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The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions into Primary Care: Executive Summary of an American College of Physicians Position PaperIntegration of Behavioral Health into Primary Care

Ryan A. Crowley, BSJ; Neil Kirschner, PhD, for the Health and Public Policy Committee of the American College of Physicians*
[+] Article, Author, and Disclosure Information

* This paper, written by Ryan A. Crowley, BSJ, and Neil Kirschner, PhD, was developed for the Health and Public Policy Committee of the American College of Physicians. Individuals who served on the Health and Public Policy Committee from initiation of the project until its approval and authored this position paper are Thomas Tape, MD (Chair); Douglas DeLong, MD (Vice Chair); Micah Beachy, DO; Sue Bornstein, MD; James Bush, MD; Tracey Henry, MD; Gregory Hood, MD; Gregory Kane, MD; Robert Lohr, MD; Ashley Minaei; Kenneth Olive, MD; and Shakaib Rehman, MD. Approved by the ACP Board of Regents on 28 April 2015.

This article was published online first at www.annals.org on 30 June 2015.

From the American College of Physicians, Washington, DC.

Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Disclosures: Authors have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0510.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Requests for Single Reprints: Ryan A. Crowley, BSJ, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, rcrowley@acponline.org.

Current Author Addresses: Mr. Crowley and Dr. Kirschner: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.

Author Contributions: Conception and design: R.A. Crowley, N. Kirschner, D. DeLong, M. Beachy, A. Minaei.

Analysis and interpretation of the data: R.A. Crowley, N. Kirschner, S. Bornstein, J. Bush, T. Henry, A. Minaei.

Drafting of the article: R.A. Crowley, N. Kirschner.

Critical revision of the article for important intellectual content: R.A. Crowley, D. DeLong, G. Hood, R. Lohr, A. Minaei, S. Rehman.

Final approval of the article: R.A. Crowley, N. Kirschner, T. Tape, D. DeLong, M. Beachy, S. Bornstein, G. Kane, R. Lohr, A. Minaei, K. Olive, S. Rehman.

Provision of study materials or patients: R.A. Crowley.

Statistical expertise: R.A. Crowley.

Administrative, technical, or logistic support: R.A. Crowley, T. Henry, S. Rehman.

Collection and assembly of data: R.A. Crowley, N. Kirschner.

Ann Intern Med. 2015;163(4):298-299. doi:10.7326/M15-0510
Text Size: A A A

Behavioral health care includes care for patients around mental health and substance abuse conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. Mental and substance use disorders alone are estimated to surpass all physical diseases as a major cause of worldwide disability by 2020. The literature recognizes the importance of the health care system effectively addressing behavioral health conditions. Recently, there has been a call for the use of the primary care delivery platform and the related patient-centered medical home model to effectively address these conditions.This position paper focuses on the issue of better integration of behavioral health into the primary care setting. It provides an environmental scan of the current state of conditions included in the concept of behavioral health and examines the arguments for and barriers to increased integration into primary care. It also examines various approaches of integrated care delivery and offers a series of policy recommendations that are based on the reviewed information and evidence to inform the actions of the American College of Physicians and its members regarding advocacy, research, and practice.





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Submit a Comment/Letter
Terminology in paper aiming to reduce stigma does the opposite; evidence for integration less convincing than implied
Posted on July 4, 2015
Richard Saitz, Sarah E. Wakeman, John F. Kelly
Boston University Schools of Public Health and Medicine; Boston Medical Center; Harvard Medical School; Massachusetts General Hospital
Conflict of Interest: Dr. Saitz reports consulting as an editor for BMJ, UpToDate, the American society of Addiction Medicine (as editor of Principles of Addiction Medicine, and as Senior Editor of Journal of Addiction Medicine), roles in which questions of terminology arise. Drs. Wakeman and Kelly report no potential conflicts or relevant financial interests. No funding was received in support of writing this comment.
We were disappointed that an opportunity was missed to use scientifically accurate non-stigmatizing diagnostic terminology in the position paper on integrated care, particularly ironic given that one of the six recommendations specified aims to reduce stigma.

The title of the paper refers to “substance abuse,” and “abuse” or its derivatives (e.g. “abuser”) appear 66 times in the manuscript. We understand its use to be unavoidable sometimes (e.g. DSM IV “abuse” diagnosis or an agency name), but such terms increase stigma and are inaccurate. Consequently, its inclusion in a policy statement in a leading scientific journal was unexpected and disconcerting. “Use,” “person who uses substances,” and “substance use disorder,” are more accurate and less pejorative. These issues are not merely semantics or political correctness. Such language negatively impacts quality of care and clinicians’ response to patients with these disorders (1). Journals and even the White House have called for use of accurate non-stigmatizing language (1, 2).

Because these disorders are stigmatizing, it is particularly important to rely on the best evidence; this was not done in two instances. First, the “Screening, Brief Interventions, Referral to Treatment” (SBIRT) approach is cited as evidence for effectiveness of integration and as being “effective” for “drug and alcohol abuse.” SBIRT can be integrated into care, but often is delivered as a separate service. More importantly, evidence does not support efficacy for people with substance use disorders, even for specialty treatment referrals (3). And randomized trials find lack of efficacy for drugs other than alcohol (4). There are important reasons to ask about substance use, such as building doctor-patient rapport, proper diagnosis of symptoms and conditions, and appropriate management (e.g. prescribing for pain), but these are not SBIRT.

Second, randomized trial evidence suggests lack of effectiveness of integrated care for substance use disorders in primary care (5). Other attempts have been successful—particularly models that focus on medication use (naltrexone, buprenorphine). The existence of serious attempts at integration that have demonstrated conflicting results should give pause to broad calls for “integration” without specifying what it means, if we are to reap its benefits.

Care for substance use and mental health disorders integrated with other medical disorders needs to improve. Integration is promising. To help achieve the aims set forth in the ACP position paper, we should use accurate medical terminology, and pay close attention to the evidence we use to support and implement it.

1. Kelly JF, Wakeman SE, Saitz R. Stop Talking ‘Dirty’: Clinicians, Language, and Quality of Care for the Leading Cause of Preventable Death in the United States. Am J Med. 2015; 128(1): 8-9.
2. Language and terminology guidance for Journal of Addiction Medicine (JAM) manuscripts. http://journals.lww.com/journaladdictionmedicine/Pages/informationforauthors.aspx#languageandterminologyguidance
3. Saitz R. Alcohol screening and brief intervention in primary care: absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev 2010; 29:631–640.
4. Hingson R, Compton WM. Screening and Brief Intervention and Referral to Treatment for Drug Use in Primary Care: Back to the Drawing Board. JAMA. 2014;312(5):488-489. doi:10.1001/jama.2014.7863.
5. Saitz R., Cheng D. M., Winter M., Kim T. W., Meli S. M., Allensworth-Davies D. et al. Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial. JAMA 2013; 310: 1156–67.
Behavioral health integration into primary care can be achieved; different approaches may be necessary
Posted on September 13, 2015
Dolores Buscemi, MD, Susan S. Hendrick, PhD, Shannon Yarbrough, MD
Texas Tech University School of Medicine
Conflict of Interest: None Declared
Crowley and Kirschner (1) provide a timely and comprehensive position paper, supported by the Health and Public Policy Committee of the American College of Physicians. The central thrust of this paper is a call for greater integration of behavioral health, broadly construed, into the primary medical setting. This call is congruent with the PCMH movement and recognizes the close connection between mental, emotional, and physical health.
We concur with the agenda outlined in the position paper. It is consistent with a major initiative proposed by other scholars (2) who presented goals for respectful, communicative, and integrated treatment to better serve the needs of patients with cancer. Crowley and Kirschner’s proposed model for integration is also consistent with existing successful behavioral health initiatives in such domains as the Department of Defense (3).
One of the goals put forth in the position paper is destigmatizing behavioral health services for patients (of which mental health is a part). The twin virtues of integrated and thus collocated services means more seamless treatment of patients and makes behavioral health an accepted and even “natural” part of a medical visit, particularly in cases of comorbidities and or chronicity, both commonly seen in internal medicine settings.
Eleven years ago, our institution started incorporating behavioral health services into our cancer center, with success. More recently, we have also implemented them in our general internal medicine resident clinics. Since doing so, we have seen improvement in both patient and resident outlooks.
The six recommendations in the position paper are decidedly ambitious, but if realized, can use appropriately trained behavioral health providers to work in concert with physicians and other healthcare personnel as a team. Such a team can provide holistic care to patients with complex conditions, relieving both patient stress and perhaps some physician pressures as well. It is likely to be some time before all six recommendations are fulfilled (e.g., increasing the behavioral health workforce, soliciting funding changes in both private and public fee for service payment). Several of these recommendations are definitely top-down. We propose that in the meantime, innovative bottom-up partnering arrangements (4), such as those in our institution, can increase the behavioral health presence in medical settings. Treating the “whole” patient is an aspirational goal that can be realized through creative teamwork

1.Crowley RA, Kirschner N. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: an American College of Physicians position paper. Ann Intern Med. 2015;162: [PMID: ] doi: 10.7326/m15-0510
2.Adler NE, Page AEK (Eds). Cancer care for the whole patient. Washington, DC: The National Academies Press; 2012.
3.Hunter CL, Dobmeyer AC, Dorrance, KA. Tipping points in the Department of Defense’s experience with psychologists in primary care. American Psychologist. 2014;69:388-98. doi:10.1037/a0035806
4.Hendrick SS, Cobos, E. Practical model for psychosocial care. Jnl Oncology Prac. 2010;6:1-3. doi: 10.1200/JOP.091066

Author's Response
Posted on October 8, 2015
Ryan Crowley, BSJ, Neil Kirschner, PhD, D
American College of Physicians
Conflict of Interest: None Declared
The authors appreciate Drs. Saitz, Wakeman, and Kelly's comments regarding the American College of Physician’s policy paper “The Integration of Care for Mental Health, Substance Abuse and Other Behavioral Health Conditions into Primary Care” and, in general, support the positions taken in their comments. Although the term substance abuse is commonly used in the literature, we agree that the term “substance use” is more respectful to the patient and reflects changes made in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. We share the authors' concern that the lingering stigma surrounding behavioral health conditions must be addressed (Recommendation 6).
We also agree that additional research is necessary to determine best practices in regards to behavioral health-primary care integration. The SBIRT approach was referenced in the paper as an example of one evidence-based substance use screening and intervention method with which primary care physicians may be familiar. In regards to the comment on the paucity of evidence supporting the effectiveness of integrated care for substance use disorders, we concur that further research is needed to determine the most effective and efficient approaches to integration, as reflected in Recommendation 4 of the position paper.
Finally, we are in full support with the commenters’ statement that “Care for substance use and mental health disorders integrated with other medical disorders needs to improve,” and believe that the policy paper is a very positive step by the College towards that goal.
R. Crowley
N. Kirschner
D. Moyer, MD FACP; Chair, ACP Health and Public Policy Committee

Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Accessed at http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf on September 22, 2015.
American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5. Accessed at http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
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