The promise and challenges of integrating mental and physical health

Healthcare delivery is typically compartmentalized and siloed, professionally, institutionally, and financially (Enthoven, 2009; Stange, 2009). The impact of a poorly coordinated healthcare delivery system that does not provide adequate mental health services is poorer health outcomes and impaired quality-of-life for patients and higher healthcare burden for society. The good news is that aspects of healthcare delivery are changing, with a focus on patient-centred care and integration of mental health and physical conditions. There is also emphasis on coordination of sectors such as social services and the health system, because social and psychological approaches need to be considered alongside biomedical ones (Baxter et al., 2018; Stephenson et al., 2018). The promise of integrating care are many, such as improvement in the well-being of patients as well as lower costs for maintaining the health of populations (Davies & Lund, 2017; Krupski et al., 2016; Wilberforce et al., 2016); however, the challenges are also many, such as funding and lack of leadership and organizational commitment. Integration of mental health is being implemented globally, with differential levels of funding and government support, workforce restrictions, and training challenges. The manuscripts in this issue review topics related to integrated care such as the meaning of integration, different models of integration, training needs, the use of technology, and implementation barriers and facilitators across conditions and global contexts.

First, Damian and Gallo review models of integrated care within the US context. They provide a conceptual framework and categorize different ways in which care for physical and mental health/substance abuse disorders can be combined in the primary care setting. In the US, collaborative care that integrates a behavioural health specialist within primary care clinics has the most evidence in terms of clinical outcomes and cost-effectiveness; however, studies of its implementation are less abundant. This article, along with others in this issue, describes the implementation challenges that are needed to successfully translate policy and financial changes into effectively functioning programmes with measurable outcomes.

Dixon et al. take a global perspective, describing a number of successful programmes with varying levels of evidence in both high income countries as well as low and middle income countries. The authors suggest that successful implementation is in part related to the magnitude of government support across societal contexts. They also emphasize the importance of looking beyond primary care facilities to expand the reach, relevance, and impact of integrated care by including community-based programmes using paraprofessionals to deliver care. In certain contexts, community health workers are indispensable due to the lack of specialty mental health providers, and successful integration requires workforce expansion. With such expansion comes training and supervision issues. Kohrt et al. describe issues associated with community health worker training that are characterized by considerable variability, and limited evidence of effectiveness in low-resource areas of the world. The authors raise an important question regarding how to think about minimum standards and competencies, regardless of context.

Training needs are not limited to a paraprofessional workforce new to providing mental health services. Integrated care models are an innovation and, as such, require training for all those who work within an integrated model. Rosenberg et al. review issues related to formal and on-the-job training for the professional workforce. Most professional training programmes remain siloed, and do not adequately prepare clinicians to work collaboratively in an integrated setting. Professionals have learned how to work with those within their own disciplines, but not across disciplines. Challenges to overcome professional biases and clinical approaches loom large. Traditional training methods still predominate, although interprofessional programmes are becoming more common in medicine, nursing, and social work.

Integration of care can occur across various kinds of settings, such as outpatient settings and the acute care hospital. Pudalov et al. review the advantages and challenges associated with integration of psychological services on inpatient medical psychiatric units. Barriers such as financing and attitudinal barriers that separate psychological and medical care are significant, although a population health focus that moves away from volume-based care may provide incentives for integration if the value proposition is well-articulated. Added value of integration may include a decreased length of stay for patients with complex behavioural needs, and fewer hospital readmissions. Although the focus in some contexts is bringing mental health into medical settings, for some populations, the reverse may be more practical. Within the health system, often primary care and community mental health settings exist separately, with little coordination or communication. Murphy et al. review what is called ‘reverse integration’ that addresses the primary care health needs of those with persistent mental illness, a population that is typically served in community mental health settings such as community mental health clinics and psychiatric rehabilitation programmes. This population typically experiences poor physical health outcomes and increased mortality, suggesting the need for interventions that address physical health. The evidence suggests that integration facilitates increases in access to medical care, but improvement in physical health conditions has not been seen.

Integration can occur across conditions and populations as well. Although initiatives for integration mainly focus on adults, the need in children and adolescents is great. In a scoping review, Platt et al. review studies examining implementation of a specific model of integration, namely, co-location. They describe multiple components that facilitate implementation, such as interprofessional communication and clear protocols to facilitate intervention delivery, and highlight ongoing barriers to implementation, including challenges with screening administration and differential engagement in integrated care services by age and other demographic factors.

On the other end of the developmental spectrum, Draper et al. review models and challenges related to integration of dementia care in various settings for different populations. Integrated care in this article is viewed more broadly, as a concept that means integration of various aspects of healthcare delivery with the patient at the centre, bringing together different delivery settings, different types of services, as well as administration, finance, and policy. Integrated care for dementia occurs across settings that include primary care clinics and hospitals. Many programmes are community-based in nursing homes and adult day care centres, some involving multidisciplinary teams that include medical care, and others that provide case management services.

Finally, technology is an indispensable resource in integration. Hilty et al. provide a comprehensive review of the technological resources that can be brought to bear in order to facilitate communication, as well as offer chronic disease self-management support, in a way that is patient-centred and cost-effective. A model of care in which technology is used effectively also requires training, and the authors describe the training components needed to achieve effective integration of physical and mental health.

The value of integrated care is not in doubt as the articles in this issue make clear. That said, successful implementation requires significant attention to important factors such as financing, leadership, ensuring adequate and ongoing training and supervision of the workforce, and attention to patient engagement and patient-centred outcomes. In order to overcome these challenges, more evidence of effective implementation processes will be needed. Given the unique geographic, economic, workforce, and cultural factors that exist globally, tailored approaches will likely be required, with local organizations, health systems, and communities choosing what and how to implement integration based on their unique needs.

Disclosure statement

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