deter the development of a public health approach. In fact, while it may frighten some of those who are doing national health insurance planning, the existence of such a large prevalence is not in itself a deterrent to a public health approach. The other contribution from health services research, and again I mention Regier, is the awareness that the delivery system can be divided into two sectors, the general health care sector, which accounts for about 60 percent of this 3D million, and the specialty sector. As I will show, the specialty sector is itself capable of being subdivided into the three somewhat fragmented components for alcoholism, drug abuse, and mental health. Although this conference has focused in its planning on the mental health component, I would hope that at times you would pay attention to the existence of com- parable but not identical problems in the recognition and treatment of persons suffering from various alcoholism and drug abuse disorders. I made mention earlier that one of the advances in policy has come from the field of health services research, and particularly from the conceptualization of primary, secondary and tertiary care. With the assistance of Gail Schecter, my research assistant, we undertook an attempt at a historical review Qua this conceptuali- zation. Surprisingly, although primary care is a catchword in today's parlance, the term is less than 15 years old. The division of the health care system into primary, secondary and tertiary levels is a relatively new conceptualization an analytic conceptualization brought to bear on the field by people like Kerr White, Alberta Parker and others, in response to the awareness about 15 years ago that this country had allowed its general practice network to dissolve and had overdeveloped its specialty network. Again, the contrast to Britain is illuminating. This had resulted in the disappearance of physicians, particu- larly from rural areas and from inner city poverty areas, and in a rapid expansion of costs, particularly at the tertiary level, of high technology. Again, it is worth making the comparison with Britain, where the percentage of the gross national product allotted to health is about 40 percent less than in this country. One reason for that is probably their having sustained and nurtured and, as a matter of public policy, continued to support a vigorous general practice component.
36 Now, to attempt to link the conceptualizations previously cited. One is the primary, secondary and tertiary care conceptualization with the distinction between the general health care sector and the specialty sector that Regier and Goldberg identified in their paper in the Archives in June of last year . Some of the charac teristic s of primary care are its relevance to relatively small populations at the neighborhood or small city level . As one goes up to level s of tertiary care, one gets to larger population bases, so Chat the tertiary care~network is usually regional hospitals or university hospitals, where highly specialized facilities with often high cost technology and often highly specialized personnel are concentrated. I propose for discussion that, in addition to primary, secondary and tertiary concepts, long-term care be brought into that conceptuali- zation, perhaps as a fourth level of endeavor, because one of the policy issues is that of determining the extent to which those patients now in the long-term care system can be shifted in reasonable ways into either the secondary or primary care networks. We have attempted to combine in a single concept or matrix the two systems or analytic concept s that I think have been most useful from a policy point of view in understanding the growth or nongrowth and the changes in the American heal th care system since World War II . Figure 2 FOUR LEVELS OF HEALTH ADM HEALTH CARE Level of General Alcohol Abuse Drug Abuse Mental Heal th Intensity Facilities Facilities Facilities Facilities of Care and Services and Services and Services and Services Primary Neighborhood Primary Care Primary Care Primary Care Health Centers Practitioners Practitioners Practitioners Secondary Community Alcohol Treat- Drug Treat- QIHCs Hospital ment Centers ment Centers Tertiary Specialized Alcohol Treat- Residential Treat- Elospitals ment Hospitals ment Centers for Children and Adolescents Long-term Ilome Care State Hospitals Community Support Services Programs; State Nursing Homes Hospitals
37 The concept makes use of the primary, secondary and tertiary care distinction, adds to it at a fourth level considerations of long-term care, whether provided in institutions or in ambulatory programs, and explicitly identifies the reality that Federal support has created at least three sectors of a semi-specialized delivery system for mental health. The most important of these are the community mental health centers, followed by the large growth of psychiatric units in general hospitals, the network of Federally supported methadone clinics and State and local supported programs, not only for methadone, but also for residential treatment units, and a similiar, less well-defined, but still important network and sector for alcoholism. Now, what is the larger context from the policy point of view? The awareness in the late sixties and early seventies that this country had allowed its general practice network to disappear and that there had been a tremendous growth in the secondary and tertiary levels of care with high technology and high cost has led to a Federal policy of previous Administrations, continued into this Administration. It is 1) to purposely strengthen primary care, 2) to limit the further development of specialty care, particularly at the tertiary care level, and 3) to attempt to transfer long-term care from institutional to ambulatory settings. This so-called deinstitutionalization policy, while perhaps most controversial in the case of mental illness, has corresponding issues for arthritis, alcoholism, and cardiovascular disease. The policy within the primary care setting is to facilitate-- with government support and legal encouragement--the development of organized modes of delivery of primary care, among them the Federally supported network of urban health centers, migrant programs, and rural health centers, and the use of Federal monies to create a new form for delivery of primary care through organized, if not operated, Federally supported programs. However, at best, it is unlikely that these will ever reach more than 5 to 10 million individuals. The other development of interest in the primary care sector, again with purposeful Federal policy, is to support HMOs, another new organizational mechanism for the delivery of primary care. Still another policy dimension has been categorical support for training programs for a new class of practitioners, family practi- tioners, and the Federal definition of three other classes of practi- tioners as primary care practitioners who receive Federal support, namely internists, pediatricians and obstetricians-gynecologists. With regard to Federal policy, it is important, once again, to recognize that at the present time there are only two classes of medical practitioners who receive categorical support at residency training~-psychiatrists, through the NIMH program, and family practi- tioners, supported by Health Resources Administration.
38 This is yet another indication of Federal policy to reinforce, in one case the sector of primary care, to hold back the continued erosion of the general health care sector; and in the case of psychiatry, to recognize the continued unmet needs with regard to clinical manpower. Again, I should like to direct your attention to the fact that, at least transiently, these considerations and the linkage between general health and mental health are part of the larger complex frame- work of interactions and linkages between mental health, alcoholism, drug abuse at both secondary and tertiary levels, as well as to the important issues around long-term care and particularly the extent to which the long-term care patient, for the most part previously treated in long-term custodial institutions, can, in fact, be treated with humanity and with quality of life in ambulatory settings, hence the controversy around deinstitutionalization. This brings me to another related policy issue, and that is the place of psychotropic drugs in treatment programs. (Figure 3) A survey of CNS psychoactive drug prescriptions indicates a downturn in the number of prescriptions for hypnotics and sedatives in the past five years, and especially rapid decrease in the number of prescrip- tions for stimulants in the 1970s. Figure 3 110 100 90L 80L 70: ant 50 40 30 10 _ O _ Antianxiety Agents / \ ~ Hypnotics Sedatives _ ____ Antidepressants `_ ~ me, ._ ~~ Antipsychotics ~ 'a__ Stimulants 1' ~ 1 1 1 1 1 1 1 1 1 1 1964 1966 1968 1970 1972 1974 1976 YEAR
39 Although the number of prescriptions for antipsychotics generally increased during the period from 1964 to 1974, it has leveled off in recent years. Prescriptions for antidepressants have shown consistent growth up to the past few years. The most dramatic increase has been in the number of prescriptions for anti-anxiety drugs, primarily chlordiazepoxide, diazepam, and meprobamate. In 1973, these accounted for over 100 million prescriptions, but more recent data indicate a leveling-off and even a slight decline. Valium is the single most prescribed drug in the world, as well as in the United States. The three most prescribed drugs in the United States are 1) Valium, 2) Darvon, and 3) Librium. The importance of this is a matter of great policy debate. Are we an overmedicated society? Is this use of psychoactive drugs inappropriate? Are physicians in general and psychiatrists in parti- cular using these drugs inappropriately in persons without mental disorder and, in particular, are women being prescribed these drugs out of cultural bias and sexism, as is claimed by some of the feminist critics of the health care system? From the point of view of the topic of your conference, a fact that emerges from recent research, that of Baiter and his associates, of Rickles of the Philadelphia group, and I think also confirmed by studies in Britain, is that the majority of prescriptions for these drugs are not written by psychiatrists. Psychiatrists account for only about 15 percent of all the psychoactive drug prescriptions written. All the others are written by general health care physicians, particularly the primary health care physicians. In fact, if one looks at what evidence we have for the mode of treatment for 60 percent of the 30 million patients with mental disorders identified by Regier and his colleagues in the health care system, the evidence seems to be that the majority are treated with what I call a combination of a pat on the back, a kick in the pants, and a of bottle Valium. I am not advocating this as the ideal mode to deal with these problems; in fact, I have some serious doubts as a clinician about its utility. But the fact is that for the most part, from the evidence that I have seen' this is the level of treatment for 60 percent of the 30 million now in the health care system. The question from the policy point of view is whether the Federal government should make any attempt to influence this curve and its future development. Do we have any responsibility for the education of the public in general or the medical profession in particular with respect to the appropriate use of psychoactive drugs and, if so, through what mechanisms? And if there is evidence that this is an inappropriate mode of treatment, what alternatives exist for the large numbers of patients with anxiety states, depression, or alcoholism, who are, in fact, in the general health care system?
40 How good is the evidence for the efficacy of psychotherapy of any kind vis a vis that of drugs alone or in combination for these conditions? Are the psychotherapies which may be proven to ~~ ~ ~ ' the primary care sector? the psychotherapies be efficacious capable of being applied in And, if so, should they be applied by the rid ~ ~ a-- se or by mental health personnel working in concert with them? again, I think of the British experience, particularly the quasi- controlled trial of locating social workers in general practitioners' centers as reported by Cooper and Shepherd, which is, I think, an important experiment for us. I have attempted to convey to you a sense of what are the types of policy issues that get discussed within HEW. They are not, to my surprise, a concern for the magnitude of the problem or for the extent of human misery. nrim~rv care nhvsicians per Here, The issues are what sectors of the health care system are most appropriate for dealing with these problems; what forms of technology of Err-rid c, available to us are, in fact, efficacious, whether they be drug or psychotherapeutic; and which types of personnel are most useful currently or in some hypothetical future. And, assuming there can be some agreement as to the goals, what is the role of the Federal government through reimbursement programs like health insurance, through categorical programs like funding of mental health care centers or linkage grants, or through training efforts, to move the system to a more rational integrated basis, instead of the avowedly fragmented basis we have now.