Experts call for integrating mental health into primary care

From AHRQ January Newsletter

A young woman's diagnosis of infertility leads her to commit suicide a short time later much to the horror of her caring and well-intentioned doctor, who never saw it coming. He thinks it may have been avoided if there had been a mental health professional on his staff. This is one of many stories recounted in a Mental Health Forum and Town Hall held by the Agency for Healthcare Research and Quality (AHRQ) at its September annual meeting. A large panel of experts discussed the importance of integrating mental health professionals into primary care practices. The goal of integration is to reduce the fragmented and inadequate care of mental health problems in primary care patients.

Primary care clinicians are not fully trained to diagnose or treat mental health problems, yet people with these conditions typically are seen in primary care more than any other setting. To make matters worse, referrals to community-based mental health providers are a persistent problem. "Studies show that well over half of primary care docs are not successful in referring patients to mental health professionals in the community for a variety of reasons," says Charlotte Mullican, M.P.H., senior advisor for mental health research at AHRQ. "This could be due to insurance and payment barriers, limited availability of mental health providers and other access problems, as well as stigma."

The result? Depression and other mental health problems are undiagnosed or inadequately treated, inappropriate psychotropic drugs are prescribed with little followup, and the contribution of these mental health problems to chronic disease symptoms is often overlooked.

While family medicine doctors get some training in mental health as residents, other primary care doctors may not, according to Frank DeGruy, M.D., chairman of the Department of Family Medicine at the University of Colorado. He told Research Activities, "The majority of family docs will tell you that they wish for more behavioral health expertise in their practice.... The training in mental health for primary care physicians is very superficial and it's not very deep.... Family docs don't want to spend the time, they don't want to deal with anything but the most straightforward mental health problems, and they don't know what to do if anything goes wrong. That's pretty much our story." What many primary care physicians would like, he says, and what patients would benefit from, is the help of mental health professionals.

Barriers to integration
Yet few mental health providers are trained to work in the primary care setting and neither primary care nor mental health physicians are trained to work as a primary care team. "These workforce and culture issues are a barrier to integration of mental health in primary care," adds Mullican. "Problems with reimbursement of mental health services in the primary care setting is another major barrier to integration. Unfortunately, the bottom line is inadequate care for patients with mental health problems. We need to change that."

The current system is fragmented and doesn't promulgate successful models of team-based care, asserts Benjamin Miller, Psy.D., assistant professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine.

Miller envisions the future role of clinical psychologists and other mental health professionals like him as embedded in a primary care practice collaborating with the other primary care providers to provide comprehensive care to the patient. These providers would be seamlessly integrated in one primary care practice and regularly see patients for 5, 7, or 15 minutes for a host of mental health issues, many of which may be affecting their chronic health problems. But the way the current health system is set up, integration of the mental health professional in primary care is not financially sustainable. That's because mental health and "physical" health are paid out of different pots of money.

"What happens if I go into the room to see the patient with the physician?" asks Miller. "Who is going to pay for that? That's where sustainability starts to rear its ugly head. What happens when I am the one who starts to do an intervention around mental health or health behaviors? There will not necessarily be a billable code to classify what I just did. It's all in the codes. The codes force you to do what they value versus what the patient sitting in front of you is telling you they value."

There is growing recognition that many health problems are affected by mental health problems. Day in and day out, primary care clinicians see a significant proportion of common symptoms such as fatigue, abdominal pain, and back pain for which they don't find a cause. "If we understood people's psychosocial stressors, their adverse childhood experience, and we were better at identifying common mental and behavioral conditions such as depression, anxiety, and substance use, we'd understand a lot more about what's driving those symptoms," noted Neil Korsen, M.D., medical director at MaineHealth, at the Forum. Embedding mental health professionals in primary care could enhance a more patient-centered approach to care.

Promising models of integrated care
The Forum panelists all agreed that payment drives practice and how services are reimbursed will have to be changed if mental health is to be integrated in primary care. That's what has happened in Maine and it's making a difference.

In the State of Maine, to participate in the patient-centered medical home (PCMH) pilot project, a primary care practice has to integrate mental health or behavioral health services. "We've been working hard on improving care for diabetes, care for people with heart disease, and you can't do that if you're not addressing the mental health components," says Korsen. "Primary care clinicians can do some of that work, but we need help. Increasingly, health care is a team sport and we need help from people who have more expertise.... So in Maine, the patient-centered medical home equals integration."

Maine is a good example of how changes in reimbursement start to change how care is delivered, explains Miller. "Look at the payment structure of the PCMH. Let's say you get $7 per patient per month in the PCMH and then you get a financial incentive for integrating mental health care by getting paid more per patient per month. This may be the money you need to offset the cost of bringing in the mental health provider to take care of these patients."


The Cherokee Health Systems in Tennessee began integrating mental health and primary care as early as 1984. Its largest payer is Medicaid, comprising 42 percent of visits. Cherokee negotiates a payment stream that covers all the professional activities that comprise the integrated care model. This includes consultation among providers (including mental health providers) and care coordination, not just face-to-face encounters with the patient.


Cherokee's clinical model uses an embedded licensed behavioral health provider (typically a clinical psychologist or clinical social worker) on the primary care team, who partners with the primary care doctor to help patients manage stress, depression, or lifestyle changes required to better manage their medical condition. The benefits are reduced emergency room use, fewer inpatient admissions, reduced specialty referrals, enhanced patient satisfaction, increased primary care use, and improved patient outcomes, notes Parinda Khatri, Ph.D., director of integrated care at Cherokee Health Systems.

Every day Khatri sees patients who are much better off with integrated care. She cites the example of a woman in her early 40s who was hospitalized in an inpatient psychiatric unit due to altered mental status and discharged with a referral to a psychiatrist. The woman showed up at Khatri's clinic on a very high dose of the antipsychotic Seroquel®, an antidepressant, and another medication for sleep. Upon Khatri's initial assessment, she realized that this was not someone with a thought disorder. So she did a full assessment and found out that the woman's calcium levels were critically low and that the woman was not taking any of her calcium tablets, which she refused to take because they were big like "horse pills."

"Since low calcium levels can cause altered mental status, this triggered her hospitalization and medications," Khatri told Research Activities. "If it had not been for our comprehensive assessment, the woman could have easily seen a psychiatrist, been on three for four psychotropic medications, which can cause weight gain and diabetes, not shown any improvement, and probably gone back to the hospital inpatient psychiatric unit, because her calcium levels would not have gotten better." Instead Khatri talked to the woman and her daughter about self management and adherence to her medical regimen. The result? The woman normalized her calcium level, was off all her psychotropic medications, and didn't need to see a psychiatrist.

Integrated care saves money
Data from Cherokee and other systems suggest that integrating primary care and mental health care saves 20 percent in health care costs. This point was underscored at the Forum by Stephen Melek, principal and consulting actuary at Milliman, Inc. Melek worked with a health plan that believed integration was valuable and developed an integrated care management approach. Medical and behavioral providers and health coaches advised by telephone an insured population of about 15,000 Medicare patients. "Long story short, a lot of disbelievers up front—16 million dollars spent on the integration initiative," said Melek. "Yet, 15,000 patients and one year later they saved $40 million dollars on avoided health costs. They are growing the program. This can work. You just need more and more evidence and innovators to get out there, do it, and spread the results."

Retraining professionals
To achieve integrated care, mental health and primary care providers will have to be retrained and rethink their roles to some extent, notes Miller. "If I'm used to seeing patients for 50 minutes and doing traditional mental health visits, in primary care you're seeing patients for anywhere between 5 and 30 minutes and you must learn to communicate a very complicated patient to a primary care physician in 30 seconds or less. That requires new training that you are not going to get in graduate school." Programs like Cherokee Health Systems use internships to train psychologists for this new role. Postdoctoral fellowships in primary care are also available at places like the University of Colorado.

Research agenda
Many of the panelists agreed there is much evidence to support the integration of mental health into primary care, even though it is not clear what exactly about integration makes it work and how best to implement it. DeGruy summed it up this way for Research Activities. "The main area of research that we need to undertake now is learning how to actually implement integration. What does a team look like? Is it better if the case manager knows how to do motivational interviewing? Should she manage many problems or just a few problems? There are a lot of details about what specifically happens in the practice that need to be researched."

Editor's note: You can access AHRQ's recently published research agenda on integrating primary care and mental health care at http://www.ahrq.gov/research/collaborativecare/collab1.htm and the AHRQ Academy for Integrating Mental Health and Primary Care at http://prezi.com/pdwleusvlceo/the-ahrq-academy-for-integrating-mental-health-and-primary-care. You can access the patient-centered medical home page at http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483.