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APPENDIX C
POSTSCRIPTS
In accordance with the original conference design, participants
in the April 2-3 meeting were encouraged to submit written follow-up
comments within 30 days. The following were selected to highlight
several of the principal themes concerning mental health services in
general heal th care .
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(1) Advantages of Coordinated Mental Health and General Health Care.
Albert J. Solnit, M.D.:
. . . The major advantage of bringing together primary and mental
health care knowledge and personnel is the primary and secondary
preventive impact on the continuity of effective care for patients.
This concept also implies that patients who need tertiary care (e.g.,
those with schizophrenia, sustained depressive conditions, etc.)
should be referred to mental health specialists who are competent
to evaluate and treat such patients, often with the collaboration
of the primary health care provider.
When primary physicians and their teams include preventive men-
tal health knowledge and techniques in their repertoire, the care of
patients should be increasingly humanized. Moreover, such health
care should assure more effective continuity of care and opportunities
to maximize primary and secondary prevention of physical and mental
health conditions.
Mack Lipkin, Jr., M.D.:
The goal of integrated primary health care and mental health
service can be justified on humanistic grounds, the grounds of caring.
However, additional data argue for such integration. First, the
nature of disease and illness phenomena is that they are, in fact,
integrated. Second, a significant majority of the cases, ranging
from 30 to 80%, according to criteria and study, involve psychologi-
cal as well as disease issues. Third, a subset of cases, in our
experience 4% (visits in an HMO), require integrated care. Failure
to provide such in these cases leads to increased costs, decreased
satisfaction, and occasionally unnecessary morbidity and mortality.
Barbara Starfield, M.D., M.P.H.
(By coincidence, at the time of the conference Dr. Starfield
was just completing an epidemiological study of psychosocial and
psychosomatic disorders in pediatric case loads. The psychosocial
disorders, including learning disabilities and behavioral dysfunctions,
have become increasingly prevalent; together with psychosomatic dis-
orders, they are present in about 20% of pediatric cases. She has
applied the term "the new morbidity" to this phenomenon. An abstract
follows of her unpublished report, "The Prevalence of Psychosocial
and Psychosomatic Diagnoses among Children in Primary Care Facilities.")
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The Prevalence of Psychosocial and Psychosomatic Diagnoses
Among Children in Primary Care Facilities
(Abstract)
In this study in seven primary care facilities, the proportion
of children recognized as having psychosocial problems was much higher
than generally assumed. Although there was great variability among
the facilities the prevalence was at least 5% and as much as 15% except
in the hospital teaching facilities where it was much lower. The
prevalence was higher in children in poor families. The variability
among facilities was much less for psychosomatic problems, which
were diagnosed in 8-10% of children. The variability in diagnosis
of psychosocial problems is most likely a result of differences in
the extent to which different practitioners recognize this type of
problem.
For both types of problems, but especially for psychosocial
ones, the proportion of visits with the diagnoses was much less than
the proportion of children with them, so that the management of these
problems was not associated with a relatively large number of visits.
Available evidence suggests that individuals with unresolved psycho-
social problems make more than their share of visits for other diag-
noses. Therefore, management of psychosocial problems in primary
care should reduce overall utilization.
The findings of this study have implications for the content
of educational programs for primary care practice and are pertinent
to current debate over policy concerning reimbursement and benefit
packages.
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(2) Organizational Issues.
Gordon H. Deckert, M.D., F.A.C.P.:
I certainly agree with the data that the majority of the mentally
ill are cared for in primary care settings. Beyond this I tend to
believe that the majority of these patients will be taken care of by
primary care physicians and in settings where being able to implement
the model of a team of mental health professionals working with primary
care physicians is unlikely. This is a point I want to emphasize since
most of the presentations tended to come from individuals working in
the large metropolitan areas of the northeast coast and metropolitan
areas of California. The vast majority of primary care physicians in
this country work in settings where it will not be possible in the
next five years or even ten years to place well-trained mental health
professionals. Hence, it will not be enough with this new initiative
to focus on the training of mental professionals to work in primary
care settings. In many instances (I would daresay even most instances)
the delivery will have to come from primary care physicians themselves.
Stephen King, M.D.:
The British contribution /to the Conference/ . . . pointed
dramatically to the difficulties inherent in attempts to effectively
integrate the private fee-for-service system extant in the United
States.
There is a significant rapidly growing system of care directly
supported by ADAMHA and HSA. In Region IV alone, the Bureau of
of Community Health Services supports approximately 300 projects at
a cost of $200,000,000 which along with 500+ NHSC provider assignees
is providing medical care to 3,000,000 people. This resource could
easily be galvanized with an effective operational linkage with
the CMHC's. Such a model would cause by its effect a great deal
more to happen, even in the private sector. It should not cost more
dollars to integrate these programs locally -- providing single
point access and point responsibility for catchment area populations
were to be established.
Primary care resources and CMH resources tend to care for very
different populations of people. The information presented at the
conference would tend to support the hypothesis that the nature of
clinical needs of these two populations are different, suggesting
to me that some scrutiny of the purposes of the various programs
is warranted.
It is my impression that a major contribution to the present
schism arises at the legislation/congressional level. The present
legislation is increasingly undergirding a conceptual isolation of
the programs, especially in the mental health area. The constituency
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is particularly turf jealous. Also, along this line is the lack of
attention to the issue by the planning legislation (93-641~. Actually
the HSA boards and staff as well as the State Health Coordinating
Committees and the State Health Planning Development Agencies are
not oriented toward mental health programs.
There are many instances of effective program integration in
the field (other than in the private sector) often established in
the face of bureaucratic indifference. These are always, I think, the
result of assertive and immaginative local leadership.
. . . I would like to assume that it is in the vested self interest
of all that there be integration of these elements of care, and further,
that this care must be available to all to be effective. When this
integration and access are assured, they are accomplished in the
field, in an arena which is most distant from those arenas of academia
and research and which is often buffeted by unthinking administrative
policy decisions by the responsible agencies.
There is in truth no discernible national health policy which
speaks to the importance of the complete Herman being, of an organism
needing care, a policy which is oriented toward effective coordination
of available resources over which we have control.
Jeffry L. Houpt, M.D.:
The problem begins with the term "primary care" medicine. It
tends to imply that we are talking about the integration of mental
health services with primary care physicians as opposed to other
nonpsychiatric physicians who provide primary care medicine. I
think it is important to keep in mind that primary care physicians
are only one group of physicians with whom we need to be concerned.
I make this point because I left the conference concerned that we
support a pluralistic system and think about ways of integrating
mental health services with the internists, surgeons, pediatricians,
and obstetricians/gynecologists who also practice primary care
.
met Scone.
If we are going to take a flexible approach to this particular
subject, we cannot pattern ourselves completely after the British
system. Under their system, all people see the generalist first
before seeing a specialist. Mental health services are provided by
the "G.P.," or on occasion with the assistance of a social worker.
Recommendations are rather one-sided for such a model: (1) better
education for primary care physicians in psychiatric management and
(~) atternpti~g to strengthen referral for severe psychopathology.
While such an approach is clearly viable, and in some areas
the only reasonable approach, I'd like to keep alive (l) the notion
of integrated ~~ulti-specialty clinics or offices for providing
.
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primary care medicine and (2) the notion that mental health profes-
sionals can provide some of these services. I would suggest that
the mental health services provided to nonpsychiatric physicians by
mental health professionals be described in terms of two broad areas
of function: a first category whereby mental health professionals
provide direct service to patients, and a second category called
liaison functions or indirect services whereby mental health per-
sonnel provide service to the nonpsychiatric physician or other
members of the health care team. Liaison functions would include
such things as providing support, advice, or teaching.
The essence of my ideas are that we provide a flexible system.
Both primary care physicians and multi-specialty groups could be
developed to meet the need for general medical care. Programs
could be developed to utilize mental health professionals in providing
direct and indirect services to either the primary care physician
or the multi-specialty group. There is no need to force such a hard
line of distinction between "primary care" and secondary care when
it comes to providing mental health services.
George J. Cohen, M.D.:
Comparing three systems of provision of mental health services
in primary care settings, I think it is important to indicate the
intensity of those mental health services as well as procedural
factors. In my score of years in private practice my approach was
very similar to Dr. Pakula's, i.e., essentially preventive, with
anticipatory guidance based on normal stages of child development
and my assessment of both the child's and the parents' temperaments.
In addition there were many times when either the family or I would
feel a need for counseling regarding behavior problems. This was
usually set up at an after hour session for which a separate charge
was generated. Fortunately in a largely middle class practice most
families are able to afford this cost out of pocket.
_At Children's /National Children's Medical Center, Washington,
D.C./, both in the past few years in my full-time work in the Out-
patient Department and in my 17 years of working in the Lead
Poisoning Clinic, a different set of circumstances prevails. In
the general Medical Clinic we try to encourage the residents to do
some anticipatory guidance especially when the children are in for
health check-ups. In addition there is a steady flow of youngsters
with the usual childhood behavior problems and habit disorders such
as bed wetting, school phobias, and somatic or functional complaints,
e.g., headaches, abdominal pains. Here again we encourage the resi-
dents to look beyond the symptoms and to identify situational or
emotional factors. This however is often done on a somewhat scatter
shot basis because the attending physician cannot work with each
and every resident with each and every patient. However, as patients
are discussed in follow-up and as charts are reviewed, these questions
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often surface even if the resident has not requested a consultation
initially. In our Lead Poisoning Pica Clinic which has not been
absorbed into the general Medical Clinic team structure, I supervised
both pediatric and psychiatric residents. As we saw each of our child-
ren with Pica and/or lead poisoning, our approach was to encourage
the residents to take a holistic approach to the child, his family
and their environment while the psychiatry resident served either
as a consultative resource for deeper emotional difficulties or
as a leader of discussions with the parents regarding anticipatory
guidance and situational adjustment.
A third model is in Mobile Medical Care, our volunteer clinic
for low-income persons in Montgomery County /Maryland/, where we
have both medical and mental health personnel working in the same
clinic. There consultation is available on a face to face profes-
sional basis, and the medical and mental health records are available
in the same jacket; any professional can see what another has been
accomplishing in his work with the patient.
In all of these settings one of the most important things is
a relationship between the primary care health person and the mental
health person. This means the primary physician must choose mental
health experts with whom he can work comfortably, as well as open
communication in both directions. In private practice this was
frequently difficult, especially if the patient went to a mental
health clinic or other agency where there was often great reluctance
to reveal any information to the referring physician. However, the
private mental health consultant was usually able and willing by
phone to render such information. In the Children's Hospital clinic
setting such personal contact is available, but the primary physician
must often be pushed to take advantage of it, and often will refer
the patient to the psychiatry clinic but not follow-up on the patient
The presence of both the mental health and the medical health workers
at the same time at the same place at Mobile Medical Care obviates
some of this difficulty.
Alan M. Jacobson, M.D.;
Funding was, is, and will be a major stumbling block to the
reasonable policy of bringing psychiatry and primary care practice
into at least shouting distance. The use of categorical monies for
linkage grants is a useful first step, but should be tested in other
settings besides neighborhood health centers and HMO's. I could
envision social workers, trained and supervised by liaison psychia-
trists and funded by linkage grants to CMHC's, approaching private
general practices located in the catchment area.
A second approach could take advantage of the Blue Cross
reimbursement policy already in place whereby hospitals build into
physician outpatient fees the cost of social work time. This could
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be expanded to Blue Shield coverage for private practices which
employ social workers and could even be used for psychiatric super-
vision and consultation time. Direct psychiatric treatment would
be funded by current methods.
Thomas Madden, M.D.:
Because of the absence of a universal primary care service in
the U.S.A. there exist large areas where both physical and mental
health care are lacking. It seemed to me that the Conference gave
very little attention to this specific problem, although its existence
is probably the main reason for such a conference being necessary at
this time. These needs are made acute by what is happening in many
individual States. For what appear to be purely fiscal reasons,
rather than the beneficent effect of modern therapeutics or a fashion-
able concern for "community care," old long-stay Victorian units are
being systematically emptied out. They are not attractive or suitable
places for mental health care, they promote chronicity, they often
provide the worst of care and have the least* skilled and the least
rewarded staffs; but it is certain that in the community, facilities
for care are usually lacking and the receiving community is often
quite unprepared and unwilling, both in terms of arrangements and
attitude, to receive or welcome. (*I throw no stones. It is the
same at home.)
An important priority will be the need for half-way houses, pro-
tected living and working environments, hostels, etc; and let us
hope once again that such facilities will not all or even mostly be
sited in the old and decaying neighborhoods; for in both countries the
attitude seems to prevail that areas which have become habituated to
tolerating anything may be allowed to tolerate everything.
Having said all this, I would not welcome special units, teams,
solutions for immediate need without considering what might be their
effect 5 to 10 years ahead. If such are set up, their existence
must not later be used as justification for saying that there is no
need for primary care, for a supply of family doctors, for example.
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(3) Provider Roles and Skills.
Carolyn B. Robinowitz, M.D.:
. . . Certain issues of quality should be studied and addressed.
There are implications about quality programs related to those sixty
million prescriptions of Valium yearly, as well as the accuracy of
diagnosis and appropriateness of certain management plans of referral
patterns.
. . . While I realize that this is both simplistic and obvious,
I continue be appalled at how little attention is paid to quality
or to what needs to be taught. There is a tendency in making family
medicine a legitimate specialty to require that family physicians
know everything that their specialist counterparts do in each area.
While any educator can recognize that it would be impossible to teach
and learn all this material in a three year residency program, we often
behave as though we expect it of the primary care physician. Therein,
I think, lies one of the major problems for the long-term viability
of the field. I do worry that in our concern to develop specialist
primary care practitioners capable of intervening early, promoting
health education and responsibility for patients' health care and
providing continuous skilled and long-term care, we may also set
up demands for someone who has more knowledge and skill than it is
possible for anyone to have. By making these demands (or creating
these expectations in the public's mind), we are setting up the
possibility of major disappointment with the real limits of the
field. This disenchantment may then cause the pendulum to swing
back the other way and lose support for what should be a growing and
necessary field. On the other hand, the practitioner who has the
sense of needing to do more and be all things to all people and
experiences constant frustration in meeting this challenge may
end up being a "drop-out" to enter a specialty in which knowledge
and skills seem more circumscribed.
Gordon Deckert, M.D., F.A.C.P.:
First, primary care physicians in my experience do not hesitate
to ask me for ''help" in dealing with patients in their practice. I
do not find them nearly as resistant as they are often portrayed.
However, in the main their first query pertains to patients with
psychosomatic disorders. Their second concern usually is how to
deal with the psychological responses of patients to illness, in
short to what we would call adjustment reactions. After these
questions come questions relative to the management of patients with
mental illness, as defined in the Conference (that is, anxiety re-
actions, tile depressive spectrum, schizophrenia and thought disorders,
alcohol and drug problems). Depending upon the study, 25% to 30%
of patient visits to primary care physicians fall into this latter
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category. The priorities of primary care physicians must be considered
when we approach them and by emphasis they have not been the priorities
of the Conference, in my opinion.
In my experience, primary care physicians do not need to be con-
vinced that a large share of their practice falls into the arena of
what I call "psychological medicine.': The skeptical physicians are
those in health sciences centers. What primary care physicians in
practice are skeptical about relates to the quality and practicality
of the offerings from the mental health professions. From long experi-
ence they have discovered that most continuing education programs or
educational approaches to them tend not to be very practical or helpful
within the context of their particular practice. I am really quite
convinced that physicians in practice are much more sensitive to the
problems in their practice than the data would indicate but like most
physicians they tend to record information and make diagnoses in
categories for which they feel they can offer some assistance. In
many instances they simply do not know how to be helpful to certain
categories of patients with psychological problems.
Thomas Madden, M.D.:
It is necessary to examine and draw conclusions from the work
of Darrell Regier and his colleagues. Their work shows that, in much
the same way as the ubiquitous OP of the United Kingdom system, the
primary care doctors of the Ua S.A., be they internists, pediatricians,
ob/gynecologists, old-style G.P.s or the new generation of family
doctors working the community (the latter, I believe, with more skill
due to better preparation for the task), are providing a service
accounting for the majority of requirements, in those areas at least
where such doctors are to be found. They are in fact handling a
major part of the mental illness in the community and providing con-
tinuing care in those more serious cases, in which specialist doctors
and institutions are only episodically involved.
It is important to examine what help, what resources, what further
training these physicians need.
. . . With regard to 'feeling unwell,' whether expressed in somatic
or psychiatric symptomatology, a well-known study in the Guy's area
(Wadsworth, Butterfield and Blaney, 1971), showed that, in a borough
regarded as well-served by family doctors, local authority and hospital
services, only 5% of a survey sample reported no complaints in the 14
day period prior to being questioned: complaints for which for the most
part they had not considered it necessary to consult any doctor. While
this and similar enquiries have encouraged speculation as to undiscovered
illness which it would be desirable to treat, they have not been held to
indicate that all symptoms require referral and that there is no place
for reasonable self-management.
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logical medicine cannot be practiced with this model in mind. Rather,
one must use the individual response specific model. In my experience,
until this concept is thoroughly grasped by my workshop attendees,
they will continue to ask such unscientific questions as "How do
you treat depression?", "How do you treat anxiety reactions?", etc.
Once they grasp that we do have something specific to offer in
terms of process when one approaches a specific kind of patient who
presents with a specific constellation of findings, we are off
and running. The next major theme is the perceptual task. By this
I mean that many physicians simply do not see the evidence for primary
emotions in the fact in front of their face. They are much better
at hearing evidence but they are relatively unskilled visually. They
are in the situation of not seeing data and hence not making the
precise diagnosis and hence not treating certain patients effectively.
They would be in a similar situation with other patients if they
did not feel the enlarged liver or did not hear the presystolic rumble
or did not notice the elevated white count in a lab report. I'm not
speculating in making this observation. Many physicians simply do
not see subtle evidence for anger in women or fear and/or sadness
in men. The educational experience of most medical students in
most medical schools and certainly in most primary care residencies
is such that they do not discover the recognition rules taught them
by their culture, rules which they brought to medical school or to
postgraduate residencies or whatever. Finally, unless one can bring
some model for therapeutic intervention all of the above comes to
naught e I have evolved a model of therapeutic intervention which
I call 'The Therapeutic Sequence" which seems very helpful in didactic
sessions with primary care physicians. This is all outlined in a
chapter on "Interviewing Techniques" in the latest Textbook of Family
Practice published by Saunders and edited by Conn and Rakel.
Morris B. Parloff, Ph.D.:
An oft-repeated "solution" was that of providing the physician
with additional training, but there was no agreement on what the
physician was to be trained to do. Recommendations ranged from
providing broader training in the behavioral and social sciences
(presumably to promote a more humanistic approach to patients);
improving diagnostic skills to permit the physician to undertake
triage in determining whether the patient's problems required
specialized attention; or enabling the physician, independently,
to provide effective treatment of the full spectrum of emotional
disorders.
In my view ~c won ~ a Indeed be appropriate for physicians in the
course of early academic training to receive information which might
permit them to differentiate among the following classes of problems:
1. those problems that will improve over time with or without formal
psychiatric intervention (e.g., crisis reactions, sadness rather than
~ ~ , . ~ . .
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depressions, phobias in young children, etc.), 2. problems which
require treatment lest the condition worsen or the patient become more
vulnerable to stresses, and 3. problems which are best treated by
the PCP or other nonparental health professionals lest the fact of
referral act to confirm the patients' fears that they are suffering
from pathological processes when in fact they are confronted with
everyday problems of "no~alcy" or "existential problems of living.
Mac k Lipkin, Jr., M.D.:
Teaching about integrated care is presently difficult. In
Rochester, despite the presence of a nationally recognized group
with a charismatic leader, the impact on the overall organization
of care has been extremely variable. For the most part, trainees
in this institution behave predominantly in ways similar to the
prevailing biotechnical culture.
Our analysis of this problem leads to the following conclusion.
In order to affect behavior (as opposed to lip service ideology)
of trainees, the important behavioral levers which control their
behavior must be managed. Most significant is the role of the prac-
tice culture. Here, the role model concept is useful, but errors
have been made in recognizing who the role models are. The attending
physician is one. However, in the tertiary hospital, the housestaff
themselves provide their own role models. Students, as well, look up
to the housestaff. Thus it is our belief that a role model cascade
is necessary in which a core group of those capable of producing
integrated care influence housestaff and attendings, as well as
students.
Learning in this area is difficult because the concepts are
complex and painful; exhausting psychological effort is involved in
applying them; and, at present, the prevailing disease oriented
culture is not hospitable. To counter these deterrents, trainees
need to experience positive integration oriented learning at each
level of their growth.
What is needed, then, is a cascade of role models -- a critical
mass of model professionals, people who believe in and can cogently
practice integrated care. As well, model services are needed which
prove, in their structure, belief in integrated care. Both model
professionals and model services must stem from a conceptual frame-
work in which the case for integrated care is clear and convincing.
This then must also reach the curriculum and every clinical teaching
service. This is seldom a priority, as services stem from analytic
discipline and integration stresses synthesis.
Government roles in relationship to development of an integrated
conceptual framework, curriculum, model services and model professionals
can be multifaceted. Centers of excellence are needed to train teachers.
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Money is needed for research in the applied issues of integration
of care and the underlying basic scientific issues. Money with strings
attached in terms of training and service formation could be very
helpful in providing opportunities for those with skills in this
area to achieve some potency in the presently biotechnically dominated
teaching institutions. Especially needed is career support for mid-
level persons in this area, since otherwise they must get support
from other kinds of activities.
. . . Finally, the notion of the great potential marginal gain
in this area was mentioned. At this point in history, relatively
small investments in centers of excellence, training of teachers,
and creation and study of model services can well be expected to pro-
duce large gains relative to the costs. This is a major argument for
well-targeted government support, at this time, for study of inte-
gration of care.
Thomas A. Madden, M.D.:
Primary care providers: helping the helpers
The resolution of these problems does not require (as some
speakers seemed to imply) investigations into "Who should provide?",
or even "How well do the present providers perform?" (although this
.
is a very interesting subject), or into "fit types of new instit_tion
will be needed?" Even to set out in such a direction may imply that
.
one has in effect already concluded that the present primary care
doctors ought not to continue to do the job, a decision which defies
both logic and experience elsewhere. The question ought rather to
be: How may they be helped to do it better?
I do not write as an English family doctor, when I say: Begin
with the primary care doctors that you have. This is certainly the
least costly and most practical way to go. Whatever the present
inadequacies of provision and cover, solving one problem in health
is often the way to solving more. Hence the long-term answer in the
mental health sphere is precisely the same as that for any other
aspect of health: the provision of adequate primary care for all
areas and the training of physicians and other professionals for this
work.
This continues to have implications for the medical schools in
training (and far better than heretofore) the future primary care
doctor and in assuring a proper supply of such doctors to the com-
munities. Our workshop particularly emphasized the need for medical
studies to include: (1) the patient in the family context and (2)
the patient in the community.
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Alan M. Jacobson, M.D.:
The move toward primary care oriented psychiatry, in whatever
form this takes, necessitates a shift in the ego ideal of psychiatry
and therefore a restructuring of psychiatric training. If, to para-
phrase the Bauhaus expression (Form follows function), training follows
money, policy recommendations should encourage NIMH stipends for
primary care psychiatrist training either as part of the general
residency or as fellowships in PGY 4 and 5.
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(5) Quality of Care Issues.
Morris B. Parloff, Ph.D.:
Quality of Care and Professional Affiliation
It seemed odd to me that so little interest was expressed by either
the primary care provider or the psychiatrist in determining the
quality of mental health services which, according to claims, are
being so promiscuously and effectively provided by the nonpsychiatri-
cally trained physician in treatment sessions limited to 13-20 minutes
each.
There also appeared to be no enthusiasm for the notion that
research be undertaken to assess the quality of care offered by the
PCP by comparing the relative effectiveness of the PCP and the mental
health specialist in treating specified classes of emotional problems.
While the psychiatrists seemed to be excessively modest in com-
mending to their medical colleagues the value of specialized mental
health training, they appeared considerably less diffident with regard
to their special competence relative to their nonmedically trained
mental health practitioner associates.
Evidence of the Effectiveness of Psychotherapy
In casting about for evidence of the efficacy of psychotherapy,
a rather oblique set of data were presented, intended presumably to
impress the PCPs and the authors of potential health insurance
legislation. The evidence presented was not that the specialized
practice of psychotherapy is demonstrably effective in ameliorating
the discomfort of the patient and enhancing his/her functioning, but
rather that psychotherapy provides a cure for excessive utilization
of medical facilities. While the evidence is clear that some emotion-
ally disturbed patients make excessive use of medical facilities
and that appropriate psychiatric care may reduce such inappropriate
drains on medical resources, this fact appeared to be less impressive
to private practitioners and physicians working in community mental
health clinics than to those in HMOs.
Concern about the patient's welfare requires that the patient be
provided appropriate medical care rather than simply less medical care.
The persistent efforts to justify mental health services on the equivo-
cal evidence of cost-offset is not only unpersuasive but promises to
be ill-advised. Costs should continue to be of lessor priority at
this stage of the field's development than evidence regarding the quality
of care provided.
Neil J. Elgee, M.D.:
My main concern is that we seem to be implicitly accepting as
a given, in the administrative and political context, the complete
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whole undifferentiated spectrum of "psychiatric services" -- like
buying and administering a package. . ~ I am not persuaded that
an analytic hour with an M.D. represents quality. In Camelot, it
is true, I would be in favor of everything we discussed and every-
body's program. I fear, however, if we promote undifferentiated
psychosocial services, we may fail to get much of anything at all
or may dilute the good with the undifferentiated. As of my present
reading of the situation, I would want to concentrate.
George J. Cohen, M.D.:
Certainly as we all agreed there is a gut feeling that most of us
have and which is often expressed by patients that attention to emotional
areas is really important and helpful. Evaluating modes of delivering
such care is difficult' first, in establishing criteria for diagnosis
and treatment methods, second, in recognizing cultural variance,
third, in finding some sort of control population to compare against
the treatment population in terms of attitudes and outcomes. Which
outcome item to use is another concern. The number of visits for
non-psychiatric complaints was shown to have many many flaws. If
we don't consider the variation in training, experience and interest
of the primary and mental health therapists, comparisons are virtually
impossible. Another important item to consider is the initial state
of physical and mental health of the patient and whether an increase
or decrease in utilization is a goal.
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(6) Research Needs.
Neil J. Elgee, M.D.:
.
/I would/ support research in all aspects of psychosocial disease.
_
Justification for wholesale delivery of therapeutic interventions is
not yet persuasive and should remain in the research arena.
Vincent J. Felitti, M.D.
. . . It is clear that a pluralistic system is already in place --
the relationship of psychiatry to primary care already exists in the
solo practice sector, in HMO's, in university settings, and in group
practices. We don't need to know what to do, we are already doing it.
What we need is to know what works best and where to allocate future
resources.
I was quite disappointed during the meeting to see that there
was so little interest in studying the outcome of the integration
of psychiatric services into primary care settings. . . A number
of important questions need to be answered and the HMO setting pro-
vides a unique opportunity to do this because for the first time a
large closed system is available in which the complex ramifications
of psychotherapy can be studied. The simple fact of having a uni-
fied medical chart serving all specialties is a sudden, significant
advantage.
Should entry into the psychiatric system be patient determined
or only by referral from a provider? Should it be passive, or should
an outreach program be used? What types of therapists are most cost
effective? Are social workers, psychologists, and psychiatrists
interchangeable as psychotherapists or not? How should triage be done
and by whom? What types of therapy are affordable and demonstrably
effective? What should be the limit on duration of therapy? There
is a small amount of significant information (e.g., Malan, D., Archives
of General Psychiatry, November 1976) indicating that a one time
visit may be significantly beneficial. What measures of effectiveness
of therapy do we have? Two issues need to be addressed here. The
first is the effectiveness of therapy to the patient and the second is
the effectiveness of therapy to the overall system. Does effective
psychotherapy decrease perverse medical utilization? Does ineffective
psychotherapy increase it? Clearly outcome studies are not only
difficult, but resisted. Some of the difficulties, and none of the
resistance, may have been reduced by Hans Strupp of Vanderbilt
University who had an important article out recently. He describes
using a tripartite system which makes diagnostic use of those very
issues that had always been a source of disagreement and confusion
in the past.
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For the first time a major undertaking is underway relating
psychiatric treatment to general medical care. If, in a flurry
of goodwill and good intent, the outcome of this is not studied
we shall have missed a golden opportunity.
Thomas A. Madden, M.D.:
. . . I consider it important NOT to devote research funds to
the development of ever more sensitive indices of personal misery
and dysfunction, such as might tend to show that 90% of the population
'could do with' brief or longer psychotherapy (however defined). To
follow such a direction would be betrayal of those in need, when so
many serious problems, untouched let alone unsolved, abound in so
many countries and here.
. . . In the sphere of research, it is necessary not merely to
look at what specialists think primary care doctors ought to do,
patently cannot do or do badly; but at the subtly acquired skills
which many excellent family doctors may have evolved, intuitively
rather than by Balint seminars, and from experience; a product of
continuity of care, familiarity and human involvement. At the
Institute of Psychiatry, such an approach has been made by Dr. Norma
Raynes, a sociologist and anthropologist who has developed interesting
techniques of direct observation. (In publication)
. . . In any comparison of the results of therapy by drugs, with
or without psychotherapy, it is necessary to look at a much more im-
portant and complex dimension, that of the patient's coping resources;
to build into the enquiry, however difficult, some measure of the
patient's position in the social network as a factor strengthening
individual resources and chances of recovery. In the wider sense,
this means family, friends and neighbors, even the members of the
primary care team or lay counselors. As it happens, there is work
precisely on the topic of post infarction career and the use of lay
counselors. A useful reference is Angela Finlayson's "Social Networks
as Coping Resources" (Social Science and Medicine, Vol 10, pp 97-103,
Pergamon Press, Great Britain, 1976~.
Need, not entrenched interest, skillful lobbying or special
pleading should determine priority. With such obvious and gross
needs, to some of which I have alluded, one would not want to
encourage inquiry into, say, the wide range of normal mood changes
reported as pathology by hypersensitive surveys.
In research, as the whole volume of Michael Shepherd's work
and his talk to the Conference reveal, the cooperation of teaching
hospital and practicing community doctors becomes a two-way process.
The learned institute acquires a population for its study which is
not selected, hospital-based. (In this case, it was the Maudsley
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doctors who first acknowledged the existence of a very large and ill
defined 'psycho-social' group of patients known to G.P.s but not at
that time to hospitals.) Conversely, I believe that every G.P. who
has participated in any part of that work, now over many years, has
thereby sharpened perception and skill in management.
Alan M. Jacobson, M.D.:
Offset is a dangerous outcome variable for psychiatric research
in primary care settings. I would instead suggest funding for repli-
cation of Goldberg's and Shepherd's intervention studies in U.S.
settings. Outcome variables developed for these and recent U.S.
psychotherapy outcome studies offer a variety of measures which could
be used in addition to offset of medical utilization.
Morris B. Parloff, M.D.:
A major concern of the conferees appeared to be service delivery
and providing some advocacy for the alleged advantages of particular
delivery systems such as neighborhood centers, CMHCs, HMOs, private
practice, group practice, team functions, etc. This all appears to
be predicated on the belief that knowledge regarding the efficacy of
the techniques to be delivered has already been well established.
Little attention was paid to the prior question of establishing the
efficacy of treatment techniques under ideal conditions. This step
is prerequisite to any research which attempts to establish the
adequacy of the treatment delivery systems since such research con-
founds efficacy of treatment with adequacy of delivery.
Mac k Lipkin, Jr., M.D.
Research concerning integrated aspects of care has been touched
on in the conference. However, certain issues were not focused on
with depth. One of these is the need for greater clarity about
the underlying conceptual models or paradigms being employed. Second
is the need for meaningful population-based studies with a problem
(as opposed to diagnostic) orientation. Third, there is a need for
outcome measures which measure goals of care systems in contrast
to present haphazard specialty-based goals or the equally mindless
body count approach.
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(7) Social Support Systems.
Marie Killilea
Although the importance of supportive others in times of crisis
has been recognized for many years, the use of personal and social
networks in health and mental health clinical practice and research,
and in the design of services, is a relatively new occurrence.
Social support systems include naturally occuring helping net-
works which often seem to be invisible because they are so much a
part of the fabric of our lives. Help is given and received outside
the structure of human services agencies. This help is based on a
commitment of reciprocity and exchange, e.g., within the family; in
kin and friendship networks; in neighborhood helping networks. In
addition to these fluid, unbounded networks, there are more organized
structures of informal social support, e.g., self-help groups such as
Alcoholics Anonymous; person-to-person mutual aid such as Widow-to-
Widow programs; cross-age helping programs such as Foster Grandparents;
peer-oriented helping programs such as school peer counseling activi-
ties; alternative community service programs such as hospices and
shelters for battered families.
These social support systems are inherently sensitive to cul-
tural and subcultural variations and build on preferred patterns on
help seeking and help accepting.
Many community institutions which have other objectives as their
primary mission in society also have important social support func-
tions; e.g., the workplace, the church, the school, and the medical
care institution.
Operational definitions of social support include Sidney Cobb's:
that social support is information that tells a person that he/she
is loved, valued and is part of a network of communication and
mutual obligation; and Gerald Caplan's: that support systems are
attachments between individuals, and between individuals and groups,
that a) promote emotional mastery; b) offer guidance about the field
of relevant forces, expectable problems, and methods of dealing with
them; and c) provide feedback about behavior which validates identity
and fosters improved competence. The processes of social support have
emotional, cognitive, and instrumental components.
Several reviews of research studies, including the Task Panel
Report on Community Support Systems of the President's Commission on
Mental Health, have found that the cumulative evidence suggests that
social support may play a major role in modifying the deleterious
health effects of stress, in influencing the use of health services,
and in affecting other aspects of health behavior such as adherence
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to medical regimens. Underlying these studies are several alter-
native hypotheses: that social support has a direct effect on health;
that social support provides a buffer against the effects of high
stress; or, that social support has a mediating effect which stimu-
lates the development of coping strategies and promotes mastery.
The evidence from these studies, and the new questions raised
by them, points to directions for the future. There is a need: to
develop the research base, and to experiment with pilot and demonstra-
tion projects on the relation of-social support, stress, health and
the utilization of health and mental health services.
In the United States, the family is the chief decision-maker
about health care and the major purchaser of health services, rather
than government which essentially is only a payer for medical ser- -
vices rendered. The' lay referral network (how people get to services)
and the lay treatment network (including self-care; mutual help
groups and other social support systems; and the wide variety of
community ~ ~ ~ ~
institutions that are not labeled or identified in our
society as health care institutions, but which may be very much
involved in health promotion, health maintenance and even, at times,
health services delivery) should be topics on the agenda to be
seriously considered when we are thinking about the future. While
there are not at the present time many models of the medical care
system stimulating the development of social and community support
systems, where they are absent, to address pressing health care
needs, some examples do exist and should be further explored. With
the prospect of national health insurance, the necessity of finding
effective ways to link health and mental health services with
effective social and community support systems becomes of crucial
importance.
.
Representative terms from entire chapter:
social support
