With Integrated Behavioral Health Care, Donohue et al. provide a handbook that both health care administrators and practitioners will find informative and useful.  The book highlights the prevalence of mental and emotional elements in many physical complaints, and suggests effective strategies for embedding mental health care providers within the physical care system.  The authors demonstrate how the marriage of what are currently separate domains would benefit both patients and providers.  For example, many physical complaints and problems have obvious psychological components, and in addition many patients with physical-based illnesses that are not obviously related to mental or emotional health would also benefit from counseling or psychotherapy.  Currently, primary care and family practice physicians are largely left to handle routine mental health issues with antidepressants or anti-anxiety medications, treatment regimens that by themselves can provide only limited benefit in most cases.

The health care system itself would also benefit from cost savings by embedding mental health workers within clinic settings:  persons with untreated or improperly treated emotional disorders and conditions, as well as non-compliant patients, are costly in dollars.  The most expensive 1% of the general physical health outpatient population accounts for 27% of health care costs, and the most expensive 20% of physical health patients account for 88% of all medical costs in the U.S.

A sampling of the statistics presented in the book bring these issues into sharp perspective: at any given time among the general U.S. population, about 10% of us are clinically depressed, but in the average outpatient physical health care clinic, this proportion rises to about 25%.  About 13% of the general population suffers from diagnosable anxiety, but at the typical outpatient medical clinic, this proportion is about a third.  Estimates are that as many as 70% of those presenting to health care providers with symptoms of heart problems are actually suffering from panic or anxiety disorders.  A further worrisome finding is that two-thirds of physical health care patients are actually non-compliant with the medications and treatment regimens prescribed for them.  And about 60% of primary care visits produce no physical health diagnosis at all, suggesting the contribution of mental or emotional issues to these patients’ reasons for seeking care.

The idea of health as having both physical and emotional components isn’t new, but the health care system in the United States has been slow to adjust to this notion.  Fifty years ago, most people would have agreed that a physical ailment needed a body-based intervention, primarily either medication or corrective surgery.  Mental illnesses were heavily stigmatized, and those who suffered from the more serious of these conditions were often hospitalized or kept out of public sight by families.

Times are changing.  The Surgeon General’s report on mental health, issued in 1999, formalized a new way of looking at these illnesses.  Although this report did not fully address the problems of co-occurring physical and mental health problems, it did observe that “Primary health care could be an important portal of entry for children and adults of all ages with mental disorders.”

The authors are knowledgeable and experienced in this area, and write authoritatively about this topic. The book itself is comprised of eleven chapters divided into three major headings:  Operational Principles, Core Knowledge, and Key Clinical Skills.  The first domain addresses the question of why it makes sense to integrate mental and physical health care models.  The second addresses the basics of medical psychology and behavioral medicine.  In the third, special topics are covered, including the Biodyne model of providing mental health care intermittently as people need it and can benefit from it; a discussion of practice guidelines; the addition of mental health care to the treatment of chronic diseases such as diabetes and hypertension; and suggestions about how to make mental health care appealing to appropriate patients in physical health care settings. 

The book’s coverage of these important topics is practical and thorough, although the focus is primarily on mental health care as an adjunct to the physical health care system rather than a elements of a fully integrated model.  Health care system administrators would have benefited from an additional section on the special physical health care needs of persons with severe and persistent mental illnesses such as schizophrenia and bipolar disorder, since high correlations have been shown between these disorders and other serious physical illnesses, and persons with these disorders are often reluctant to seek and follow through with referrals to physical health care providers.

© 2007 Keith Harris

Keith Harris, Ph.D., is Chief of Research for the Department of Behavioral Health in San Bernardino County, California. His current interests include the empirical basis for mental health research, behavioral genetics, and the shaping of human nature by evolutionary forces.

Categories: Psychology, MentalHealth