Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: A Qualitative Study

The recent article by Malatre-Lansac et al. provided crucial insights about behavioral care in the U.S. (1). Even though collaborative care has been conclusively demonstrated to be successful, the authors nicely underscore, as many have, its lukewarm reception in practices sufficiently interested to try it. The far greater problem with collaborative care is the severe and predicted-to-worsen shortage of psychiatrists. Unhappily, the remedies proposed by the authors, similar to those of others, have been ineffective at a population level. During the last 20 or more years, mental health care has actually worsened according to Healthy People 2020 (2).

What to do?

Medicine’s principles of access, safety, and quality of care cannot give any more ground, now at the break point over the mental health puzzle. We’re at an impasse where nothing of the scope required has worked, many yeoman efforts notwithstanding. Can we tolerate only 25% of mental health patients having access to care—compared to 60-80% for medical problems. Psychiatrists see no more than 15% of all mental health patients, and psychologists also are in short supply, other counselors even less able to function on the frontlines.

Medical physicians now provide 85% of all mental health care, yet they are completely untrained, no more than 2-3% of total training time (medical school and residency) devoted to supervised mental health instruction (3, 4)—even though mental disorders are more common and more disabling than cancer and heart disease combined, the most common health condition we care for.

The only tenable solution at the population level, in my opinion, is one recommended by the Institute of Medicine:  train the physicians who provide the care (5). The idea is not to make everyone a psychiatrist, only that they graduate as competent with mental disorders as with physical diseases. They would then provide care for most common mental disorders (depression, anxiety, prescription drug misuse), still referring difficult problems, the same referral model we use for challenging diseases. The present numbers of psychiatrists and psychologists would support this.

There’s no quick fix, it will take time. Yet, if we’d heeded those in the 1970s advocating a similar major re-direction in medical education, mental disorders and disease problems would receive equal treatment today. There would be no mental health crisis. It’s not too late to begin.

REFERENCES

1. Malatre-Lansac A, Engel CC, Xenakis L, Carlasare L, Blake K, Vargo C, et al. Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: A Qualitative Study. Ann Intern Med. 2020.
2. Dept. of Health and Human Services. Healthy People 2020. Washington, DC: Dept. of Health and Human Services; 2017.
3. Wang P, Demler O, Olfson M, Pincus HA, Wells KB, Kessler R. Changing profiles of service sectors used for mental health care in the United States. Am.J. Psychiatry. 2006;163:1187-98.
4. Association of American Medical Colleges. Basic Science, Foundational Knowledge, and Pre-Clerkship Content -- Average Number of Hours for Instruction/Assessment of Curriculum Subjects. Association of American Medical Colleges; 2012.
5. Institute of Medicine. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: National Academy of Sciences; 2004.