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Second Opinion

Examining the role of primary care

Photo: Annemie Tonken

“What is the role of primary care diagnosis and treatment in terms of the nation’s mental health?”

Primary care behavioral health services, which embrace mental health, substance use, and health behavior change, are the foundation of the nation’s mental health care system. More mental health care is rendered in the primary care setting than anywhere else, including mental health care settings. Here we find enormous numbers of common mental and substance use disorders that are neither simple nor minor. Since most patients are unwilling to accept a mental health referral outside the primary care setting, these problems are addressed in primary care, or not at all. Yet, when the primary care practitioner is the only behavioral health provider, treatments are marginally effective and often frustrating to patients and providers.

When services are available from a mental health professional who is part of the primary care team and is trained to provide primary care behavioral health, access improves, treatment courses shorten, health behaviors can be addressed earlier and more effectively, and race- and culture-based disparities in care are reduced. In addition, it is comparatively easy and convenient to use the primary care setting to screen for depression, anxiety, PTSD, alcohol and substance use, and domestic violence. Most chronic illnesses are identified and treated in primary care, ideally with close coordination and support from specialty services for difficult or complex cases. For the vast majority of patients, the same model is proving relevant for mental health and substance use disorders.

For a few people, usually those receiving long-term treatment for serious and persistent mental illness, a mental heath setting is more comfortable and accessible than a primary care setting. Yet ensuring this population has access to primary care is vital; on average, people with serious, persistent mental illness die 25 years earlier than their peers in the general population. Locating primary care services in mental health centers could improve the health of this population and help bridge the divide between mental and physical health service delivery. This change has been transformative for the mental health centers where it has been implemented.

The rising cost of health care is squeezing the nation’s employers. It also has set the stage for new aggregations of cost data, showing that when the loss of employee productivity is added to the cost of health care and medications, depression is the most costly illness for employers. New approaches to payment, spurred by leading employers and the Affordable Care Act, are making it financially possible to broadly implement the integration of behavioral health and primary care. The growing evidence for increases in clinical effectiveness, long-term cost reduction, patient and provider satisfaction, and improved access should keep the evolution toward integration continuing for the foreseeable future.

Alexander Blount is a professor of clinical family medicine and psychiatry and director of the Center for Integrated Primary Care at the University of Massachusetts Medical School in Worcester. He also is editor of Families, Systems & Health, a journal of the American Psychological Association.