report of a surgeon general s working meeting on the...

REPORT OF A SURGEON GENERAL’SWORKING MEETING ON

THE INTEGRATION OF

MENTAL HEALTH SERVICES

AND PRIMARY HEALTH CAREHELD ON NOVEMBER 30 - DECEMBER 1, 2000

AT THE CARTER CENTER: ATLANTA, GEORGIA

2001U.S. Department of Health and Human ServicesPublic Health ServiceOffice of the Surgeon GeneralRockville, MD

National Library of Medicine Cataloging in PublicationSurgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care(2000 : Atlanta, Ga.)

Report of a Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care: held on November 30-December 1, 2000, at the Carter Center, Atlanta, Georgia. — Rockville, MD : U.S. Dept. ofHealth and Human Services, Public Health Services, Office of the Surgeon General ; Washington, D.C. : For sale bythe Supt. of Docs., U.S. G.P.O., 2001.

Includes bibliographical references.

1. Delivery of Health Care, Integrated / congresses. 2. Mental Health Services / congresses. 3. PrimaryHealth Care / congresses. 4. United States. I. United States. Public Health Service. Office of the SurgeonGeneral.

02NLM: W 84 AA1 S961r 2001

Suggested CitationDepartment of Health and Human Services (DHHS). Report of a Surgeon General’s working meeting on the inte-gration of mental health services and primary health care; 2000 Nov 30–Dec 1; Atlanta, Georgia. Rockville, MD:U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.

This publication is available on the World Wide Web at http://www.surgeongeneral.gov/library.

For sale by the Superintendent of Documents, U.S. Government Printing Office,Internet: www.bookstore.GPO.gov Phone: Toll Free 1 (866) 512-1800; DC area (202) 512-1800

Fax: 1 (202) 512-2250 Mail: Stop SSOP, Washington, D.C., 20402-0001

iii

This report was prepared by the Department of Health and Human Services. It is an outgrowth of Mental Health: A Report of the Surgeon General,

which was released in December 1999.

ACKNOWLEDGEMENTS

Special thanks to the leadership and staff of the Office of Public Health and Sciencefor their enthusiastic support of this interdepartmental effort.

RADM Kenneth P. Moritsugu, M.D., M.P.H., Deputy Surgeon General, USPHSNicole Lurie, M.D., M.S.P.H., Principal Deputy Assistant Secretary for Health

Beverly L. Malone, Ph.D., R.N., F.A.A.N., Deputy Assistant Secretary for Health

Coordinating EditorsIrene Stith-Coleman, Ph.D.

Ann L. Elderkin, P.A.

Science WriterMiriam Davis, Ph.D.

Planning Committee

ChairKate Godfried, J.D., M.S.P.H

MembersBernard Arons, M.D.

Elaine Baldwin, M.Ed.

Eric Goplerud, Ph.D.

Nicole Lurie, M.D., M.S.P.H.Beverly Malone, Ph.D., R.N., F.A.A.N.

Ron Manderscheid, Ph.D.

Harriet G. McCombs, Ph.D.Charlotte Mullican, B.S.W., M.P.H.

Rochelle Rollins, Ph.D.

Marc Safran, M.D., F.A.C.P.M.Frank Sullivan, Ph.D.

Bertha Williams, M.S., R.N.

Other ContributorsCamille Barry, Ph.D., R.N.

Helen Burstin, M.D., M.P.H.

Junius Gonzales, M.D.

Kevin Hennessy, Ph.D.Brenda Reiss-Brennan, M.S., A.P.R.N., C.S.

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Introduction ..............................................................................................................................................1

Brief Summary of Dr. Satcher’s Remarks ............................................................................................1

Meeting Format ........................................................................................................................................2

Meeting Highlights ....................................................................................................................................3

Recommendations Toward Core Principles ..........................................................................................6

Recommendations Toward a National Action Strategy ........................................................................6

References ..................................................................................................................................................8

Appendix ....................................................................................................................................................9

TABLE OF CONTENTS

1

Agroundbreaking meeting was held November 30 –December 1, 2000, to advance the integration of

mental health services and primary health care. Themeeting was an outgrowth of the U.S. Surgeon General’slandmark report on mental health.1

That report’s single recommendation was to encour-age people to seek help for mental illness. It found that astartling majority of adults and children with mental ill-ness do not receive any services. The report featured pri-mary care as one of the prime portals of entry into treat-ment—especially for those reluctant to access, orunaware of their need for, mental health services.Primary care was also seen as an opportune site foremphasizing wellness and prevention of mental illness.Yet few programs nationwide are expressly organized tointegrate mental health services and primary healthcare—and even fewer have been evaluated fully.

The meeting2 was designed to set a blueprint for thefuture. Its specific objectives were to forge consensusamong diverse participants on core principles and on anational action strategy for the integration of mentalhealth services and primary health care.

Participants invited to the meeting represented across-section of consumers and families, insurers andhealth care systems, researchers and other experts, clini-cians, and representatives from foundations and govern-ment (Appendix A). These groups are key to launching anew public/private approach.

This meeting report covers Surgeon General DavidSatcher’s remarks, the format of the meeting, its high-lights, and, finally, the core principles and nationalaction strategy generated and voted upon by participants.The report does not include activities that have occurredsince the Carter Center Meeting.

Brief Summary of Dr. Satcher’sRemarksThe meeting opened with an eloquent speech from Dr.David Satcher. He began by noting, in particular, thediversity of the participants including business, healthcare systems, consumers, families, and foundations, aswell as government agencies. He was particularlyimpressed with the balanced presence of primary careand mental health experts who were well established intheir fields. These experts included “real world” and“front line” people who would be key to helping solvesome of the unfortunate barriers within our currenthealth care system. He then challenged the participantsto think beyond each of their individual perspectives andconsider ways to overcome barriers between primarycare and mental health. He noted that many goldenopportunities exist for integrating mental health servicesand primary care.

He presented his thoughts regarding the highlights ofthe Millis report on the role of primary providers (Millis,1966). That report identified a number of roles for pri-mary care providers. They included providing first con-tact of care, providing comprehensive care, providingthe coordination and integration of care, and providingcommunity leadership.

Dr. Satcher acknowledged, as a family physician,both the frustrations and opportunities presented to theprimary care provider on a daily basis. As the SurgeonGeneral he pronounced the evidence in 1999 in MentalHealth: A Report of the Surgeon General and the need tocreate a system of care that not only treats illness but alsopromotes health. He named building a balanced commu-nity health system as one of his top three national prior-ities. A balanced community health system balanceshealth promotion, disease prevention, early detection,and universal access. This system concept would requirea partnership between primary care and mental healthand between public health and medicine.

Primary care offers golden opportunities as a pointof first contact with patients and their families, in whicha meaningful relationship can be established to educate

INTRODUCTION

1 U.S. Department of Health and Human Services (DHHS). Mental Health: AReport of the Surgeon General. Rockville, MD: Author, Substance Abuseand Mental Health Services Administration, Center for Mental HealthServices, National Institutes of Health, National Institute of Mental Health,1999.

2 Sponsored by the Assistant Secretary for Health/Surgeon General of DHHS.

and motivate patients, as well as to detect health condi-tions. A “balanced partnership” provides an opportunityfor the coordination and integration of patient care. Thisis actualized by involving the health team and the fami-ly and targets continuity of care, which ensures compre-hensive high-quality care.

Dr. Satcher addressed specifically the lack of time inprimary care that providers have to adequately attend tothe many responsibilities that our health care systemsrequire of them. He urged primary care providers toremember that they are not alone. In fact, he challengedthe primary care provider to be the quarterback of thehealth care team that collaboratively makes the systemwork for the patients and their families. He spoke of ournegligence of the health care system for not engaging thepotential resources available within families. Not only isfamily involvement therapeutic for the patient, but it isthe key to sustaining continuity of care and providinghigh-quality care.

He then encouraged providers to act as responsiblecommunity leaders who educate, motivate, and mobilizethe public regarding the definition of mental health asstated in Mental Health: A Report of the SurgeonGeneral. He went on to define mental health as a per-son’s ability to function and to be productive in life; toadapt to changes in his/her environment; to cope withadversity; and to develop positive relationships with oth-ers. He emphasized that without good mental health onecannot have good health and well being. Therefore theprimary care and mental health partnership is crucial foroverall balanced health.

The good news in the mental health report, he indi-cated, is that we have the ability, perhaps 80 to 90 per-cent of the time, to treat mental disorders with a range ofdifferent treatments. However, the bad news is that lessthan half who suffer each year seek treatment. And manywho make contact with the health system don’t neces-sarily make contact with the mental health systembecause they are experiencing mental illness, becausethey are unaware, or because of the stigma surroundingmental illness. Others have trouble because of barriersassociated with the health care system itself.

Dr. Satcher moved on to ask what is the vision forthe future and what is the task ahead. He then pointed outthat Mental Health: A Report of the Surgeon Generaldevoted an entire chapter to laying a vision for thefuture. He went on to identify the eight courses of actionin that chapter to include the following:

l Our work should be based on the best availablescience so that we may prevent disease and pro-mote good mental and physical health. Thus, we

must continue and enhance mental health research,especially prevention and promotion.

l We must acknowledge and find ways to overcomethe barriers of stigma.

l We need to build public awareness regarding men-tal health and effective treatments.

l We must address the serious shortage of mentalhealth providers and the lack of training availablefor many community helpers who could potential-ly impact a person’s health.

l We need to ensure the delivery of state-of-the-arttreatment which means moving front-line knowl-edge to front-line care so that primary careproviders have access to knowledge, technologyand teams of experts to support their work withtheir patients and families.

l We need to tailor treatment to age, gender, race,and culture.

l We need to facilitate entry into treatment.

l We need to remove the financial barriers that cre-ate complexity and restrictions within our healthcare system.

Dr. Satcher ended with a quote from John Gardner,Secretary of Health, Education, and Welfare in the1960s, “Life is full of golden opportunities carefully dis-guised as irresolvable problems.”

Meeting FormatThe conference agenda was structured around formalpresentations, question-and-answer sessions, and smallbreakout groups for detailed deliberation. Panel presen-tations and question-and-answer sessions furnished acommon understanding of the nature of the problem,some “real world” programs, the hurdles and opportuni-ties programs face, and findings from research.

Dr. Satcher’s speech was followed by a state-of-the-art review of practice and research findings gatheredfrom structured interviews. The structured interviewshad been conducted before the meeting by consultantand meeting organizer Brenda Reiss-Brennan, Presidentof Primary Care Family Clinics, Inc. Over 90 interviewswere completed of attendees and nonattendees from adiverse group of experts representing business, founda-tions, federal agencies, consumers and families,research, employers, economists, epidemiologists,providers, health care consultants, and payors. Ms.

The Integration of Mental Health Services and Primary Health Care

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Reiss-Brennan gave an overview of her findings aboutparticipants’ level of interest in the process of integra-tion3 and their rationale for developing systemicapproaches to promoting healthy families and communi-ties.

The interviews indicated that clinical researchknowledge appears to be directing the field toward inte-gration and economic knowledge appears to be directingthe field away from integration. In the middle of thisquality gap, being squeezed to maximum capacity, areproviders of care and their patients and families, whoattempt to negotiate major health disabilities in stressedenvironments. This current nonintegrated process of carecreates costly burdens for the health care system, thefamily, and the community.

Interviews revealed consensus among participants tobuild collaboration and commitment among stakeholdersthat result in strong leadership, mobilization of success-ful implementation strategies, and demonstration ofaffordable, evidence-based integrated care.

After plenary and panel presentations, participantswere divided into five breakout groups, covering seminalissues of design, training, economics, research, and qual-ity. The breakout groups were charged with developingideas for core principles and action steps, and then bring-ing those ideas forward for general discussion by all par-ticipants.

A reporter from each breakout group presented theirgroup’s priorities when participants reconvened in a gen-eral session. With the aid of a professional facilitator toguide the discussion and build consensus, participantsseparately voted on their top core principles and actionsteps.

Meeting Highlights

Nature of the ProblemEvery year, about 20 percent of U.S. adults and childrenhave a mental disorder. Despite an array of effectiveknown treatments, the majority of those with mental dis-orders do not receive treatment and thus needlessly suf-fer from distress and disability. Mental disorders arehighly disabling, ranking second only to cardiovascularconditions as a leading cause of worldwide disability bythe World Health Organization (Murray & Lopez, 1996).Moreover, these disorders impose substantial cost burdento patients, their families, and communities at large. Thatburden is reflected in lost productivity and premature

death and in the amount of medical and communityresources expended.

The prevalence of mental disorders in primary care issomewhat higher than that in the population. About 25percent of people receiving primary care have a diagnos-able mental disorder (Olfson et al., 1997), most com-monly anxiety and depression. Depression occurs inabout 6 to 10 percent of primary care patients (Katon &Schulberg, 1992). Older adults are particularly vulnera-ble in an unintegrated system because many of them aretreated in primary care for a variety of health conditions,and depression may go undiagnosed and untreated. Low-income minority populations face similar identificationbarriers because primary care services are often cost pro-hibitive and difficult for them to access.

Major depression is one of the more prevalent condi-tions observed in the primary care setting afflicting anestimated 5 to 9 percent of presenting patients. Suchprevalence coupled with evidence that most depressedpatients receive mental health care from primary carephysicians (Coyne et al., 1994; Reiger et al., 1993; Rostet al., 1998) has prompted much attention in the field.

Mental disorders frequently co-occur with othermental or somatic (physical) disorders. Estimates of this“comorbidity” range from about 20 to 80 percent of pri-mary care patients (Sherbourne et al., 1996; Olfson et al.,1997). Comorbidity adds to disability and contributes tomorbidity and mortality.

There are a number of barriers to effective diagnosisand treatment of mental illness in primary care.Overwhelming societal stigma is partly to blame forpatients resisting diagnosis, resisting treatment altogeth-er, or not adhering to treatment recommendations(DHHS, 1999). Primary care providers vary in theircapacity to recognize and diagnose disorders, and, if theydo so correctly, they may not adequately treat or monitorpatients. Some estimates are that about half of those withmental disorders go undiagnosed in primary care(Higgins, 1994). Finally, mental health services—ineither primary care or through referral to specialty care—are often difficult to access, fragmented, or poorlyfinanced. Thus, the integration of mental health servicesand primary health care faces broad-sweeping attitudinal,educational, organizational and financing problems.These problems stem in part from the historical separa-tion of mental health from the mainstream of medicine(DHHS, 1999).

OpportunitiesPrimary care holds a myriad of opportunities to engagepatients in need of mental health care. These opportuni-


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3 Participants spent a significant amount of time discussing integration butwere unable to reach a consensus on a definition for integration.

ties range from health promotion to disease preventionand treatment.

As a first point of patient contact with the health caresystem, primary care is often closer to home or work andmore affordable than specialty care. It offers the possi-bility of cost-effective treatment, particularly with lesssevere mental disorders. Primary care also has the poten-tial for early identification of symptoms and for coordi-nation and continuity of care for both mental and somat-ic disorders. This is highly important given the frequen-cy of comorbidity and the long-term nature of manymental disorders. Further, a focus on mental health with-in primary care underscores a message of the SurgeonGeneral’s report: Mental health is fundamental to overallhealth.

Primary care is not only where individuals receivecare; it is where family members do too. By establishingrelationships with the family, primary care providershave the advantage of tapping the family as a source ofsupport. These relationships with the family are key forchildren and older people with mental disorders.

Perhaps most importantly, primary care is wheremany consumers prefer to receive mental health services(Annexure et al., 1997). Primary care is often perceivedby consumers as less stigmatizing than the specialtymental health sector.

Most of these opportunities for integrating mentalhealth care have yet to be realized, with the exception ofone mental disorder: depression. Research and practiceon prevention, diagnosis, and treatment of depression inprimary care have been proceeding for more than adecade (Schulberg et al., 1999). A special subgroup ofmeeting participants met to explore depression as amodel for service integration.

There are many possible ways to organize and staffmental health services in primary care, for integrationdoes not exclusively rely on a single setting or type ofprofessional. Some programs described at the meetinguse a psychiatric social worker to deliver mental healthservices and to “bridge” primary care and specialty men-tal health care, with patients seen in either setting. Otherprograms use multidisciplinary teams, including mentalhealth care, to furnish care in the context of routinehealth visits and follow-up within the primary care set-ting. Regardless of the variation, a central feature ofmany programs is enhanced training of primary careproviders in the detection of mental health problems.

Obstacles and ChallengesAs is true for any new approach to health care, an arrayof obstacles stand in the way of attaining the promise of

integrated and collaborative care. The nature of the prob-lem is compelling, and the opportunities plentiful. OurNation’s health care system is a highly complex anddiverse system serving the interests of consumers, pro-fessionals and providers, hospitals, insurers, employers,and government. The rationale for integration of care,according to meeting participants, needs to be made foreach of these stakeholder groups and bolstered by empir-ical research on cost, efficacy, quality, and consumer sat-isfaction.

And beyond these traditional stakeholders are manyvulnerable populations who are uninsured and thus leftout of public or privately funded systems of care. Theobstacles and challenges described by meeting partici-pants are highlighted below.

Design

A major design challenge to the integration of mentalhealth services and primary health care is the lack ofmotivation—on the part of consumers, providers, andpayors.

l Consumers are hesitant to accept and followthrough on mental health services.

l Primary care providers are overwhelmed by limit-ed time to attend to each patient’s needs. Visits laston average 13 to 16 minutes, and patients have anaverage of six problems to address with theirprovider (Williams et al., 1999).

l Partnerships between primary care providers andmental health professionals have been stymied bydifferent cultures of care, including styles of com-munication and duration of office visits.

l Payors have limited motivation to offer integratedprograms owing to what they see as high start-upcosts, lack of consumer demand, and limited evi-dence for cost neutrality or cost offsets (in terms oflower overall health care costs, lower disabilitycosts, or improved worker productivity) (Malek,1999).

l Other major design challenges include delegationof roles and responsibilities of primary care physi-cians and other professionals (e.g., mental healthspecialists, nurses, health educators) and the needfor common integrated information technologiesfor medical records, scheduling, billing, andreporting.


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Training and Practice Guidelines

There are few training programs and practice guidelinesthat emphasize the integration of mental health servicesand primary care.

l Primary care providers generally have little formaltraining in the diagnosis and treatment of mentaldisorders and even less in promoting mental healthwellness and disease prevention.

l Primary care providers have sparse guidance aboutdecision support, i.e., what disorders (alone or incombination) and at what level of severity can betreated effectively in primary care versus beingreferred to mental health specialty care.

l There are few incentives for educational institu-tions and professional organizations to step beyondexisting training and practice programs to embraceintegrated and collaborative approaches.

l If demand for services expands, integrated pro-grams may be unable to keep apace because of aninsufficient supply of well-trained mental healthprofessionals in rural areas and many other parts ofthe country (Peterson et al., 1998).

Economics

There are many economic barriers to the creation andimplementation of integrated care.

l The funding of mental health services is generallyseparate from the funding of general medical serv-ices.

l There is lack of parity, i.e., the level of funding ofmental health services is more restrictive than andnot on an equal footing with that for general healthservices. Further, over the past decade, spendingfor mental health services has decreased as a per-centage of overall spending for health care (DHHS,1999).

l An increasing number of health plans are movingto “carved-out” mental health services, i.e., sepa-rate systems of financing, delivering, and manag-ing specialty mental health services. Carved-outmental health plans have little economic incentiveto offer, or to participate in, integrated treatmentbecause these plans cannot recoup cost offsets(reductions in overall health care utilization/costsas a result of treatment of mental disorders).

l There is little, if any, economic incentive for men-tal health and primary care providers to collaborateacross disciplinary lines and develop a teamapproach to care.

Quality

There are few explicit programs for measuring quality ofservices that integrate mental health care and primaryhealth care. One step forward has been the developmentof quality improvement programs for treating a singlemental disorder—depression—in primary care (Wells etal., 2000).

l The development and continued monitoring ofquality-improvement programs rests on a founda-tion of skills and knowledge concerning staffingand treatment of mental disorders in primary care,yet such knowledge has yet to be developedbeyond that for depression.

l Greater attention to quality improvement is likelyneeded for vulnerable populations. For example,research has found that patients at greatest risk ofhaving their mental health problems go undetectedin primary care include African Americans, men,and younger patients (Borowsky et al., 2000).

Research

With the exception of depression, research is sparse onthe development or evaluation of programs for the inte-gration of mental health services and primary care.

l Research funds are generally limited to the conductof research and thus cannot be used to sustainresearch programs found successful.

l Programs with strong efficacy based on researchare difficult to translate into the “real world” ofpractice owing to heterogeneity and diversity ofpatient populations, comorbidity, and less monitor-ing of outcomes by providers (DHHS, 1999).

l Little research has been directed to integrating pri-mary care and mental health services for peoplewith severe mental illness.

l There has been a paucity of investigator-initiatedresearch applications in this area.


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Recommendations Toward CorePrinciplesMeeting participants agreed to the following princi-ples—or fundamental elements required to facilitate thedevelopment and implementation of programs that inte-grate mental health services and primary health care.They provide a framework, not only for local programs,but also for a National initiative.

1. Emphasis on Consumers and Their Families. Theneeds of mental health consumers and their fami-lies should drive service delivery and systems ofcare. Cultural and ethnic diversity should berespected. The integration of mental health andprimary care is meant to expand access to care andis not intended to preclude availability of mentalhealth specialty care for those who need it.

2. Promoting Health and Overcoming Disparities.Promote health for all Americans and overcomedisparities in the burden of illness and death expe-rienced by African Americans, Hispanics, NativeAmericans, Alaska Natives, and Asians andPacific Islanders.

3. Basic Characteristics. Research, training, andpractice should incorporate consumer, family, andprofessional partnerships; cross-disciplinary pro-fessional collaborations; population-based healthcare; a holistic approach to health care; and respectfor, and understanding the role of, spirituality andalternative medicine/traditional healing practices.

4. Financial Incentives for Team Approach. Newtypes of financial incentives should be offered toencourage team approaches to care. The teamincludes consumers and families, primary careproviders, mental health professionals, and nurs-ing case managers. The team may also includecare management, consultation, and specialtyservices.

5. Reimbursement. Reimbursement should bedesigned to support evidence-based care.

6. Collaboration/Colocation. Integrated servicedelivery should be guided by a commitment to col-laboration or colocation of services.

7. Chronic Illness, Continuity of Care. Integratedservice delivery should feature the treatment ofchronic illness and continuity of care.

8. Standardized Quality and Outcome Measures.Quality and outcome measures should be stan-dardized across systems and levels of care andinclude consumer/family participation. The collec-tion of information should respect consumer andfamily privacy. The information should be trans-portable and longitudinal.

9. Building on Existing Models. The development ofintegrated programs should build on existingknowledge and/or models of care.

10. Research and Demonstrations. Research findingsmust be salient to key stakeholders, includingdiverse ethnic and cultural communities.Successful research and demonstration programsshould be sustainable through multifaceted part-nerships brokered by funding agencies.

11. Investment in Training. Training should build col-laborative partnerships that are grounded in clini-cal and systemic decision making of the highestquality. Quality should reflect evidence-basedknowledge that is disseminated in culturally sensi-tive ways to promote health and reduce stigma.

12. Information Technology. Information technologyshould be marshaled as a tool for communication,patient education, data collection, and access tocare. This technology should support the infra-structure needed to deliver high-quality care whileprotecting patient and family confidentiality.


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Recommendations Toward aNational Action StrategyThe core principles provided the foundation on whichparticipants were able to build consensus in developingactual strategies that would promote the bridging of pri-mary care and mental health. These strategies were pri-oritized into the following action strategy recommenda-tions. The recommendations reflect the merging of mul-tistakeholder expert opinions from the fields of practiceand research and were put forth as a guide to spawning anational action strategy to promote implementation ofevidence-based quality care. Since the Carter Centermeeting, this National Action Strategy has undergonefurther evolution.

1. Convene a group under the auspices of the DHHSto develop a framework for the integration of men-tal health care and primary care, including a focuson comorbidities, diverse modalities, and diversepopulations.

2. Incorporate a list of skills, knowledge, attitudes,and simple tools that reflects evidence-based “bestpractices” and treatment management, leading toimproved outcomes.

3. Design education and training standards for theintegration of mental health care and primaryhealth care—with all stakeholders, includingaccreditation bodies—and promote implementa-tion of those standards by schools of health andbehavioral health.

4. Evaluate whether program and policy initiatives onintegration lead to the elimination of racial and eth-nic health disparities and promote equal access tohigh-quality health care.

5. Develop a plan for research and demonstrationprojects on integration that meet basic method-ological requirements for generalizability withrespect to service delivery models and health out-comes.

5.1 Articulate a vision for success for a con-sumer-driven integrated service deliverysystem that includes the following: aware-ness of the culture of primary care, patienteducation, professional training, follow-upcare, and care management.

5.2 Bring together multiple private and publicfunding sources for projects and develop a

plan for projects—sustainability, if the proj-ects are found successful.

5.3 Convene accreditation and licensure andregulatory agencies to reduce barriers toimplementation of research and demonstra-tion projects (e.g., funding and/or regulatorywaivers).

5.4 Lead to development of initiatives that fos-ter the development of service and econom-ic models with these basic features: (a) col-laborative/integrated care among con-sumers, primary care providers, and mentalhealth specialists to meet local needs; (b)evidence-based approach to care deliverybased on scientific methods (e.g., random-ized controlled trial, quasi-experimentaldesign, case-control study, survey designs);and (c) measurement of outcomes, such asaccess, costs, functional status, quality oflife, patient/family/provider satisfaction,health beliefs/stigma, relapse reduction, sen-tinel events, recovery, and the effects of con-sumer and provider incentives on health out-comes and process measures.


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Annexure J, Katon W, Sullivan M, Miranda J. The effective-ness of treatments for depressed older adults in primarycare. Paper presented at Exploring Opportunities toAdvanced Mental Health Care for an Aging Population,sponsored by the John A. Hartford Foundation, Rockville,MD, 1997.

Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells, KB. Who is at risk of non-detection ofmental health problems in primary care? J Gen InternMed 2000;15(6):381–8.

Coyne JC, Fechner B, Ates S, Schwenk TL. Prevalence, natureand comorbidity of depressive disorders in primary care.Gen Hosp Psychiatry 1994;9(4):267–76.

Department of Health and Human Services (DHHS). MentalHealth: A Report of the Surgeon General. Rockville, MD:U.S. Department of Health and Human Services,Substance Abuse and Mental Health ServicesAdministration, Center for Mental Health Services,National Institutes of Health, National Institute of MentalHealth, 1999.

Higgins ES. A review of unrecognized mental illness in pri-mary care. Prevalence, natural history, and efforts tochange the course. Arch Fam Med 1994;3(10):908–17.

Katon W, Schulberg H. Epidemiology of depression in pri-mary care. Gen Hosp Psychiatry 1992;14(4)237–47.

Malek SP. Financial, risk and structural issues related to theintegration of behavioral health care in primary care set-tings under managed care. Research report published byMilliman & Robertson, Inc., 1999.

Millis JS. The Graduate Education of Physicians. Report ofthe Citizens’ Commission on Graduate MedicalEducation. Chicago: American Medical Association,1966.

Murray CJL, Lopez AD (Eds.). The global burden of disease.Comprehensive assessment of mortality and disabilityfrom diseases, injuries, and risk factors in 1990 and pro-jected to 2020. Cambridge, MA: Harvard School ofPublic Health, 1996.

Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV,Kathol RG, Hoven C, Farber L. Mental disorders and dis-ability among patients in a primary care group practice.Am J Psychiatry 1997;154(12):1734–40.

Peterson B, West J, Tanielian T, Pincus H. Mental health prac-titioners and trainees. In RW Manderscheid, MJHenderson (Eds.), Mental Health United States 1998 (pp.14–246). Rockville, MD: U.S. Department of Health andHuman Services, Center for Mental Health Services.

Reiger DA, Narrow WE, Rae DS, Manderscheid RW, LockeBZ, Goodwin FK. The de facto US mental and addictivedisorder system: Epidemiologic Catchment Area prospec-tive 1-year prevalence rates of disorders and services.Arch Gen Psychiatry 1993;50(2):85–94.

Rost KM, Zhang M, Fortney J, et.al. Persistently poor out-comes of undetected major depression in primary care.Gen Hosp Psychiatry 1998;20(1):12–20.

Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinicalpractice: guidelines for managing major depression in pri-mary medical care. J Clin Psychiatry 1999;60(Suppl7):19–26.

Sherbourne CD, Jackson, CA, Meredith LS, Camp P., WellsKB. Prevalence of co-morbid anxiety disorders in primarycare outpatients. Arch Fam Med 1996;5(1):27–34.

Wells KB, Sherbourne C, Schoenbaum M, Duan N, MeredithL, Annexure J, Miranda J, Carney MF, Rubenstein LV.Impact of disseminating quality improvement programsfor depression in managed primary care: a randomizedcontrolled trial. JAMA 2000;283(2):212–20.

Williams JW, Ross K, Dietrich AJ, Ciotti MC, Zyzanski SJ,Cornell J. Primary care physicians’ approach to depres-sive disorders: effects of physician specialty and practicestructure. Arch of Fam Med 1999;8(1):58–67.

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REFERENCES

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APPENDIX

Participants

A Surgeon General’s Working Meetingon The Integration of Mental HealthServices and Primary Health Care, Heldon November 30 — December 1, 2000

Business / Health Care Systems

Kris ApgarDirectorWashington Business Group on Health 50 F Street, N.W.Suite 600Washington, DC 20001-1566

Ron I. Dozoretz, M.D.Chairman and Chief Executive OfficerValue Options8614 Westwood Center Drive, Suite 200Vienna, VA 22182-2233

Saul Feldman, M.D., Ph.D. Chairman & Chief Executive OfficerUnited Behavioral Health425 Market Street, 27th FloorSan Francisco, CA, 94105-2426

Gary Gottlieb, M.D., M.B.A.ChairmanPartners Psychiatry and Mental Health SystemProfessor of PsychiatryHarvard Medical Schoolc/o Massachusetts General HospitalBulfinch Building, Suite 370E55 Fruit StreetBoston, MA 02114-2696

Suzanne Paranjpe, Ph.D.Senior Vice PresidentGreater Detroit Area Health CouncilHealth Information Action Group333 West Fort Street, Suite 1500Detroit, MI 48226-3156

Dennis E. Richling, M.D.Union Pacific1416 Dodge, Room 908Omaha, NE 68179

Tara Wooldridge , L.C.S.W. ManagerEmployee Assistance ProgramDelta Airlines1050 Delta BoulevardAtlanta, GA 30320-1989

Consumer / Patient / Family

Moe Armstrong, M.B.A., M.A.P.O. Box 390812Cambridge, MA 02139-0009

Don DavesPresidentBoard of Directors for NAMI GeorgiaAn Affiliate of the National Alliance for the Mentally Ill3125 Presidential ParkwaySuite 335Atlanta, GA 30340-3700

Carolyn Nava Federation of Families for Children’s Mental Health1101 King Street, Suite 420Alexandria, VA 22314-2944

Delilah J. Ramirez1150 Syracuse StreetBuilding # 8Apartment # 141Denver, CO 80220-3242

Experts

Elise Berryhill, Ph.D.Muscogee (Creek) Nation Behavioral Health Services100 West 7th StreetOkmulgee, OK 74447-5007

Virginia Trotter Betts, R.N., J.D., M.S.N.,F.A.A.N.

Associate Director for Health Policy InitiativeUniversity of TennesseeCenter for Health Services Research66 North Pauline, Suite 463Memphis, TN 38163

Homer L. Chin, M.D.500 Northeast Multnomah StreetSuite 100Portland, OR 97232-2022

Allen Dietrich, M.D.ChairMacArthur Foundation Initiative on Depression andPrimary CareDartmouth Medical SchoolNorth College StreetHanover, NH 03755

Lynn Elinson, Ph.D.Deputy DirectorNational Program on Depression and Primary CareUniversity of Pittsburgh, School of MedicineWestern Psychiatric Institute and Clinic3811 Ohara Street, Room 417Pittsburgh, PA 15213-2597

Richard Frank, Ph.D.ProfessorDepartment of Health Care PolicyHarvard University180 Longwood AvenueBoston, MA 02115-5821

Greg Fricchione, M.D.DirectorThe Carter Center Mental Health Program Associate Professor of PsychiatryHarvard Medical SchoolOne Copenhill453 Freedom ParkwayAtlanta, Georgia 30307-1496

Pablo Hernandez, M.D.AdministratorWyoming State Commission for Mental HealthDivision of Behavioral HealthP.O. Box 177Evanston, WY 82931

Dennis Hulet, A.A.A.Principal and Healthcare Management ConsultantMilliman and Roberts1301 5th AvenueSuite 3800Seattle, WA 98101-2646

Brent James, M.D., M.Stat.Vice President for Medical ResearchIntermountain Health Care36 South State StreetSalt Lake City, Utah 84111-1486

Wayne KatonDepartment of Psychiatry and Behavioral SciencesBox 356560University of Washington1959 NE Pacific StreetSeattle, WA 98195-6560

Donald R. Lipsitt, M.D.Clinical Professor of PsychiatryHarvard Medical SchoolMedical DirectorInstitute for Behavioral Science in Health Care15 Griggs RoadBrookline, MA 02446-4701

Anthony Radcliffe, M.D.Director of Addiction MedicineKaiser Permanente Southern California740 Buckingham DriveRedlands, CA 92374-6421

Bruce Rollman, M.D., M.P.H.Assistant ProfessorMedicine, Psychiatry, and Health ServicesAdministrationUniversity of Pittsburgh, School of MedicineSuite E8202000 Lothrop StreetPittsburgh, PA 15213-2582

Lisa V. Rubenstein, M.D., M.S.P.H.Professor in ResidenceUniversity of California at Los Angeles and theVeterans’ AdministrationGreater Los Angeles Health Care SystemDirectorVeterans’ Administration Health Services Researchand Development Center of Excellence for the Studyof Health Care Provider BehaviorSenior Natural ScientistRand1700 Main StreetSanta Monica, CA 90401-3208


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Dawn Swaby-Ellis, M.D.Assistant Professor of PediatricsNorth DeKalb Health Center3807 Clairmont RoadChamblee, GA 30341-4911

Michael Von Korff, Sc.D.Center for Health StudiesGroup Health Cooperative1730 Minor AvenueSuite 1600Seattle, WA 98101

“Real World” Programs

David N. Broadbent, M.D., M.P.H.Rochester Primary Care NW259 Monroe AvenueRochester, New York 10032-3632

Wayne Cannon, M.D.Intermountain Health Care36 South State StreetSalt Lake City, Utah 84111-1486

Henry Chung, M.D.Medical DirectorDepression /Anxiety Disease Management TeamPfizer, Inc.235 East 42nd Street235/10/20New York, NY 10017-5755

J. Sloan Manning, M.D.Family Medicine1127 Union AvenueMemphis, TN 38104-6646

Linda Weinreb, M.D.DirectorHomeless Families ProgramThe Family Health CenterDepartment of Family Medicine and Community HealthUniversity of Massachusetts Medical School55 Lake Avenue NorthWorcester, MA 01655

Facilitators

Brenda Reiss-Brennan, M.S., A.P.R.N., C.S.PresidentPrimary Care Family Therapy Clinics, Inc.3570 West 9000 SouthSuite 120West Jordan, UT 84088-8874

Miriam Davis, Ph.DMedical Writer and Consultant13420 Montvale DriveSilver Spring, MD 20904-1232

Steven GrossmanSenior Managing DirectorHill and Knowlton600 New Hampshire Avenue, N.W.Suite 601 Washington, DC 20037-2413

Core Group

Bernard Arons, M.D.DirectorCenter for Mental Health Services5600 Fishers Lane, Room 17–99Rockville, MD 20857

Elaine Baldwin, M.Ed.DirectorConstituency Outreach and Education ProgramsOffice of Communications and Public LiaisonNational Institute of Mental HealthNational Institutes of Health31 Center Drive, Room 4A52Bethesda, MD 20892-2475

Eric Goplerud, Ph.D.Associate Administrator for Managed CareSubstance Abuse and Mental Health ServicesAdministrationParklawn Building, Room 10–99Rockville, MD 20857

Kate Gottfried, J.D., M.S.P.HSenior Health Policy AdvisorOffice of Public Health and ScienceOffice of Disease Prevention and Health PromotionDepartment of Health and Human Services200 Independence Avenue, S.E., Room 738GWashington, DC 20201


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Nicole Lurie, M.D., M.S.P.H.(Then) Principal Deputy Assistant Secretary forHealthDepartment of Health and Human Services200 Independence Avenue, S.E., Room 716GWashington, DC 20201

Beverly Malone, Ph.D., R.N., F.A.A.N.(Then) Deputy Assistant Secretary for HealthDepartment of Health and Human Services200 Independence Avenue, S.E., Room 716GWashington, DC 20201

Ron Manderscheid, Ph.D.Substance Abuse and Mental Health ServicesAdministrationCenter for Mental Health Services5600 Fishers Lane, Room 15C–04Rockville, MD 20857

Harriet G. McCombs, Ph.D.Health Resources and Services AdministrationBureau of Primary Health Care4350 East-West Highway, 11th FloorBethesda, MD 20814

Charlotte Mullican, B.S.W., M.P.H.Department of Health and Human ServicesAgency for Healthcare Research and QualityBuilding 6010, Room 300Rockville, MD 20852

Rochelle Rollins, Ph.D.Office of the DirectorBureau of Primary Health CareHealth Resources Services Administration, 11th Floor4350 East-West HighwayBethesda, MD 20814

Marc A. Safran, M.D., F.A.C.P.M.Chief Medical Officer and Psychiatrist Diabetes Program Branch ChairMental Health Work GroupCenters for Disease Control and Prevention4770 Buford Highway (Mail Stop K–10)Atlanta, GA 30341

VADM David Satcher, M.D., Ph.D.Surgeon General(Then) Assistant Secretary for Health and SurgeonGeneralDepartment of Health and Human Services200 Independence Avenue, S.E., Room 716GWashington, DC 20201

Frank Sullivan, Ph.D.Department of Health and Human ServicesThe Health Care Financing Administration7500 Security BlvdMail Stop C4–25–15Baltimore, MD 21244-1850

Foundations

Andrea Gerstenberger, Sc.D.Senior Program OfficerCalifornia Health Care Foundation476 Ninth StreetOakland, CA 94607-4048

Peter PeccoraCasey Family Programs1300 Dexter Avenue North, Suite 300Seattle, WA 98109-3542

Constance M. Pechura, Ph.D.Robert Wood Johnson FoundationP.O. Box 2316Route 1 and College Road EastPrinceton, NJ 08543-2316

Observers

Irene Stith-Coleman, Ph.D.Public Health AdvisorDepartment of Health and Human Services200 Independence Avenue, S.E., Room 701HWashington, DC 20201

Pat Cunningham, F.N.P.Family Medicine1127 Union AvenueMemphis, TN 38104-6646

Karen DaleVice President / Product DevelopmentLifescape, LLC8614 Westwood Center DriveSuite 200Vienna VA 22182-2233

Linda Gask, M.D.MacColl Institute for HealthCare Innovation1730 Minor Avenue, Suite 1290Seattle, WA 98101-1448


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John M. HillPresidentValueOptions3110 Fairview Park DriveFalls Church, VA 22042

Shelley Jackson, J.D.Senior Civil Rights AnalystDepartment of Health and Human ServicesOffice of Civil Rights200 Independence Avenue, S.W., Room 574E Washington, DC 20201

Maria Llorente, M.D.Associate Professor and ChiefDivision of Geriatric Psychiatry, Department ofPsychiatry and Behavioral SciencesUniversity of Miami School of Medicine and MiamiVeterans’ Administration Medical Center1201 N.W. 16th Street, #116AMiami, FL 33125-1693

Sue MartonePublic Health AnalystHealth Resources and Services AdministrationDepartment of Health & Human Services5600 Fishers LaneRockville, MD 20857

Darlene Marion Meador, Ph.D.DirectorProgram and Policy Development Section Division of Mental Health, Mental Retardation andSubstance Abuse Georgia Department of Human Resources2 Peachtree Street, N.W.Suite 23–410Atlanta, GA 30303-3171

David Mosen, Ph.D.Outcomes Analyst/Research AssociateInstitute for Health Care Delivery ResearchIntermountain Health Care36 South State Street, 16th FloorSalt Lake City, UT 84111-1633

Joanne Nicholson, Ph.D. Associate ProfessorDepartment of Psychiatry, andAssociate DirectorCenter for Mental Health Services ResearchHomeless Families ProgramThe Family Health CenterDepartment of Family Medicine and CommunityHealthUniversity of Massachusetts Medical School55 Lake Avenue NorthWorcester, MA 01655-0242

CAPT Tina Russ, Ph.D.Health Psychology ConsultantUSAFOffice for Prevention and Health Services AssessmentAFMOA/SGZZ 2602 Doolittle Road, Building 804Brooks Air Force Base, TX 78235-5249

Pat Salomon, M.D.DirectorOffice of Early ChildhoodSubstance Abuse and Mental Health ServicesAdministration5600 Fishers LaneRockville, MD 20857

Bertha N. Williams, MS, RNPresidential Management InternOffice of Public Health and ScienceDepartment of Health and Human Services200 Independence Avenue, S.E., Room 714BWashington, DC 20201


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