Almost every time I bring up the topic of behavioral healthcare being integrated with general healthcare delivery, a private mental health practitioner responds questioning how this could possibly work. In response to my June post on this issue, one of our customers shared his thoughts (see comments) about just how this might occur and the obstacles to making it happen in the private setting. I responded like this:
I think many private practitioners are in the same position you are. Unless they do a very health-oriented practice, they see themselves continuing to function quite separately from general healthcare.
The picture is not the same in the public arena. At this time, about 60% of the funding for all mental health and substance abuse services comes from public, not private, sources. Of the people receiving such services, a large percentage have serious physical illnesses as well.
SAMHSA and The National Council for Community Behavioral Healthcare are moving forward with pilot programs and research on the integration of general and behavioral healthcare since this makes lots of sense in the public sector for the seriously mentally ill. But it may also have implications in the private arena. In fact, the move to provide integrated healthcare services in the public sector, and wherever possible in the private sector (like in Accountable Care Organizations – ACOs) has many folks exploring obstacles that may exist to such integration and ways to overcome those obstacles.
Yesterday, I was reading a September SAMHSA-HRSA Center for Integrated Health Solutions newsletter that linked to an interesting article on the use and evaluation of Telephone Administered Cognitive Behavioral Therapy (CBT) for depression. The research started from the current reality that most treatment for depression is provided in primary care physician offices. Of course, this treatment usually consists of medication. While patients prefer psychotherapy to medication for treatment of depression, and both CBT and medication appear to be about equally effective, access to psychotherapy is limited for most people. Cost or convenient access to a psychotherapist covered by their health insurance or some other equally valid reason interferes with provision of psychotherapy.
The research demonstrated that telephone administered CBT was more effective in keeping the client participating in therapy. Both telephone administered CBT and face-to-face CBT were equally effective in diminishing symptoms of depression at time of termination. Face-to-face CBT seemed to maintain the effects better at a six-month measure.
At this point in reading the results, I was reminded of Dr. Suzanne Bennett Johnson’s initiative as President of American Psychological Association (APA) for 2012. She wanted to remind psychologists that they are part of a healthcare profession, and that most of us are well-trained in conducting research. We are ideally suited to design and conduct the studies that will demonstrate just where psychologists and other mental health professionals can best serve in integrated healthcare. I could instantly imagine the re-design of the study reported above to include Skype or other Internet service-based delivery of the CBT so that at least some of the elements of the face-to-face therapy would be present.
There is already lots of opinion about the potential benefits and detriments of remotely-administered behavioral health treatment. Psychologist David C. Mohr, Ph.D., Professor in Preventive Medicine, Medical Social Sciences, and Psychiatry and Behavioral Sciences at Northwestern University lists Internet Intervention and Telemental Health as significant aspects of his interests. Quoted in that 2008 Time Magazine article, Dr. Mohr sees distinct areas where teletherapy or other internet programming might be of use, especially CBT for depression.
Other cutting-edge practitioners have already added internet-based services including videotherapy into their retinue. Given a solid research foundation, video-based therapeutic services might well be a way for the private practitioner of behavioral healthcare to integrate their services with general healthcare.
We can sit back and watch as our healthcare system changes all around us, letting others dictate to us the role we will play. Alternatively, we can be active participants in designing the models for inclusion of behavioral healthcare in primary care. We can design the models, do the research, and market the methods to ACOs, health plans, and medical providers.
We would love to hear from any of you who already work in a setting where mental health services are integrated into primary healthcare. Please let us know your experience and what you think.