This will be the ninth time you’ve visited your primary care doctor in three months. Your arm rests on the chair, and you wonder why your fatigue has not subsided despite different treatments she has tried with you. You considered seeking out a second opinion, but you stopped yourself since you’ve been seeing this doctor for more than 20 years. What you don’t realize, and what your doctor has been unable to see, is that you’re suffering from depression, of which fatigue is a classic symptom. Without this knowledge, you would likely continue to see your doctor and only grow more frustrated or to seek out a second opinion from someone who may or may not screen you for depression. Common mental disorders like depression and anxiety can present with somatic symptoms like headaches, fatigue, pain, gastrointestinal problems, and this makes an accurate diagnosis in an exclusively primary care setting challenging.
The scenario described above is not unusual. As many as 70 percent of primary care visits are estimated to stem from psychosocial issues, with underlying mental health or substance abuse issues often triggering these visits rather than physical health needs alone. Additionally, the Agency for Healthcare Research and Quality estimated in 2007 that nearly 13 percent of ER visits (about one in eight) are related to a mental health or substance use disorder. More broadly, nearly one-third of adults and one-fifth of children had a diagnosable addiction or mental health problem in the last year, according to the Kaiser Commission on Medicaid and the Uninsured.
Despite the prevalence of patients with behavioral health conditions in primary care, not all primary care providers are actively screening for behavioral health. This lack of screening is notable because the majority of patients will not receive behavioral health treatment from a specialist for a number of reasons, including excessive costs due to a lack of insurance or inadequate coverage for behavioral health services, or perceived stigma associated with mental illness and/or substance use disorders. The lack of access to treatment is a significant concern, considering how few patients receive the care they need. According to SAMHSA, only 4.1 million of the 9.8 million Americans that needed treatment for a serious mental illness received it in 2009, and only 4.3 million people received treatment for an illicit drug or alcohol problem among the 23.5 million Americans who needed it.
The passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act in October of 2008 was paramount in ensuring increased access to behavioral health services as well as improved insurance coverage. The law dictates that insurance plans are required to offer comparable levels of behavioral health service coverage as they do for physical health if they already provide behavioral health service coverage. Additionally, there cannot be differential annual or lifetime caps on coverage for physical and behavioral health. For consumers, this means that mental health and substance use services may be more accessible than before if a major barrier to their use of mental health or substance abuse treatment services was insurance that such a barrier is rapidly going away.
The good news for consumers –and the system as a whole—is that attitudes and incentives are changing. Many individuals in healthcare services, both primary care and behavioral health care, have been envisioning and implementing a system of integrated care where you and your condition would not slip through the cracks. The National Council for Community Behavioral Healthcare has been leading the conversation regarding the integration of behavioral healthcare with primary care for the last ten years. But a funny thing has happened recently — many more people are becoming engaged in the conversation, including federal policymakers. More people are convening around the idea of integrating these often-separate worlds to provide better care for patients while at the same time, reducing costs in the process.
There is now broad recognition that behavioral health services are a fundamental part of the healthcare system, helping move our system toward better integration of physical and behavioral health services to both improve the quality of care provided and reducing costs. For generations, care has been provided in a fragmented system where individual specialties have operated in virtual silos, but more and more providers across the country are working toward integration. Although some have been integrated for quite some time, many have been spurred by the incentives provided in the Affordable Care Act to work in new service delivery models like Health Homes and Accountable Care Organizations (ACOs).
Although there are a variety of specific models that will take shape, consumers can generally expect to have more team-based care comprised of a number of different providers or more streamlined referral processes from primary care providers. For instance, if the practice in the beginning scenario had been fully integrated with behavioral health, the primary care physician would have likely screened you for depression and/or anxiety as part of standard practice, which could have led to your being seen by an in-house or referred to an affiliated behavioral health specialty practice.
Patients with mental health or substance use disorders are more likely to suffer from one or more co-occurring physical health conditions and are less likely than the general population to receive preventative services like immunizations, cancer screenings, and smoking cessation counseling. The Robert Wood Johnson Foundation’s Synthesis Report recently found that integrated care interventions improve quality and treatment of major depressions and anxiety disorders, based on more than 30 random-control trials.
Behavioral and primary care integration can also help patients overcome another major obstacle in obtaining proper behavioral health treatment: stigma. Society’s perception of mental illness and substance abuse, paired with industry biases against behavioral health, have negatively impacted patients’ access to needed care. Integration of behavioral health and primary care has the potential to minimize the stigmatization of behavioral health disorders and those affected by them and also helps mitigate discriminatory treatment patients may have experienced from providers prior to integrated care models being adopted.
Stigma is a key component of discussions around integration. Stigma not only manifests itself in negative connotations, stereotypes, or explicit discriminatory treatment but may be the reason for the lack of behavioral health screening in primary care, the reluctance among patients to consider they need behavioral health treatment, and the remaining resistance to see that behavioral health is as important to general well-being and health status as physical health.
Structural and system reforms must occur in order for individuals living with behavioral health disorders to receive proper care, regardless of how complex the physical and behavioral health needs are. All over the country, organizations are successfully integrating healthcare for patients, by providing team-based, person-centered care.
By embracing this vision, the hope is that fewer patients fall through the cracks in the healthcare system and fewer behavioral conditions go undiagnosed and untreated. Our minds and bodies are both essential components of good health and well-being, which is why you and I should be able to sit down in waiting rooms assured that our primary care institutions can effectively treat them both.
For more information about the bi-directional integration of primary and behavioral health, please email firstname.lastname@example.org or go to www.centerforintegratedhealthsolutions.org for materials and resources.