Am
J Psychiatry
/35:1/,
November
/978
RICHARD
REFERENCES 1.
Myers and
ES: future
2. Nelson 3.
SH:
health. Mechanic
The
Insurance prospects.
Am
A new
BY
coverage Am
look
for
RICHARD
illness:
Health
at national
health
4. Regier health
status 1970
insurance
for mental health
Health
ben-
orders.
in Primary
.
,
,
PRIMARY HEALTH CARE is currently undergoing a significant revitalization in this country as a result of past overspecialization, patient dissatisfaction rising health cane costs, and new government funding priorities. At the same time there has been a continuing trend toward increasing organization in health care delivery, e.g., group practice and health maintenance organizations. The intersection of these trends is primary health care on comprehensive health care through organized ambulatory health care delivery settings. This presents important new opportunities to reverse ,
Revised version of a paper presented the American Psychiatric Association, 2-6, 1977. Morrill
is Clinical
Government
Director,
Center,
insurance.
35:685-693, 1978 MM, Klerman GL:
Arch Gen
Health
Am
I
Public
CA: The de facto health perspective. Epidemiology
of
Health
US mental Arch Gen mental
dis-
Psychiatry 35:705-712, 1978
Care
Programs
some of the isolation and fragmentation that separate mental health programs have undergone in relation to the rest of health cane. This paper will present issues and findings gathered from the literature and from my work in integrated health-mental health settings: the Roxbuny Comprehensive Community Health Center and Upham’s Corner Neighborhood Health Center in Boston. A number of potent forces leading toward the integration of health and mental health services have developed in recent years. Psychiatry has undergone considerable role diffusion since the social movements of the 60s and is generally rediscovering its linkage with medicine. Some primary care training programs are trying to give higher priority to the psychological side of health cane. Mental health services are more likely to be reimbursed by third-party payers than formerly, and health care programs are less defensive about including them. The much heralded community mental health centers have not fulfilled their promise because of lack of financing and perhaps because they attempted too much too soon. Deinstitutionalization is usually not followed by the promised comprehensive community care. Mental health services are making progress, albeit with difficulty, in quality control, cost containment, and utilization review-thus following trends present in health care generally. The federal government is withdrawing support from the training of mental health care providers in favor of the training of primary health care providers with mental health skills. The traditional areas of health-mental health interaction have been several. Consultation and liaison units from departments of psychiatry have worked within general and teaching hospitals. Such units were often quite peripheral to their health cane setting, on which they had little influence. In the ambulatory area, hospitals have run separate medical, pediatric, gynecological, and psychiatric clinics, with little communi-
.
Dr.
health
MORRILL
M.D.
Our large/v separate nental health s’stem has developed in relationship to a health care systeFn oriented tott’ard specialization and solo practice. Noti’ the health care system is moving in the direction of primary care and group and organizational practice. Nett’ftrms of,nental health delivery’ are needed to ‘naximize the potential ofthese nest’ health care programs for nental health services The author describes these tie ti integrated programs which bring mental health providers into the primar’ health care progra,nsfor direct services as ;i’ell as consultation. Issues discussed include mutual roles, changes in services, the referralprocess, and provider relationships The advantages ofsuch integrated programs include decreased stigma increased prevention through earlier detection and referral, increasedfam i/v orientation greater coordination of care, and less duplic’ation.
Center,
national 1978
DA, Goldberg ID, Taube services system: a public
Psychiatry
5. Weissman
1973 of mental
Mental
MORRILL,
present
60:1921-1930,
43:622-631, in the design
for C.
mental
I Public
I Orthopsychiatry D: Considerations
Future
efits under 68:482-488,
0.
at the 130th annual meeting of Toronto, Ont., Canada, May
Erich
Boston,
Lindemann
Mass.
0002-953X/78/00l
Mental
Health
02114. 1-135 l$0.50
©
1978
American
Psychiatric
Association
1351
PRIMARY
HEALTH
CARE
Am
PROGRAMS
cation and an exceedingly high no show’ rate on cross-referral. Attempts at postgraduate psychiatric education for general practitioners reached very fewusually only those who were already committed. There has been little interest in the general health of patients in psychiatric clinics and mental health centens. In addition, the expressed attitudes of psychiatnists and their medical colleagues toward each other have often been derogatory. Given the above situation, it seems that there has developed not only a fragmented system but two mental health care systems-one through the primary health care provider and the other through the separate private psychiatrists, CMHCs, and mental hospitals. Part of the answer lies in working out new joint health-mental health programs by taking advantage of these new forms of ambulatory health care delivery. These include group practices, health maintenance organizations, neighborhood health centers, hospital pnimany cane clinics, and rural health centers. The punpose of this paper is to explore joint health-mental health programming in these expanding organized forms of primary health care. Areas I will discuss indude roles, types ofdisorders, new forms of services, the referral process, and provider relationships. Pnimany health care is defined as general health care that 1) exists at the point offirst contact by the patient, 2) is continuing to ensure the patient’s overall health, and 3) coordinates the delivery of other specialized health and social services. ‘ ‘
‘
J Psychiatry
‘ ‘
PRIMARY
OF CARE
MENTAL
HEALTH
PROVIDERS
IN
SETTINGS
There seems to be a broad consensus that there is much mental health care to be done in primary health cane programs and that some mental health input is thus needed. Two general approaches have developed. In the first (1) the mental health provider carries out direct on indirect consultation only. In the second (2-6) he provides consultation and a variety ofdirect mental health treatment services. The principle embodied in the first approach is that one should facilitate mental health work by the primary health care provider but not risk taking it over. The second approach is based on the supposition that many patients will never leave the primary health cane program to be diagnosed or treated in a separate mental health system and therefone the two should be integrated in the ambulatory cane area. There seem to be additional benefits for mental health providers carrying out the latter approach-full senvice in the primary health cane program. Several authons (2, 3, 5, 6) have pointed out that, given the mistrust and poor communication between the mental health provider and health providers in general, carrying out direct service in the primary health cane program serves to educate, sensitize, and create a feeling 1352
/978
‘ ‘
‘
‘
‘ ‘
‘ ‘
WHO
VERSUS
TREATS ‘ ‘
‘
‘
‘
WHAT?
‘
MENTAL
‘
PROBLEMS
IN
‘
LIVING”
DISORDER”
Certainly, there is not yet a widely recognized conceptual framework in which to apportion mental health treatment tasks, although there does seem to be a broad emerging consensus in the literature. The general turfs seem to be the vicissitudes of everyday life” for the primary health care provider, self realization” for religion and to a growing extent the new human potential movement, and pathological symptom and behavior patterns’ for the mental health provider. Of course there is broad overlap between these and the problem areas listed below. The primary care literature (7, 8) suggests that problems in living’ might better be cared for by the primary health care provider. A partial list would indude helping the patient with life crises (birth, adolescent identity, marriage and divorce, loss, death, etc.), alcoholism, normal development issues, encouraging strengths, dealing with normal feeling states in health and illness (anger, guilt, depression, low self-esteem), anticipatory guidance for mothers, changing roles of women, adjustment to chronic illness, and others. This list would also include working with stable or compensated chronic psychotics. (More primary health care providers might be willing to do this if mental health backup were more readily accessible.) The mental health provider working in an integrated setting naturally begins to see the patients with whom the primary health care provider is not trained to work or who do not respond to his intervention. This includes adults and children with serious or life-threatening disorders, the clearly psychotic, those who require long-term or specialized treatments (e.g., group or behavioral), chronic patients who need a complex variety of backup supportive services, diagnostic problems, patients who require complicated drug treatment (e.g., lithium), and others. ‘ ‘
‘ ‘
‘
‘ ‘
‘
ROLE
November
of colleagueship. This often serves to sharpen cnitenia for referral and remove the “mystery” of just what the mental health provider does. As the communication and mutual respect improve, the primary health care provider becomes freer to ask for consultation for some of his problem patients. Thus a patient seen as a ‘crock’ might be perceived instead as a patient who sets up recurrent hostile dependent relationships. The semantic difference is not important. The new perception of patient needs and feelings that might be amenable to change is important. If the mental health provider plays a full role in the primary health care program, including consultation, evaluation, and treatment, is the primary health care provider encouraged to dump’ all the patients he finds difficult, bad,’ uncooperative, or ‘crazy’ ? In general, we have not found this to be the case. There are too many other factors impinging on this referral process, which will be further elaborated below.
‘ ‘
THE
/35:/i,
‘ ‘
‘
‘
Am
J Psychiatry
/35:1/,
November
/978
RICHARD
It might be said that if primary health cane providers miss too much mental illness, mental health providers find too much. Coleman and associates (9) noted, Pediatnicians start out from the assumption of health, psychiatrists from the assumption of illness, but both may err. What then, is preferable-a false negative (labeling a chronic depression in a young woman that affects her parenting as You’re tired-take a vacation’ ‘) or a false positive (labeling a culturally determined time-limited hysterical grief reaction as schizophrenia, You’re sick’ ‘)? Both practitioners take the perspective of their experience. One provider has to assume the best, which serves to support patient assets, and the other has to find the illness if he is not to miss that which may be treatable. The conclusion seems to be that each approach has its purpose and can inform, educate, and improve the other if they work together. ‘ ‘
‘ ‘
0.
and the ready availability of physical and cal diagnosis and treatment, which improves with the psychosomatic disorders.
THE
REFERRAL
PROCESS-A
MORRILL
psychologiour work
COMPLEX
TRANSACTION
‘ ‘
‘ ‘
THE PRIMARY
SHAPE
OF HEALTH
MENTAL CARE
HEALTH
IN
THE
SETTING
What forms of mental health service are appropriate to the primary health care program? A number of programs have successfully provided evaluation and thenapies, including crisis, short-term, group, family, couples, behavioral, and drug treatments. Long-term psychotherapy has depended on the resources available. There are, however, some unique aspects of a primary health care program that the mental health services can use to become more effective. The primary health care provider typically follows patients in brief episodes over long spans of time in contrast to a separate mental health clinic, where patients are usually seen for prolonged episodes oven a relatively brief span of time. Thus the separate mental health program may try to turn out a finished product because most patients are not expected to return. However, the primary health care program assumes patients tt’ill continue to return for health care for themselves or their families. This makes possible new treatment formats. Long-term observation and less intensive therapeutic input for a chronic problem may be more acceptable to many patients, more effective, and more efficient. Alternatively, one might employ a “string of beads” approach. The patient may work on the same theme or conflict over a succession of interrupted crisis episodes for which he returns to the same provider to take up where he left off-a type of interrupted continuity more possible in a primary health care setting. This allows us to reach patients who cannot easily accept the traditional time scales of psychotherapy. Other unique aspects of this setting include a wider variety of patients and problems, which tests the adaptability and flexibility of mental health staff; the diversity of “helping figures” (doctors, nurses, dietitians, and others), which allows us to structure a wider variety of therapeutic plans to reach more patients;
Referrals of ambivalent patients from the primary health care program to a separate mental health program have always been marked by low patient cornpliance. Important factors in understanding the process ofreferral include the primary cane provider’s conception of the need for referral, fear of losing a patient on having to share a professional relationship, or feeling that all mental health services are bad or dangerous in some way. Education of primary health care providers is of course one way to reduce these resistances. A second response, which seems to be more effective where it has been put into full operation, is to bring the primary health care and mental health providers into close physical proximity in the same program (10). One study’ showed that referral to a mental health professional within the primary health cane program produced 23% first appointment failures, whereas referral to a separate outside mental health clinic produced 75% first appointment failures. In the view of the primary health cane provider, the mental health resource is thus changed from a distant clinic or hospital to Dr. Jones’ or Mrs. Williams” in the office down the hall-a professional who has shared work with your difficult patients and whose attitudes and effectiveness you have come to have a feel for. This relation increases the number, appropriateness, and timeliness of referrals by 1) allowing trust and respect to develop between the staff, 2) improving the informal communication, which can gradually break down some of the stereotypes about mental illness and treatment (1 1), and 3) creating a larger work envelope or a formal on informal interdisciplinary team, which can reduce the issue of territoriality on ‘giving up’ the patient. ‘ ‘
‘
‘
‘ ‘
‘
IDENTITY,
STATUS,
AND
THE
PROVIDER
RELATIONSHIP
Historically the relationship between psychiatrists and their medical colleagues has been problematic and not based on mutual respect. These issues will have to be dealt with in any joint endeavor. Potent factors in this relationship are identity and status. In joining a health care specialty, one is selfselected to share certain traits and is gradually socialized into shared assumptions about priorities in health ,
‘Data from an unpublished entitled “The Psychiatric Group
Medical
Setting”
paper by 1K. Carpenter and L.K. Social Worker as a Practitioner
Towle in a
(1974).
1353
PRIMARY
HEALTH
CARE
Am
PROGRAMS
care and the limitations on one’s role to act on these. The concept of the reference group is useful in clanfying apparently contradictory changes in attitude and behavior. A physician may in the course of a day play out different roles by virtue of belonging to several diffenent reference groups. The ‘we’ might be pediatricians’ at 9 a.m. in the pediatrics clinic, ‘doctorf at 1 p.m. when negotiating with the director of nursing, or “team member’ at 4 p.m. when reviewing the day’s patient load with the team. His receptiveness to mental health roles and issues may vary accordingly. In the past few years there has been tremendous interest in a new breed of doctor-the primary cane physician (a specially trained internist, pediatrician, on family practitioner). Training programs are in the process of shaping new generalist identities and show a tendency to want their own mental health teachers-at times shutting out an associated department of psychiatny. The basic issues, often unspoken, are as follows: Does the presence of a psychiatrist in a primary cane program undermine the generalist yes, we can do it all” approach? Does the psychiatrist with his associated status denigrate the developing identity and pride of the young generalist trainee and his teachers? Does he represent a punitive big brother’ function? These are factors that should be worked with so that they will not subvert the promise of a new health-mental health collaboration. One promising vehicle for productive interaction between health and mental health practitioners is an intendisciplinany team approach. These have existed mainly in training programs thus fan and have been difficult to establish in the real world because of lack of real administrative autonomy on support for the team in most programs, the costs of team meeting time in terms of measurable benefits, and the relative absence of training in true settings in most health cane professions. ‘
‘
‘ ‘
‘
‘
‘
‘
‘ ‘
‘ ‘
‘
DISCUSSION
This paper has described mental health practice within a primary health care program-the roles, services, provider relationships, and cost issues. In the pnimany health care programs of the future, there is an advantage to be gained in incorporating mental health programs that go beyond the traditional consultation and liaison model, which is more suitable for mental health input into medical inpatient wards. The consultant or liaison person often functions in these settings as an emissary between separate departments or clinics. If the new primary health care settings are to maximize an integrated approach to health care, they should bring mental health providers into the primary health care programs for direct services as well as consultation (12). The advantages of such an integrated health-mental health endeavor include 1) decreased stigma associat1354
J Psychiatry
/35:/i,
November
/978
ed with mental health services and less patient resistance to referral; 2) greater family orientation of mental health services, which are shaped by the family onentation of the setting they are in; 3) increased coordination of care; 4) more effective treatment of psychosomatic illness: 5) earlier contact with the patient and family, resulting in more opportunity for preventive services through earlier detection and education: and 6) less duplication ofeffort and greater manpower efficiency. To maximize these advantages, an integrated program should incorporate the following general primciples, based on existing mental health programs in primary health care settings: a broad spectrum of ambulatory mental health services on site, mental health staff who work at least 60% of the time (preferably full time), delivery of mental health and health care in the same contiguous space to promote communication, some form of interdisciplinary team activity, and accountability by the mental health care program both to the primary health cane program and to any sponsoring mental health organization. One might ask at this point whether increasing the primary health care provider’s knowledge of and readiness to refer patients to the mental health provider is in fact desirable if it increases demand and thus reduces the apparent insurability of such services. Increasing the availability of mental health services will necessitate increased attention to the initial evaluatiom of the patient and to more appropriate use of a greater variety of resources and treatment modalities. This can meet the increased demand for services and better match the service to the need, thus helping keep costs in bounds. The mental health staff presence can also facilitate higher quality mental health services by a larger group of health care providers, thus enlarging the effective mental health manpower pool. Two studies (13, 14) have shown that mental health services may decrease utilization of health services, but further studies are needed to validate this finding. These integrated programs can originate from different sources. One possibility is linkage with a CMHC which can deliver much of its ambulatory care through primary health care programs to expand its availability and effectiveness. If the primary care program is neighborhood-based, the decentralization enhances accessibility. The CMHC cam in turn provide backup subspecialized services that are not appropriate for the primary cane site, such as hospitalization, partial hospitalization, drug abuse treatment, community residences, and special services for the mentally retarded. Integrated health-mental health programs have been slow to form, in part due to lack of leadership. The existing separate health and mental health systems are preoccupied with developing their own programs and often find integrated services not among their shortterm interests or priorities. There must develop both consumer and professional leadership that sees the field of health as a whole and provides the stimulus and
Am J Psychiatry
/35:/i,
accountability care.
November
to integrate
our
/978
ROBERT
fragmented
systems
7.
of
8.
I.
Lowenkopf EL, Zwerling I: Psychiatric services in a neighborhood health center. Am I Psychiatry 127:916-920, 1971 1. MomlI RG: A new mental health services model for the comprehensive neighborhood health center. Am I Public Health 62:1108-1111, 1972 3. Momll RG: Comprehensive mental health through a neighborhood health center, in Mental Health, the Public Health Challenge. Edited by Liebenman J. Chicago. American Public Health Association, 1976
H: A psychiatrist’s
experience
in a primary
11.
Psychiatric BY
ROBERT
L.
Mental
Health
Patient
in the
Community
OKIN,
I Public
59:245-260,
Follette zation
version
2-6,
of a paper
presented
at the
130th
Association,
Toronto,
Department 160 North
of Mental Washington
annual
Ont.,
meeting
Canada,
Dr. 0km
is Commissioner, of Massachusetts,
Primary DC, US
ofchildren 1977
health
services
into
“filter-down” care program.
procAm
1976
1969
Public Health Association resolution on mental part of comprehensive Health 66:189-190, 1976
ID, Krantz
G, Locke
health
care
BZ, et al: Effect
programs.
of a short
health Am
term
benefit on the utilization of medipractice medical program. Med
W, Cummings N: Psychiatric in a prepaid health plan setting.
for
in
the
services and medical Med Care 5:25-35,
utili1967
Chronic
Health, CommonSt., Boston, Mass.
1-1355$0.45
OF
DE
INSTITUTIONALIZED
Over the last 20 years, states have discharged thousands of chronic patients from their institutions. There is no doubt that many of these patients have benefited greatly from life outside the institution. Many others,
02114.
0002-953X/78/OOl
SITUATION ENTS
of
May
1977.
wealth
for
eral reasons. First, the problems faced by the chronic psychiatric patient in the community constitute a public health issue of the most enormous proportions. Moreover, the way in which a state grapples with its responsibility for this group of patients will have significant implications for the way it deals with the problems of other disadvantaged groups. Finally, the last few years have witnessed profound changes in the care of the chronic psychiatric patient. These changes will continue in the future and must be understood by professionals and citizens alike so that their character can be shaped by the needs of our patients and not solely by extraneous, although powerful, political and economic considerations.
of the chronic psychiatric patient in the and the future role of the states in dealing problems are of critical importance for sev-
Psychiatric
5, et al: The practice medical
DC,
M.D.
PATI Revised
Health
Programs
THE
the American
Washington,
of Physicians 13. Washington,
IV, Patrick DL: Integrating mental care. Med Care 14:654-661,
OKIN
1974
1974 5: The mental health I Pediatr 91:150-153,
outpatient psychiatric therapy cal services in a prepaid group Cane 8:419-428, 1970 14.
Care.
Colleges,
medical
5, Goldensohn in a group
13. Goldberg
PROBLEMS
community with these
Primary
Education HRA-74-31
Fink R, Shapiro ess to psychiatry
I Public
The author explores the probleinsfacing the chronic psychiatric’ patient in the conmunitv and discusses the response offederal and state governments to these pn)blem.s’. Errors ofthe past andpresent are delineated and corrective actions are suggested for thefuture. Finally, it is argued that ifsociety is able to meet tile challenge posed by the chronic psychiatric patient in the c’oinnlunitv it ;t’ill simultaneously have set up mechanisms to solve tile problems of other disa bled and disadvantaged groups of people as well.
THE
on
Medical
as an essential
health
of State
Institute
II, Charney E: The DHEW publication
12. American
setting. mt I Psychiatry Med 7:229-240, 1976-77 I: Neighborhood health centers as providers of primary mental health care. N Engl I Med 295:140-145. 1976 Borus IF, Ianowitch LA, Kieffer F, et al: The coordination of mental health services at the neighborhood level. Am I Psychiatry 132:1177-1 181, 1975
Future
Alpert Care.
primary
cane
The
of American
10. Coleman
5. Bonus 6.
of the
Association
Government Printing Office, 9. Coleman I, Patrick D, Baker an integrated HMO program.
REFERENCES
4. Schniewind
Proceedings
L.
©
1978
American
Psychiatric
Association
1355
J Psychiatry
/35:1/,
November
/978
RICHARD
REFERENCES 1.
Myers and
ES: future
2. Nelson 3.
SH:
health. Mechanic
The
Insurance prospects.
Am
A new
BY
coverage Am
look
for
RICHARD
illness:
Health
at national
health
4. Regier health
status 1970
insurance
for mental health
Health
ben-
orders.
in Primary
.
,
,
PRIMARY HEALTH CARE is currently undergoing a significant revitalization in this country as a result of past overspecialization, patient dissatisfaction rising health cane costs, and new government funding priorities. At the same time there has been a continuing trend toward increasing organization in health care delivery, e.g., group practice and health maintenance organizations. The intersection of these trends is primary health care on comprehensive health care through organized ambulatory health care delivery settings. This presents important new opportunities to reverse ,
Revised version of a paper presented the American Psychiatric Association, 2-6, 1977. Morrill
is Clinical
Government
Director,
Center,
insurance.
35:685-693, 1978 MM, Klerman GL:
Arch Gen
Health
Am
I
Public
CA: The de facto health perspective. Epidemiology
of
Health
US mental Arch Gen mental
dis-
Psychiatry 35:705-712, 1978
Care
Programs
some of the isolation and fragmentation that separate mental health programs have undergone in relation to the rest of health cane. This paper will present issues and findings gathered from the literature and from my work in integrated health-mental health settings: the Roxbuny Comprehensive Community Health Center and Upham’s Corner Neighborhood Health Center in Boston. A number of potent forces leading toward the integration of health and mental health services have developed in recent years. Psychiatry has undergone considerable role diffusion since the social movements of the 60s and is generally rediscovering its linkage with medicine. Some primary care training programs are trying to give higher priority to the psychological side of health cane. Mental health services are more likely to be reimbursed by third-party payers than formerly, and health care programs are less defensive about including them. The much heralded community mental health centers have not fulfilled their promise because of lack of financing and perhaps because they attempted too much too soon. Deinstitutionalization is usually not followed by the promised comprehensive community care. Mental health services are making progress, albeit with difficulty, in quality control, cost containment, and utilization review-thus following trends present in health care generally. The federal government is withdrawing support from the training of mental health care providers in favor of the training of primary health care providers with mental health skills. The traditional areas of health-mental health interaction have been several. Consultation and liaison units from departments of psychiatry have worked within general and teaching hospitals. Such units were often quite peripheral to their health cane setting, on which they had little influence. In the ambulatory area, hospitals have run separate medical, pediatric, gynecological, and psychiatric clinics, with little communi-
.
Dr.
health
MORRILL
M.D.
Our large/v separate nental health s’stem has developed in relationship to a health care systeFn oriented tott’ard specialization and solo practice. Noti’ the health care system is moving in the direction of primary care and group and organizational practice. Nett’ftrms of,nental health delivery’ are needed to ‘naximize the potential ofthese nest’ health care programs for nental health services The author describes these tie ti integrated programs which bring mental health providers into the primar’ health care progra,nsfor direct services as ;i’ell as consultation. Issues discussed include mutual roles, changes in services, the referralprocess, and provider relationships The advantages ofsuch integrated programs include decreased stigma increased prevention through earlier detection and referral, increasedfam i/v orientation greater coordination of care, and less duplic’ation.
Center,
national 1978
DA, Goldberg ID, Taube services system: a public
Psychiatry
5. Weissman
1973 of mental
Mental
MORRILL,
present
60:1921-1930,
43:622-631, in the design
for C.
mental
I Public
I Orthopsychiatry D: Considerations
Future
efits under 68:482-488,
0.
at the 130th annual meeting of Toronto, Ont., Canada, May
Erich
Boston,
Lindemann
Mass.
0002-953X/78/00l
Mental
Health
02114. 1-135 l$0.50
©
1978
American
Psychiatric
Association
1351
PRIMARY
HEALTH
CARE
Am
PROGRAMS
cation and an exceedingly high no show’ rate on cross-referral. Attempts at postgraduate psychiatric education for general practitioners reached very fewusually only those who were already committed. There has been little interest in the general health of patients in psychiatric clinics and mental health centens. In addition, the expressed attitudes of psychiatnists and their medical colleagues toward each other have often been derogatory. Given the above situation, it seems that there has developed not only a fragmented system but two mental health care systems-one through the primary health care provider and the other through the separate private psychiatrists, CMHCs, and mental hospitals. Part of the answer lies in working out new joint health-mental health programs by taking advantage of these new forms of ambulatory health care delivery. These include group practices, health maintenance organizations, neighborhood health centers, hospital pnimany cane clinics, and rural health centers. The punpose of this paper is to explore joint health-mental health programming in these expanding organized forms of primary health care. Areas I will discuss indude roles, types ofdisorders, new forms of services, the referral process, and provider relationships. Pnimany health care is defined as general health care that 1) exists at the point offirst contact by the patient, 2) is continuing to ensure the patient’s overall health, and 3) coordinates the delivery of other specialized health and social services. ‘ ‘
‘
J Psychiatry
‘ ‘
PRIMARY
OF CARE
MENTAL
HEALTH
PROVIDERS
IN
SETTINGS
There seems to be a broad consensus that there is much mental health care to be done in primary health cane programs and that some mental health input is thus needed. Two general approaches have developed. In the first (1) the mental health provider carries out direct on indirect consultation only. In the second (2-6) he provides consultation and a variety ofdirect mental health treatment services. The principle embodied in the first approach is that one should facilitate mental health work by the primary health care provider but not risk taking it over. The second approach is based on the supposition that many patients will never leave the primary health cane program to be diagnosed or treated in a separate mental health system and therefone the two should be integrated in the ambulatory cane area. There seem to be additional benefits for mental health providers carrying out the latter approach-full senvice in the primary health cane program. Several authons (2, 3, 5, 6) have pointed out that, given the mistrust and poor communication between the mental health provider and health providers in general, carrying out direct service in the primary health cane program serves to educate, sensitize, and create a feeling 1352
/978
‘ ‘
‘
‘
‘ ‘
‘ ‘
WHO
VERSUS
TREATS ‘ ‘
‘
‘
‘
WHAT?
‘
MENTAL
‘
PROBLEMS
IN
‘
LIVING”
DISORDER”
Certainly, there is not yet a widely recognized conceptual framework in which to apportion mental health treatment tasks, although there does seem to be a broad emerging consensus in the literature. The general turfs seem to be the vicissitudes of everyday life” for the primary health care provider, self realization” for religion and to a growing extent the new human potential movement, and pathological symptom and behavior patterns’ for the mental health provider. Of course there is broad overlap between these and the problem areas listed below. The primary care literature (7, 8) suggests that problems in living’ might better be cared for by the primary health care provider. A partial list would indude helping the patient with life crises (birth, adolescent identity, marriage and divorce, loss, death, etc.), alcoholism, normal development issues, encouraging strengths, dealing with normal feeling states in health and illness (anger, guilt, depression, low self-esteem), anticipatory guidance for mothers, changing roles of women, adjustment to chronic illness, and others. This list would also include working with stable or compensated chronic psychotics. (More primary health care providers might be willing to do this if mental health backup were more readily accessible.) The mental health provider working in an integrated setting naturally begins to see the patients with whom the primary health care provider is not trained to work or who do not respond to his intervention. This includes adults and children with serious or life-threatening disorders, the clearly psychotic, those who require long-term or specialized treatments (e.g., group or behavioral), chronic patients who need a complex variety of backup supportive services, diagnostic problems, patients who require complicated drug treatment (e.g., lithium), and others. ‘ ‘
‘ ‘
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of colleagueship. This often serves to sharpen cnitenia for referral and remove the “mystery” of just what the mental health provider does. As the communication and mutual respect improve, the primary health care provider becomes freer to ask for consultation for some of his problem patients. Thus a patient seen as a ‘crock’ might be perceived instead as a patient who sets up recurrent hostile dependent relationships. The semantic difference is not important. The new perception of patient needs and feelings that might be amenable to change is important. If the mental health provider plays a full role in the primary health care program, including consultation, evaluation, and treatment, is the primary health care provider encouraged to dump’ all the patients he finds difficult, bad,’ uncooperative, or ‘crazy’ ? In general, we have not found this to be the case. There are too many other factors impinging on this referral process, which will be further elaborated below.
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/978
RICHARD
It might be said that if primary health cane providers miss too much mental illness, mental health providers find too much. Coleman and associates (9) noted, Pediatnicians start out from the assumption of health, psychiatrists from the assumption of illness, but both may err. What then, is preferable-a false negative (labeling a chronic depression in a young woman that affects her parenting as You’re tired-take a vacation’ ‘) or a false positive (labeling a culturally determined time-limited hysterical grief reaction as schizophrenia, You’re sick’ ‘)? Both practitioners take the perspective of their experience. One provider has to assume the best, which serves to support patient assets, and the other has to find the illness if he is not to miss that which may be treatable. The conclusion seems to be that each approach has its purpose and can inform, educate, and improve the other if they work together. ‘ ‘
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0.
and the ready availability of physical and cal diagnosis and treatment, which improves with the psychosomatic disorders.
THE
REFERRAL
PROCESS-A
MORRILL
psychologiour work
COMPLEX
TRANSACTION
‘ ‘
‘ ‘
THE PRIMARY
SHAPE
OF HEALTH
MENTAL CARE
HEALTH
IN
THE
SETTING
What forms of mental health service are appropriate to the primary health care program? A number of programs have successfully provided evaluation and thenapies, including crisis, short-term, group, family, couples, behavioral, and drug treatments. Long-term psychotherapy has depended on the resources available. There are, however, some unique aspects of a primary health care program that the mental health services can use to become more effective. The primary health care provider typically follows patients in brief episodes over long spans of time in contrast to a separate mental health clinic, where patients are usually seen for prolonged episodes oven a relatively brief span of time. Thus the separate mental health program may try to turn out a finished product because most patients are not expected to return. However, the primary health care program assumes patients tt’ill continue to return for health care for themselves or their families. This makes possible new treatment formats. Long-term observation and less intensive therapeutic input for a chronic problem may be more acceptable to many patients, more effective, and more efficient. Alternatively, one might employ a “string of beads” approach. The patient may work on the same theme or conflict over a succession of interrupted crisis episodes for which he returns to the same provider to take up where he left off-a type of interrupted continuity more possible in a primary health care setting. This allows us to reach patients who cannot easily accept the traditional time scales of psychotherapy. Other unique aspects of this setting include a wider variety of patients and problems, which tests the adaptability and flexibility of mental health staff; the diversity of “helping figures” (doctors, nurses, dietitians, and others), which allows us to structure a wider variety of therapeutic plans to reach more patients;
Referrals of ambivalent patients from the primary health care program to a separate mental health program have always been marked by low patient cornpliance. Important factors in understanding the process ofreferral include the primary cane provider’s conception of the need for referral, fear of losing a patient on having to share a professional relationship, or feeling that all mental health services are bad or dangerous in some way. Education of primary health care providers is of course one way to reduce these resistances. A second response, which seems to be more effective where it has been put into full operation, is to bring the primary health care and mental health providers into close physical proximity in the same program (10). One study’ showed that referral to a mental health professional within the primary health cane program produced 23% first appointment failures, whereas referral to a separate outside mental health clinic produced 75% first appointment failures. In the view of the primary health cane provider, the mental health resource is thus changed from a distant clinic or hospital to Dr. Jones’ or Mrs. Williams” in the office down the hall-a professional who has shared work with your difficult patients and whose attitudes and effectiveness you have come to have a feel for. This relation increases the number, appropriateness, and timeliness of referrals by 1) allowing trust and respect to develop between the staff, 2) improving the informal communication, which can gradually break down some of the stereotypes about mental illness and treatment (1 1), and 3) creating a larger work envelope or a formal on informal interdisciplinary team, which can reduce the issue of territoriality on ‘giving up’ the patient. ‘ ‘
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IDENTITY,
STATUS,
AND
THE
PROVIDER
RELATIONSHIP
Historically the relationship between psychiatrists and their medical colleagues has been problematic and not based on mutual respect. These issues will have to be dealt with in any joint endeavor. Potent factors in this relationship are identity and status. In joining a health care specialty, one is selfselected to share certain traits and is gradually socialized into shared assumptions about priorities in health ,
‘Data from an unpublished entitled “The Psychiatric Group
Medical
Setting”
paper by 1K. Carpenter and L.K. Social Worker as a Practitioner
Towle in a
(1974).
1353
PRIMARY
HEALTH
CARE
Am
PROGRAMS
care and the limitations on one’s role to act on these. The concept of the reference group is useful in clanfying apparently contradictory changes in attitude and behavior. A physician may in the course of a day play out different roles by virtue of belonging to several diffenent reference groups. The ‘we’ might be pediatricians’ at 9 a.m. in the pediatrics clinic, ‘doctorf at 1 p.m. when negotiating with the director of nursing, or “team member’ at 4 p.m. when reviewing the day’s patient load with the team. His receptiveness to mental health roles and issues may vary accordingly. In the past few years there has been tremendous interest in a new breed of doctor-the primary cane physician (a specially trained internist, pediatrician, on family practitioner). Training programs are in the process of shaping new generalist identities and show a tendency to want their own mental health teachers-at times shutting out an associated department of psychiatny. The basic issues, often unspoken, are as follows: Does the presence of a psychiatrist in a primary cane program undermine the generalist yes, we can do it all” approach? Does the psychiatrist with his associated status denigrate the developing identity and pride of the young generalist trainee and his teachers? Does he represent a punitive big brother’ function? These are factors that should be worked with so that they will not subvert the promise of a new health-mental health collaboration. One promising vehicle for productive interaction between health and mental health practitioners is an intendisciplinany team approach. These have existed mainly in training programs thus fan and have been difficult to establish in the real world because of lack of real administrative autonomy on support for the team in most programs, the costs of team meeting time in terms of measurable benefits, and the relative absence of training in true settings in most health cane professions. ‘
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DISCUSSION
This paper has described mental health practice within a primary health care program-the roles, services, provider relationships, and cost issues. In the pnimany health care programs of the future, there is an advantage to be gained in incorporating mental health programs that go beyond the traditional consultation and liaison model, which is more suitable for mental health input into medical inpatient wards. The consultant or liaison person often functions in these settings as an emissary between separate departments or clinics. If the new primary health care settings are to maximize an integrated approach to health care, they should bring mental health providers into the primary health care programs for direct services as well as consultation (12). The advantages of such an integrated health-mental health endeavor include 1) decreased stigma associat1354
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ed with mental health services and less patient resistance to referral; 2) greater family orientation of mental health services, which are shaped by the family onentation of the setting they are in; 3) increased coordination of care; 4) more effective treatment of psychosomatic illness: 5) earlier contact with the patient and family, resulting in more opportunity for preventive services through earlier detection and education: and 6) less duplication ofeffort and greater manpower efficiency. To maximize these advantages, an integrated program should incorporate the following general primciples, based on existing mental health programs in primary health care settings: a broad spectrum of ambulatory mental health services on site, mental health staff who work at least 60% of the time (preferably full time), delivery of mental health and health care in the same contiguous space to promote communication, some form of interdisciplinary team activity, and accountability by the mental health care program both to the primary health cane program and to any sponsoring mental health organization. One might ask at this point whether increasing the primary health care provider’s knowledge of and readiness to refer patients to the mental health provider is in fact desirable if it increases demand and thus reduces the apparent insurability of such services. Increasing the availability of mental health services will necessitate increased attention to the initial evaluatiom of the patient and to more appropriate use of a greater variety of resources and treatment modalities. This can meet the increased demand for services and better match the service to the need, thus helping keep costs in bounds. The mental health staff presence can also facilitate higher quality mental health services by a larger group of health care providers, thus enlarging the effective mental health manpower pool. Two studies (13, 14) have shown that mental health services may decrease utilization of health services, but further studies are needed to validate this finding. These integrated programs can originate from different sources. One possibility is linkage with a CMHC which can deliver much of its ambulatory care through primary health care programs to expand its availability and effectiveness. If the primary care program is neighborhood-based, the decentralization enhances accessibility. The CMHC cam in turn provide backup subspecialized services that are not appropriate for the primary cane site, such as hospitalization, partial hospitalization, drug abuse treatment, community residences, and special services for the mentally retarded. Integrated health-mental health programs have been slow to form, in part due to lack of leadership. The existing separate health and mental health systems are preoccupied with developing their own programs and often find integrated services not among their shortterm interests or priorities. There must develop both consumer and professional leadership that sees the field of health as a whole and provides the stimulus and
Am J Psychiatry
/35:/i,
accountability care.
November
to integrate
our
/978
ROBERT
fragmented
systems
7.
of
8.
I.
Lowenkopf EL, Zwerling I: Psychiatric services in a neighborhood health center. Am I Psychiatry 127:916-920, 1971 1. MomlI RG: A new mental health services model for the comprehensive neighborhood health center. Am I Public Health 62:1108-1111, 1972 3. Momll RG: Comprehensive mental health through a neighborhood health center, in Mental Health, the Public Health Challenge. Edited by Liebenman J. Chicago. American Public Health Association, 1976
H: A psychiatrist’s
experience
in a primary
11.
Psychiatric BY
ROBERT
L.
Mental
Health
Patient
in the
Community
OKIN,
I Public
59:245-260,
Follette zation
version
2-6,
of a paper
presented
at the
130th
Association,
Toronto,
Department 160 North
of Mental Washington
annual
Ont.,
meeting
Canada,
Dr. 0km
is Commissioner, of Massachusetts,
Primary DC, US
ofchildren 1977
health
services
into
“filter-down” care program.
procAm
1976
1969
Public Health Association resolution on mental part of comprehensive Health 66:189-190, 1976
ID, Krantz
G, Locke
health
care
BZ, et al: Effect
programs.
of a short
health Am
term
benefit on the utilization of medipractice medical program. Med
W, Cummings N: Psychiatric in a prepaid health plan setting.
for
in
the
services and medical Med Care 5:25-35,
utili1967
Chronic
Health, CommonSt., Boston, Mass.
1-1355$0.45
OF
DE
INSTITUTIONALIZED
Over the last 20 years, states have discharged thousands of chronic patients from their institutions. There is no doubt that many of these patients have benefited greatly from life outside the institution. Many others,
02114.
0002-953X/78/OOl
SITUATION ENTS
of
May
1977.
wealth
for
eral reasons. First, the problems faced by the chronic psychiatric patient in the community constitute a public health issue of the most enormous proportions. Moreover, the way in which a state grapples with its responsibility for this group of patients will have significant implications for the way it deals with the problems of other disadvantaged groups. Finally, the last few years have witnessed profound changes in the care of the chronic psychiatric patient. These changes will continue in the future and must be understood by professionals and citizens alike so that their character can be shaped by the needs of our patients and not solely by extraneous, although powerful, political and economic considerations.
of the chronic psychiatric patient in the and the future role of the states in dealing problems are of critical importance for sev-
Psychiatric
5, et al: The practice medical
DC,
M.D.
PATI Revised
Health
Programs
THE
the American
Washington,
of Physicians 13. Washington,
IV, Patrick DL: Integrating mental care. Med Care 14:654-661,
OKIN
1974
1974 5: The mental health I Pediatr 91:150-153,
outpatient psychiatric therapy cal services in a prepaid group Cane 8:419-428, 1970 14.
Care.
Colleges,
medical
5, Goldensohn in a group
13. Goldberg
PROBLEMS
community with these
Primary
Education HRA-74-31
Fink R, Shapiro ess to psychiatry
I Public
The author explores the probleinsfacing the chronic psychiatric’ patient in the conmunitv and discusses the response offederal and state governments to these pn)blem.s’. Errors ofthe past andpresent are delineated and corrective actions are suggested for thefuture. Finally, it is argued that ifsociety is able to meet tile challenge posed by the chronic psychiatric patient in the c’oinnlunitv it ;t’ill simultaneously have set up mechanisms to solve tile problems of other disa bled and disadvantaged groups of people as well.
THE
on
Medical
as an essential
health
of State
Institute
II, Charney E: The DHEW publication
12. American
setting. mt I Psychiatry Med 7:229-240, 1976-77 I: Neighborhood health centers as providers of primary mental health care. N Engl I Med 295:140-145. 1976 Borus IF, Ianowitch LA, Kieffer F, et al: The coordination of mental health services at the neighborhood level. Am I Psychiatry 132:1177-1 181, 1975
Future
Alpert Care.
primary
cane
The
of American
10. Coleman
5. Bonus 6.
of the
Association
Government Printing Office, 9. Coleman I, Patrick D, Baker an integrated HMO program.
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4. Schniewind
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L.
©
1978
American
Psychiatric
Association
1355
