Families, Systems, & Health 2014, Vol. 32, No. 2, 135–136
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000057
EDITORIAL
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
How Do We Know When to Celebrate? Larry B. Mauksch, MEd
Colleen T. Fogarty, MD, MSc
University of Washington School of Medicine
University of Rochester School of Medicine
For centuries philosophers, healers, and scientists have debated the distinction between the mind and the body. The reluctance to embrace the natural unity of mental and physical existence may be fueled by shame, stigma, pride, and other emotions or from beliefs that the mind has no mass and therefore cannot have physical existence. Our modern Western health care system evolved in response to this dualistic model. In recent decades we have chipped away at the impact of dualistic thinking through a series of incremental changes, none of which are complete. How often do we celebrate these advances? New knowledge emerging in the last half-century has changed how we think and practice. Researchers have documented the relationship between stress and assorted diseases, noting that our social and psychological make-up affect physical health. We now recognize depression as a leading cause of disability worldwide. But, until recently, the recognition and treatment of mental illness and physical disease officially existed in separate health care sectors. In the 1950s Michael Balint, MD, a British psychoanalyst, recognized that many mental health problems presented first and only in the office of general practitioners (GPs). As a result of his observation, he began convening group meetings of GPs to help them help their patients. In the late 1970s epidemiologists studying the prevalence and treatment of mental disorders found that the “de facto mental health service system” was the general medical sector. During this time the birth of a new medical discipline, Family Practice (now Family Medicine), the specialty of generalism, was marked by an unusual attribute in the culture of medicine. Family Medicine residencies were required to include training on mental health, family dynamics, communication skills, and other behavioral science topics. These are celebrated events. The next two decades witnessed an explosion of clinical research. People with more physical symptoms were found to have a higher likelihood of underlying psychological distress. We focused on medically unexplained symptoms and the association with mental illness. Then we learned that the relationship was more complicated. People with mental illness were more likely to have more chronic medical problems. A simple count of physical illnesses predicts increasing vulnerability to mental illness. Not surprisingly, high users of general medical services were found to have a two- to threefold higher prevalence of mental illness. These patients consumed disproportionate amounts of health care dollars, suggesting that cost containment may require mental health treatment. The synthesis of this knowledge is worth celebrating.
Larry B. Mauksch, MEd, Family Medicine Residency, University of Washington School of Medicine; Colleen T. Fogarty, MD, MSc, Department of Family Medicine, University of Rochester School of Medicine. Correspondence concerning this article should be addressed to Larry B. Mauksch, MEd, University of Washington School of Medicine, Family Medicine Residency, 331 NE Thornton Place, Seattle, WA 98125. E-mail: [email protected] 135
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
136
MAUKSCH AND FOGARTY
Knowledge travels slowly into practice. Over the last 30 years researchers have demonstrated that combining biomedical and psychosocial expertise in collaborative treatment models produces better outcomes for patients with mental illness, with physical illness, and for the majority who have a complicated mixture of biopsychosocial ailments. The advent of collaboration between disciplines and the integration of service designs is something to celebrate. Health policy lags behind science and innovation. Mental health parity legislation first surfaced in the early 1990s. Congress and state legislatures continue to battle over whether, when, and how mental health should be covered by insurance plans. Today the federal government and just about every state has some form of parity legislation. Is this something to celebrate? While parity laws require neither interdisciplinary collaboration nor integration of services, we no longer debate the merits of collaboration. Instead we work to integrate clinical, operational, and financial elements of health care systems. In 2007, in response to the growing complexity of primary care across our life span, representatives of four primary care disciplines defined the principles of the patient-centered medical home. These experts were laying a foundation for a new primary care system, however their focus remained biomedical. These principles did not recognize the bio-psycho-social complexity of health and health care. The recent publication of supplemental principles (The Working Party Group on Integrated Behavioral Healthcare et al., 2014a, 2014b), republished in this issue, now affirms the importance of behavioral health integration. Is this something to celebrate? Yes! Is there something else to celebrate in this issue of Families, Systems and Health? Representatives of eight organizations, spanning behavioral health, nursing, medicine, and interdisciplinary practice, all endorse behavioral health integration in the health home. But there are areas of disagreement, most notably about leadership. Should the health home (patient-centered medical home, or PCMH) be physician led? Should any discipline be given sole responsibility for leading a process whose very nature is interdisciplinary and complex? We wish to celebrate the agreement across these commentaries and their differences. The endorsement of an integrated system design by the array of health professionals who constitute its foundation is essential. We are confident that the points of disagreement represented in these commentaries will propel our dialogue to a new synthesis. We move closer and closer to designing health care systems whose complexity mirrors that of the patients, families, and communities they serve. We should pause, notice where we are, and celebrate. References The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . Degruy, F. (2014a). The development of joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1634 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . Degruy, F. (2014b). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1633
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000057
EDITORIAL
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
How Do We Know When to Celebrate? Larry B. Mauksch, MEd
Colleen T. Fogarty, MD, MSc
University of Washington School of Medicine
University of Rochester School of Medicine
For centuries philosophers, healers, and scientists have debated the distinction between the mind and the body. The reluctance to embrace the natural unity of mental and physical existence may be fueled by shame, stigma, pride, and other emotions or from beliefs that the mind has no mass and therefore cannot have physical existence. Our modern Western health care system evolved in response to this dualistic model. In recent decades we have chipped away at the impact of dualistic thinking through a series of incremental changes, none of which are complete. How often do we celebrate these advances? New knowledge emerging in the last half-century has changed how we think and practice. Researchers have documented the relationship between stress and assorted diseases, noting that our social and psychological make-up affect physical health. We now recognize depression as a leading cause of disability worldwide. But, until recently, the recognition and treatment of mental illness and physical disease officially existed in separate health care sectors. In the 1950s Michael Balint, MD, a British psychoanalyst, recognized that many mental health problems presented first and only in the office of general practitioners (GPs). As a result of his observation, he began convening group meetings of GPs to help them help their patients. In the late 1970s epidemiologists studying the prevalence and treatment of mental disorders found that the “de facto mental health service system” was the general medical sector. During this time the birth of a new medical discipline, Family Practice (now Family Medicine), the specialty of generalism, was marked by an unusual attribute in the culture of medicine. Family Medicine residencies were required to include training on mental health, family dynamics, communication skills, and other behavioral science topics. These are celebrated events. The next two decades witnessed an explosion of clinical research. People with more physical symptoms were found to have a higher likelihood of underlying psychological distress. We focused on medically unexplained symptoms and the association with mental illness. Then we learned that the relationship was more complicated. People with mental illness were more likely to have more chronic medical problems. A simple count of physical illnesses predicts increasing vulnerability to mental illness. Not surprisingly, high users of general medical services were found to have a two- to threefold higher prevalence of mental illness. These patients consumed disproportionate amounts of health care dollars, suggesting that cost containment may require mental health treatment. The synthesis of this knowledge is worth celebrating.
Larry B. Mauksch, MEd, Family Medicine Residency, University of Washington School of Medicine; Colleen T. Fogarty, MD, MSc, Department of Family Medicine, University of Rochester School of Medicine. Correspondence concerning this article should be addressed to Larry B. Mauksch, MEd, University of Washington School of Medicine, Family Medicine Residency, 331 NE Thornton Place, Seattle, WA 98125. E-mail: [email protected] 135
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
136
MAUKSCH AND FOGARTY
Knowledge travels slowly into practice. Over the last 30 years researchers have demonstrated that combining biomedical and psychosocial expertise in collaborative treatment models produces better outcomes for patients with mental illness, with physical illness, and for the majority who have a complicated mixture of biopsychosocial ailments. The advent of collaboration between disciplines and the integration of service designs is something to celebrate. Health policy lags behind science and innovation. Mental health parity legislation first surfaced in the early 1990s. Congress and state legislatures continue to battle over whether, when, and how mental health should be covered by insurance plans. Today the federal government and just about every state has some form of parity legislation. Is this something to celebrate? While parity laws require neither interdisciplinary collaboration nor integration of services, we no longer debate the merits of collaboration. Instead we work to integrate clinical, operational, and financial elements of health care systems. In 2007, in response to the growing complexity of primary care across our life span, representatives of four primary care disciplines defined the principles of the patient-centered medical home. These experts were laying a foundation for a new primary care system, however their focus remained biomedical. These principles did not recognize the bio-psycho-social complexity of health and health care. The recent publication of supplemental principles (The Working Party Group on Integrated Behavioral Healthcare et al., 2014a, 2014b), republished in this issue, now affirms the importance of behavioral health integration. Is this something to celebrate? Yes! Is there something else to celebrate in this issue of Families, Systems and Health? Representatives of eight organizations, spanning behavioral health, nursing, medicine, and interdisciplinary practice, all endorse behavioral health integration in the health home. But there are areas of disagreement, most notably about leadership. Should the health home (patient-centered medical home, or PCMH) be physician led? Should any discipline be given sole responsibility for leading a process whose very nature is interdisciplinary and complex? We wish to celebrate the agreement across these commentaries and their differences. The endorsement of an integrated system design by the array of health professionals who constitute its foundation is essential. We are confident that the points of disagreement represented in these commentaries will propel our dialogue to a new synthesis. We move closer and closer to designing health care systems whose complexity mirrors that of the patients, families, and communities they serve. We should pause, notice where we are, and celebrate. References The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . Degruy, F. (2014a). The development of joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1634 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . Degruy, F. (2014b). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1633
