Integration of behavioural and medical care: What was old is new again

What was old is new again, and so it is with developing the capacity to diagnose and treat behavioural health conditions in medicosurgical care settings. Integrating behavioural health into general medical settings, which is commonly preferred to as ‘integrated care’ has been advanced as a valuable component in the contemporary transformation of health systems. Integrated care in this context refers to the ‘systematic coordination of physical and behavioral health care’ that supports the systematic identification, evaluation and treatment of mental and/or substance use disorders in general healthcare settings (Hogg Foundation for Mental Health, 2008). Throughout the world, health systems are striving to develop and manage cost-effective health service models that facilitate the identification and treatment of mental conditions in order to reduce overall disability. Lifelong disability may be related to undiagnosed and untreated mental illnesses as well as the contribution that untreated mental illness makes to the management of other health conditions, especially chronic conditions. This is juxtaposed against the reality of a nearly universal shortage of specialist mental health providers. In this edition of the International Review of Psychiatry, several models of integrated care are presented in detail.

In some respects, integrated care is a reaffirmation of the traditional healthcare design that layers care into primary, secondary and tertiary care. In our current era, this includes the assertion that identification and treatment of mental illnesses is an essential component of primary care and that the role for unusually complex or treatment-resistant conditions be managed in a secondary or tertiary speciality psychiatric care setting (where they exist). Historically, tertiary and intensive psychiatric care was ideally provided in long-term asylums that also had responsibility for treatment of general medical conditions. With deinstitutionalization and the advancement of community-based mental health outreach and services, it now becomes apparent that psychiatrically complex individuals might best appropriately receive primary somatic care in a community-based psychiatric setting. Thus a medical home or place where individuals receive primary general medical care for individuals with more severe mental illnesses, might best be provided in a community-based mental health centre.

There is growing appreciation for the direct and indirect burden of untreated mental illness on population health and well-being. This has been supported in numerous national health policy initiatives. In September 2011 the United Nations (UN) General Assembly convened a High Level Meeting on Non-Communicable Diseases in order to raise international attention on the contribution to premature mortality that non-communicable diseases make. Four non-communicable disease (NCD) conditions were identified as priority conditions: cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. These four NCDs were identified in the 2010 global status report on NCDs as being responsible for mortality in 63% of all deaths worldwide (World Health Organization, 2011). Furthermore, these deaths were disproportionately seen in low and middle income countries, with 80% of all deaths by NCD occurring in these countries. Individuals dying of NCD in low and middle income countries died earlier than in higher income countries. For each of the four NCD conditions, psychiatric co-morbidities are associated with higher morbidity and mortality among those with existing NCD conditions.

Furthermore, deaths associated with mental illness are difficult to accurately count, particularly in low income countries. Suicide may be reported in physiological terms, for example as a cardiovascular death, for many reasons including limiting the stigma associated with suicide for the surviving family members. Premature mortality or years of life lost (YLL) is one of two critical components involved with characterizing a population's burden of disease, the other component, years lived disabled (YLD), is critical and is particularly relevant to understanding the population burden of mental illnesses and substance use. Because of the long-term nature of mental disease and the fact that it so often has onset early in life, the kind of disability burden associated with mental disease and substance use is the years that an individual lives with the disease and is unable to fully function due to that disease. Although the current WHO and UN emphasis is on the four conditions, there is growing pressure from mental disease stakeholders internationally to overtly include mental disorders and substance among these priority NCDs (World Federation on Mental Health, 2014).

Mental and substance use diseases are significant causes of disability among NCDs when disability associated with years lived with a disability (YLD) is included in calculations. In a recent analysis of the 2010 Global Burden of Disease study, Whiteford et al. (2013) calculated that mental and substance use disorders were the leading cause of YLD worldwide. They determined that mental and substance use disorders accounted for 22.9% of all YLD and for 0.5% of YLL. In their analysis and with regard to the proportion of causes of disability due to mental and substance use disease, they calculated that depressive disorders accounted for 40.5% of the disability-adjusted life years caused by mental and substance use disorders, anxiety disorders accounted for 14.6%, illicit drug use disorders for 10.9%, alcohol use disorders for 9.6%, schizophrenia for 7.4%, and bipolar disorder for 7.0%. These population statistics are important in considering the high and long-term erosive impact that untreated mental and substance use diseases cause. Fortunately there is treatment available that is effective, and integrated care is an obvious component in finding and successfully treating previously untreated mental and substance use disease in populations.

For low income countries, the adoption of integrated care often includes attention to the capacity of a primary care workforce so that mental disease and substance use diseases can be identified and basic treatment can be provided. This often includes capacity building through training of general practitioners and also includes the use of specifically trained community health workers. Referrals to more specialized psychiatric care may or may not be available. Scaling up such programmes or implementation in a national health system is an additional challenge. van Ginneken describes such challenges in an article entitled ‘The development of mental health services within primary care in India: Learning from oral histories’ (van Ginneken et al., 2014). Conclusions of van Ginneken's work indicate that while capacity is important in scaling up implementation, consistent leadership, policy prioritization and ongoing technical support are also critical elements.

Just as is the case in low income countries, capacity development and consistent programme leadership and resourcing may also be a challenge in middle and higher income countries. Additional challenges include uneven distribution of specialist psychiatric providers. As specialist and consultant physicians and allied mental health professionals become more available, and the proportion of primary care to specialist psychiatric care changes, more specialist care is available, and more individual patients seek expert specialist care. This is a system that is more expensive and may be less efficient, with a mismatch regarding how specialist time is ‘rationed’, so that patients who are more complex and disabled are directed to specialist care. An additional focus with integrated care in more developed countries is the enhancement of care coordination. Chief among the modern tools that facilitate enhanced communication is the adoption of electronic medical records which create streamlined processes for communication and exchange of health information.

One further additional current challenge in the USA is the funding of integrated care programmes. In the USA the predominant method for healthcare financing has been a fee-for-service model. The extensive care coordination that is required in most integrated care models is not directly billable, which often renders the model operating at a financial deficit when only the treatment of mental and substance use diseases are considered in fiscal calculations. When global costs are considered, integrated care approaches have been found to reduce the global costs of healthcare.

We hope that this edition of the International Review of Psychiatry informs and expands working knowledge of effective approaches to reduce the population prevalence and overall burden of untreated mental and substance use disorders. In the USA there has been a recent advertisement campaign that is centred on the re-envisioning of a new and much more stylized version of an automobile that has been a long-standing component of General Motors. This type of car, a Buick, had a reputation as being popular among elderly drivers. In an effort to emphasize the new design, modern technology and style the slogan is: ‘This is not your grandmother's Buick.’ In thinking about contemporary integrated care, it is the case that what's old is new again, and also that this new era of integrated care is informed by substantial experience and significant improvements and upgrades. Yes, in many ways a focus on better and more effective integrated care in our current millennium is founded on traditional population health planning and healthcare delivery; however, the current versions of integrated care that are being implemented are increasingly evidence based and effective. In short, contemporary identification and treatment of mental and substance use diseases is not your grandmother's integrated care.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.