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3 II BACKGROUND AND OVERVIEW The recognition of benefits from a strengthening of the relation- ship between general medicine and psychiatry in hospitals has stimulated interest in extending the coordination of medical and mental health care to ambulatory primary care. Better coordination of mental health services with primary care holds a promise of better treatment for disturbed individuals in the general health care system who are not referred for specialized mental health care. The potential benefit of the general health care system to the delivery of mental health care is illustrated by recent epidemiologi- cal findings: (l) at any one time, 15 percent of the American popu- lation suffers from some form of mental disorder; (2) 21 percent of identifiably disordered individuals receive specialty mental health services; (3) 54 percent of identifiably disordered individuals are seen only in the ambulatory general health care sector, 3 percent are in nursing homes or general hospitals, and 20 percent are in contact with-no recognized health care providers of any kind. 1/ In addition to those with identifiable mental disorders, a great many patients seen in primary care settings have significant emotional or behavioral problems expressed as somatic symptoms or personal distress. The onset of physical illness often is precipitated by psychosocial stress or elicits maladaptive behavioral responses. Failure to recognize a correlation of physical and behavioral factors can impair the restoration of the patient to health. The limitations of specialty mental health resources, however, would make it difficult for the mental health sector to absorb high numbers of patients with mental disorders being seen in the primary care sector. To provide appropriate care to those who need it, closer ties between mental health services and general health care should be effected in the organization of health care delivery, the training of both health professionals and mental health professionals, and the financing of health care. The 1966 Report of the Citizens Commission on Graduate Medical Education stated the shortage of physicians delivering general medical care was the leading deficiency of the U.S. medical care system. The Commission promoted the concept of the "primary physician" who would "serve as the primary medical resource and counselor to an individual or family." 2/ In the more than ten years since the publication of the report, training of more primary care physicians has been advanced by legislation and other health policy decisions. In 1976, the Health Professions Education Assistance Act (Public Law 94-484)

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4 encouraged development of training programs for ambulatory care-based primary care physicians in order to increase their number and thereby accomplish certain improvements in health care for the American people. It was expected that elimination of certain deficiencies in the health care system (such as limited comprehensiveness of treat- ment, disrupted continuity of care, maldistribution of physicians, high costs, and overly technical focus of the medical profession) would be accomplished by the implementation of this legislation. Other developments in medical education have indicated a growing appreciation of the need to train physicians to recognize the role of psychosocial factors in illness, and of the impossibility of separating the mental and physical aspects of health care. There are increased emphases on social and behavioral sciences in medical curricula, pro- motion of primary care residency training programs with psychiatrists and other mental health specialists helping in the design and collabor- ative teaching arrangements, and development of neighborhood health centers and pre-paid health plans with psychiatric components. The President's Commission on Mental Health in its report sub- mitted to the White House in April, 1978, emphasized a need to strengthen the working alliance between mental health and the general health care system: General health care settings represent an important resource for the mental health care in the community. There is ample evidence that emotional stress is often related to physical illness and that many physical disorders coexist with psychological disorders. While general health care settings frequently serve as an entry point to the mental health care system, many millions of persons with some level of mental disorder are never referred to mental health specialists. They are cared for by office-based practitioners, in in- dustrial health care settings, in homes, in general hospital outpatient clinics and emergency rooms. While the interdependence of the mental health and general health system is evident, cooperative working arrangements between health care settings and community mental health service programs are rare. If we are to develop a truly comprehensive system of mental health services at the community level, greater attention must be paid to the relationship between health and mental health. As initial steps toward coordinating the working alliance between the health and mental health systems, the Commission recommended

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5 o Funding by the Department of Health, Education, and Welfare of a limited number of research projects to assess integrated general health care and mental health care services. o Requiring community mental health centers and community mental health service programs, where appropriate, to establish cooperative working arrangements with health care settings. These arrangements should allow for: c) a) mental health personnel to provide direct care and treatment in the health care setting to patients with emotional disorders whose problems exceed the skills of non-psychiatric health care practitioners; b) consultation directed toward altering behavioral patterns that increase the risk of physical illness; collaborative treatment with non-psychiatric health care practitioners for those patients with combined physical and mental illness; and d) training non-psychiatric physicians and other health rare personnel to enhance their skills in the treatment of patients with relatively mild emotional disorders. 3/ Strategies for implementing these recommendations of the President's Commission on Mental Health have been developed on the agency policy level and at the legislative level. The Department of Health, Education, and Welfare has supported a number of activities to encourage linkages between health services and alcohol, drug abuse, and mental health ser- vices to promote a comprehensive health system. Notable among these is an agreement between the Alcohol, Drug Abuse, and Mental Health Adminis- tration and the Health Services Administration to spend $1.5 million of Community Health Center funds to provide on-site mental health personnel, and encourage linkages of community health centers with a nearby mental health center. Fifty-seven linkage grants were approved for funding in fiscal year 1979. The Mental Health Systems Act (S.1177) introduced in the Senate in May, 1979 is the Carter Administration's proposal for reform of the nations mental health program. Title IV' Section 404, would authorize grants to assist ambulatory health care centers to participate in provision of mental health services to their patients. An Institute of Medicine conference, which this report summarizes was convened to examine some of the underlying concepts and long range implications of these "linkage" efforts. Major themes of the

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6 conference were developed by individual speakers and in workshop sessions. These themes are outlined briefly in the pages that follow. Definitions of Primary Health Care and Mental Health Services In the 1978 Institute of Medicine report, "A Manpower Policy for Primary Health Care," primary care is defined as "accessible, compre- prehensive, coordinated, and continual care provided by accountable providers of health services." _/ The five essential attributes of primary care as it should and could be practiced in the United States today were described as follows: (1) Accessibility of care refers to the provider's responsibility to assist patients or potential patients to overcome temporal, spatial, economic, and psychologic barriers to health care; i.e., to promote the availability, attainability, and acceptability of services provided. (2) Comprehensiveness of care refers to the willingness and en. ability of providers to handle the great majority of health problems arising in the populations served (which may be limited to a given age group or sex). While the primary care practitioner may have an area of special medi- cal interest, his or her services are not restricted by concentration on that specialty. (3) Coordination of care denotes the primary care practitioner's role as ombudsman, coordinating the total care -- including that provided by specialists -- of his or her patients. This role presupposes awareness of patients' financial capabilities and personal desires. (4) Continuity of care depends largely on the first three attributes of primary care, requiring active commitment on the practitioner's part to maintaining an ongoing relationship with each patients Record-keeping is an important aspect of continuity. (5) Accountability requires that primary care providers review - regularly both the process and outcomes of care with attention to potential improvement, and also entails commitment to ensuring that patients are informed deci- sion-makers. Providers also should respect their obliga- tion to maintain appropriate financial accountability, including adequate professional liability coverage. Primary care generally is recognized as the first level of personal health services, in which initial professional attention is paid to current or potential health problems. Primary care frequently is associated with care of the "whole person" as opposed to care for an

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7 illness. Primary care is distinguished from other levels of personal health services by the scope, character, and integration of the services, and is not necessarily limited to provision by any particular type of practitioner or practice setting. Mental health services (primary mental health services) are de- fined in terms of direct and indirect care to patients with mental dis- orders in ambulatory settings. 5/ Direct services consists of diagnostic and problem evaluation, crisis intervention, individual, group and family psychotherapies, supportive counselling, prescription of psychoactive medication, and post-hospital care for the chronically mentally ill in the community. Indirect and preventive services are provided through consultative and collaborative arrangements with schools, welfare agencies, police, and a wide range of other community organizations. In some se-t- tings the provision of these mental health services is almost exclusively in the domain of specialty mental health professionals: psychiatrists, psychiatric social workers, psychologists, or psychiatric nurses. In other settings, these services are provided by the primary health care provider trained in mental health skills. Nature and Scope of Mental Health Problems in Primary Care Epidemiologic and health services utilization studies suggest that the number of patients with psychiatric disorders seen in primary care settings is higher than indicated by current data. It cannot be deter- mined, however, whether the majority of the mentally ill have always - been treated by the general health practitioner or whether these patients have become more numerous in the past few years. In the absence of com- pletely objective criteria, researchers have used a variety of techniques to identify the rates of psychiatric morbidity in primary care settings. The reported rates of mental disorder vary with its definition, with the method of case identification, and with the setting and the sampling method. An increase in the medical treatment of mental disorders, speci- fically pharmacotherapy, and in outpatient treatment make it not sur- prising that the majority of the mentally ill already are being cared for by primary care practitioners. Several studies have suggested factors that act as barriers to the use of specialized mental health services, including 1) patient fear of stigma associated with psychiatric treatment; 2) the generally high cost of psychiatric treatment, limited private insurance coverage, and the major portion of public funds spent on inpatient care, particularly long-term institutionalization; and 3) the patient's lack of knowledge about the availability and nature of specialized mental health services. Advocates of integrated mental health and general health services in prepaid plans or community health centers contend that those arrangements improve access to mental health professionals. Such health care models, typically report relatively high utilization rates of mental health services.

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8 The distribution of mental illness by health care models is important to note. Of research conducted to date, eighteen studies from fee-for-service settings indicate prevalence rates ranging from 4 to 39.6 percent; studies from prepaid practices indicate a range of prevalence for mental illness from 1.2 to 14.6 percent; and studies from community health centers indicate a range of 15.6 to 50 percent. Finding the lowest rates of disorder in prepaid practices may reflect particular incentives in such plans to under-diagnose. Some data suggest that referral rates among health care delivery models are highest in prepaid settings, perhaps because of a physical proximity of health and mental health professionals in those and certain community health center settings. Proximity encourages close relationships, making referral more feasible and attractive both to the patient and the referring physician. Models for Coordinated Mental Health and Primary Care Services There is general agreement that implementing the linkage of the mental health system and the general health service system in the United States requires the development of many conceptual and organiza- tional models for health care. There are at present three principal types of health care delivery in this country: fee-for-service, prepaid, and community health centers. Fee-for-service health care is the predominant type of health care in the United States for both general medical services and mental health services. The distinguishing feature of fee-for-service health care is that physician services are purchased on an individual basis. Availability of non-specialty mental health care from a fee-for-service primary care practice-appears to depend largely on the individual pri- mary care physician's training, skills, personal interest, and individ- ual practice style. Economic incentives or disincentives also are likely to have significant effect an the kind and extent of mental health service in this setting. Prepaid health care, typified by health maintenance organizations (HMOs), is a system in which subscribers pay a prearranged amount for an established set of medical services, which may or may not include mental health care. Physicians delivering prepaid health care are usually salaried. Prepaid health care plans currently cover only about 3 percent of the American population, mostly middle-income families. Federally-funded EMOs are required to provide enrollees with up to 20 visits per year to mental health clinicians, along with unlimited visits to primary physicians for treatment of emotional problems. In keeping with the traditional separation of health and mental health services in this country, HMO s typically have set up separate psychiatric clinics for referrals within their organizations

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9 or have purchased specialized psychiatric services outside of the plan. Community health centers are much like prepaid health plans in that a geographically defined population is provided a comprehensive set of medical services. Almost all employ salaried physicians. These centers are largely subsidized by public funds and provide free or low-cost services to disadvantaged persons. Identification and Management of Mental Health Problems in Primary Care Settings Although many patients with disorders that are both distressing and disabling seek primary care, it appears that primary care providers identify only a limited number of such patients who could benefit from specialty mental health care. A small segment of the adult primary care population may be utilizing medical services at high levels in an effort to remedy their undetected chronic psychiatric disorders. Studies have shown that primary care case identification improved where mental health and primary care services are integrated profes- sionally, administratively, and structurally -- particularly when the physical setting is shared and when training takes place in the primary care setting. Formal hospital consultation liaison applied to ambulatory care settings may also improve case identification. However, case detection does not guarantee successful, or even feasi- ble, treatment. A lack of uniformly applied diagnostic criteria is documented by many surveys of mental disorders among patients attending primary care physicians. These studies have shown wide variations among individual practitioners' estimates of the frequency of such conditions, although psychiatric screening tests used during the surveys typically show less variation between various practice populations than indicated by the physician assessments. It has been suggested that differences in physician assessments may reside not in the patients but in the physicians' concepts of psychiatric disorder and the threshholds adopted for case identification. There is general agreement that high priority needs to be given to developing more effective screening and evaluation of psychiatric illness in primary care settings. Further study is needed of the interaction of the three dimensions - syndromes, functional status, and socially unacceptable behavior -- that furnish the basis for the widely used Research Diagnostic Criteria (RDC) evaluation. Improved detection of psychiatric illness by primary care providers could promote more appropriate therapeutic interventions and decrease the financial burden on the ambulatory medical care system.

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10 Little is known of the treatments provided to patients with mental disorders or other emotional or behavioral problems who remain in the general health care sector. Referrals for mental health services usually are low; even when primary care physicians identify patients as emotionally disturbed, they are likely to make a referral for specialized mental health care for only one in 10 to 20 such patients. In terms of treatments received by emotionally disturbed patients from family physicians, evidence suggests that drug therapy is more common than other psychotherapeutic help, including counseling and referral to specialists. Evidence on the appropriateness of drug prescriptions, however, is not encouraging, and suggests a need for further research on the utilization of psychotropic drugs in the management of emotionally ill patients by primary care physicians. Unresolved questions include: 1) When are such prescriptions appro- priate? 2) Are psychotropic drugs efficacious when used alone, or should they always be combined with psychotherapy? 3) Is management of psychiatric patients with psychotropic drugs cost-effective rela- tive to other alternatives? 4) What is the quality of psychothera- peutic prescribing by primary care physicians? 5) When should patients be referred to psychiatrists for drug therapy? Although definitions of psychotherapy vary, 60 to 80 percent of patients with recognized mental disorder reportedly receive such therapy in some form from their primary care physicians. However, such therapy occurs in only 22 percent of the patient visits, and the difficulty of conducting formal psychotherapy due to time con- straints in primary care settings are cited frequently. Although short-term life crisis therapy seems to be emphasized, with more than half of the patients receiving Psychotherapy in one to four visits, there is little data on the intensity and nature of psycho- therapy in general.~ Studies on psychotherapy outcomes among primary care patients are almost nonexistent. Unanswered questions about psychotherapy by primary care physi- cians include: 1) For which patients is primary care psychotherapy indicated, rather than psychiatric referral? 2) Which psychothera- peutic techniques are most successful for a specific diagnosis? 3) Is psychotherapy cost-effective in this setting? Education and Training The relationship between general health and mental health has important implications for the training of both health professionals and mental health professionals. Given the substantial amount of mental illness identified and treated in general medical practice, there was agreement at this conference that general health profes- sionals should receive adequate training in the psychological aspects of patient care, and should demonstrate competence in when and how

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to treat patients, when and how to refer patients to mental health professionals, and how to collaborate with mental health professionals. Three broad categories of skills required by primary care physi- cians to work effectively in mental health are: 1) sensitivity skills, including physicians' awareness of their own reactions and the effects on treatment, understanding of a life cycle context, and understanding of both the psychosocial factors involved in illness and community resources for treatment; 2) therapeutic skills for counseling, based on a psychosomatic approach to history taking and interviewing, minor psychotherapy, and recognition and management of anxiety and depression related to illness; and 3) referral skills, which involve learning to recognize serious psychiatric disorders that can best be treated by mental health specialists. Conversely, there is agreement that mental health professionals should be better trained to understand the relationships between medical and mental illness. They should be required to demonstrate competence in collaborating with health professionals. One educational opportunity that could benefit both professional groups is experience in integrative health care settings that could provide a model for future collaboration and sensitize professionals to the needs and issues of the other members of the health care team. Issues of Financing and Cost-Offset If efforts to link services are to be successful, the financing of health care must take into account the integral relationship between general health and mental health. Recent increases in insurance coverage notwithstanding, mental health services typically are covered to a lesser extent than general health services in private health insurance plans. Mental health insurance also more frequently includes deductible and co-insurance requirements than do plans for medical illness. Some evidence suggests that adequate coverage for treatment of mental dis- orders within primary care settings and by primary care physicians as well as mental health professionals may lead to increased utilization of mental health services and a decrease in the utilization of general medical services. Whether the change in the locus of care will be cost-saving is not yet clear. It may, however, be an important step toward assuring the quality and appropriateness of care. There appear to be both conceptual and methodological problems in studying the effects of providing mental health services at the primary care level. It was suggested that the following conceptual issues be considered: 1) The assumption that the cost of mental health care should offset the cost of physical health care may be valid when physical health care has been misused as a substitute for needed mental health care. However, there are mentally ill patients, who, with treatment, should have utilization of general

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12 medical services that increases to more optimal levels as they become less likely to neglect their overall health. 2) Cost-effectiveness may not be an appropriate indicator of effective mental health care. Other outcome indicators such as improved ability to function may be more reasonable. 3) The common assumption that mental health care and physical health care services can be evaluated separately may be inaccurate if they are as integrally related as are mental and physical illness in the individual. 4) Medical utilization is often used as an indicator of health status. Accordingly, persons discharged from the medical care system are assumed to have improved health. In fact, nothing may be known about their subsequent health status or utilization of other service. There was consensus at the conference that methods should be developed to assure adequate reimbursement for consultation and collaboration between health and mental health professionals. These services, along with the cost of such preventive services as be- havioral therapy for smoking or obesity are unlikely now to be covered by any private insurance plan or proposed models of national health insurance .

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13 REFERENCES 1. Regier, D.A., Goldberg, I.D., Taube, C.A., The DeFacto Mental Health Services System, Archives of General Psychiatry, Vol 35, June, 197B, pp. 685-693. 2. Report of the Citizens Commission on Graduate Medical Education. . American Medical Association, Chicago, 1966. 3. Report to the President from the President's Commission on Mental . . Health submitted April, 1978, p. 20. 4. National Academy of Sciences, Institute of Medicine. Policy for Primary Care. Report of a Study. Washington, D.C.. 1978. A Manpower J. Borus, B. Burns' A. Jacobson, L. Macht, R. Merrill, E. Wilson' Coordinated Mental Health Care in Neighborhood Health Centers, Vol. II Mental Health Services in General Health Care, National Academy of Sciences, Institute of Medicine, Washington, D.C., 1979 .

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