Behavioral health primary care integration
Integrating behavioral health into primary care practice brings mental health and/or substance abuse screenings and treatments into a primary care setting. These efforts can include coordination between primary care providers, case managers or behavioral health consultants, and mental health specialists (e.g., psychiatrists), and often require training and redefinition or realignment of staff roles1, 2. Telehealth tools such as electronic health records (EHRs), text messaging, mobile applications (apps), and online therapies may be used to support integration3. Mental health conditions and substance abuse issues often occur with other chronic medical conditions; patients with severe conditions are referred to specialty care1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved mental health
Increased adherence to treatment
Improved quality of life
Increased patient engagement
Increased patient satisfaction
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced drug and alcohol use
What does the research say about effectiveness?
There is strong evidence that integrating behavioral health into primary care practice improves mental health4, 5, 6, 7, especially depression symptoms2, 6, 8, 9. Integrating care also increases patients’ adherence to treatment10, 11, improves their quality of life11, and increases patient satisfaction6, 10 and engagement with health care providers12.
Integrating depression screening and treatment into primary care has been shown to improve depression symptoms for adolescent, adult, and elderly patients2, 13. Such care appears effective in various settings, including practices with limited resources and practices in rural and urban areas2, 14, 15. Integrated care improves youth mental health outcomes, including depression and substance use, more than usual care4. Integrated care in pediatric practices increases initiation and completion of treatment, improves behavior problems, and reduces hyperactivity and parental stress10. Experts suggest that increasing incentives to integrate primary care and behavioral health care may improve children’s health4.
Collaborative care approaches that use case managers to organize and integrate behavioral and primary care improve response to treatment, increase remission and recovery from symptoms, and increase satisfaction with care among patients with depression in the short- and long-term2, 9. Coordination which includes regular and planned psychiatrist supervision of case managers has been shown to be more effective than efforts with unplanned supervision9. Collaboration and communication between medical and behavioral health providers has also been shown to increase success and sustainability of integration efforts16.
Integrated care has been shown to reduce depression and anxiety for veterans with heart failure and chronic obstructive pulmonary disease (COPD), and can improve health-related quality of life for veterans with COPD in the short-term5. For patients suffering from chronic pain and substance abuse disorders in addition to depression, multiple interventions in primary care settings (e.g., motivational interviewing and cognitive behavioral therapy) may improve mental health and reduce drug and alcohol use more effectively than a single intervention17.
Universal mental health screening during pediatric appointments can increase parent, youth, and primary care provider willingness to discuss mental health concerns. Framing screening as universal, confidential, and designed to improve communication may further support patient and family engagement12. A Bronx-based study of a pediatric behavioral health integration program suggests programs that use pediatric psychologists and psychiatrists to integrate care can increase referral rates to pediatric mental health practitioners and increase primary care provider comfort managing school-age and adolescent attention deficit hyperactivity disorder-related behaviors (ADHD) more than clinics that use social workers to integrate behavioral health18. Experts suggest that psychologists who integrate behavioral health into pediatric primary care use principles of culturally adapted care to meet the needs of racial and ethnic minority youth19.
Tailoring behavioral health integration to address the needs of specific populations has the potential to encourage adoption in particular settings (e.g. schools, workplace, home-based care)20. Behavioral health integration in specialties like gynecology can help patients cope with complex health challenges such as pain management21.
Economic studies indicate that integrating behavioral health and primary care to treat depression is associated with greater costs and better health outcomes than traditional care models. Overall, studies have shown integrated care to be cost effective in terms of quality adjusted life years (QALYs) saved2. Integrated care may reduce costs and medical utilization in rural areas22.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by intervention design.
Behavioral health primary care integration has the potential to decrease disparities in mental health outcomes if they are culturally adapted and designed to reach groups that experience worse mental health outcomes. Experts suggest that culturally adapted care implemented by primary care psychologists may better meet the needs of racial and ethnic minority youth, but further research is needed to confirm these effects19. Some experts suggest that integrating behavioral health care into primary care may reduce stigma and cultural barriers faced by underserved racial and ethnic minority populations27.
What is the relevant historical background?
Mental health conditions and neurodiversity have long been stigmatized by society, seen as a source of shame for both the individuals who suffer from it and their families28. Mental illness was typically viewed as a moral or spiritual failing29; people with mental health conditions were regarded as a burden and ignored or minimized at best. Individuals with more severe issues were locked in asylums and kept from greater society, where treatments were often brutal, and almost always ineffective30. The system could also be exploited, and those who stepped outside the bounds of society could be subjected to cruelty and incarceration in asylums, and later institutions31.
While society’s understanding of and treatments for mental health have evolved over time, stigma around mental health conditions remains common in many communities28. Stigma against mental health and substance use disorders, as well as distrust of the mental health care system, may prevent those who need help from seeking care, even if it is covered by their insurance32, 33. Barriers in access to care for mental illness are a problem worldwide, and estimates for the U.S. suggest that less than half of individuals with mental illness receive treatment34. In western cultures, including the U.S., there are often assumptions about individuals with mental health conditions, such as the mistaken belief that they are unpredictable or dangerous, contributing to discrimination and social exclusion28, and reducing options for work, education, housing, and social connections35.
Integrated behavioral health care was introduced in the U.S. in the 1970s through two federally qualified health centers (FQHCs) that expanded their services to include behavioral health care36. This area of care continues to advance as support and knowledge around behavioral health and its implications on physical health are better understood. The 2010 Affordable Care Act (ACA) emphasized integrated care, which has strengthened support for integrated care through policy solutions, education and training, and more36. Currently, there are around 23,000 primary care practices that integrate behavioral health clinicians in the U.S.37.
Equity Considerations
- Do the health systems in your community integrate behavioral health into primary care settings? Do they include specific tailoring and culturally adapted care to reach specific populations within your community that lack access to behavioral health care?
- Are there partnerships that can lead to or strengthen behavioral health primary care integration efforts in your community?
- How can you reduce stigma around behavioral health topics? What cultural barriers are prominent in your community regarding behavioral health and mental health?
Implementation Examples
The Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral Health and Primary Care (AHRQ Academy) includes resources, research, and tools to support integrated care23. The Substance Abuse and Mental Health Services Administration (SAMHSA) includes numerous resources from federal agencies and national organizations on integrating behavioral health and primary care24. The Primary Care Team LEAP is another example of an organization that offers guidance on how to integrate behavioral health into primary care through co-location or collaborative agreements25.
There are several models to integrate behavioral health into primary care practice. The AIMS Center at the University of Washington, for example, uses a Collaborative Care model based on five core principles: patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care26.
Implementation Resources
‡ Resources with a focus on equity.
AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care.
AIMS-Collaborative care - University of Washington. Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS).
SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrated models for behavioral health and primary care.
WIPHL - Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL).
PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF).
SNMHI-BHI - Safety Net Medical Home Initiative (SNMHI). Organized, evidence-based care: Behavioral health integration (BHI). Sponsored by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute.
SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources.
Footnotes
* Journal subscription may be required for access.
1 SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrated models for behavioral health and primary care.
2 CG-Mental health - The Guide to Community Preventive Services (The Community Guide). Mental health.
3 Raney 2017 - Raney L, Bergman D, Torous J, Hasselberg M. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Current Psychiatry Reports. 2017;19:86.
4 Asarnow 2015 - Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics. 2015;169(10):929-937.
5 Cully 2017 - Cully JA, Stanley MA, Petersen NJ, et al. Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: A pragmatic randomized clinical trial. Journal of General Internal Medicine. 2017;32(9):1014-1024.
6 ICER-Tice 2015 - Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. Institute for Clinical and Economic Review (ICER); 2015.
7 Cochrane-Bower 2011 - Bower P, Knowles S, Coventry, PA, Rowland N. Counselling for mental health and psychosocial problems in primary care: Review. Cochrane Database of Systematic Reviews. 2011;(9):CD001025.
8 Butler 2011 - Butler M, Kane RL, McAlpine D, et al. Does integrated care improve treatment for depression: A systematic review. The Journal of Ambulatory Care Management. 2011;34(2):11-25.
9 Gilbody 2006a - Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine. 2006;166(21):2314-21.
10 Kolko 2014 - Kolko DJ, Campo J, Kilbourne AM, et al. Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics. 2014;133(4):e981-e992.
11 CG-Thota 2012 - Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: A Community Guide systematic review and meta-analysis. American Journal of Preventive Medicine. 2012;42(5):525-538.
12 Wissow 2013 - Wissow LS, Brown J, Fothergill KE, et al. Universal mental health screening in pediatric primary care: A systematic review. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(11):1134-1147.e23.
13 AHRQ-Butler 2008 - Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville: Agency of Healthcare Research and Quality (AHRQ); 2008.
14 Berger-Jenkins 2012 - Berger-Jenkins E, McCord M, Gallagher T, Olfson M. Effect of routine mental health screening in a low-resource pediatric primary care population. Clinical Pediatrics. 2012;51(4):359-65.
15 Serrano 2011 - Serrano N, Monden K. The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ. 2011;110(3):113-119.
16 Muse 2017 - Muse AR, Lamson AL, Didericksen KW, Hodgson JL. A systematic review of evaluation research in integrated behavioral health care: Operational and financial characteristics. Families, Systems, & Health. 2017;35(2):136-154.
17 Haibach 2014 - Haibach JP, Beehler GP, Dollar KM, Finnell DS. Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care. Medical Care. 2014;52(4):322-27.
18 German 2017 - Germán M, Rinke ML, Gurney BA, et al. Comparing two models of integrated behavioral health programs in pediatric primary care. Child and Adolescent Psychiatric Clinics of North America. 2017;26(4):815-828.
19 Arora 2017 - Arora PG, Godoy L, Hodgkinson S. Serving the underserved: Cultural considerations in behavioral health integration in pediatric primary care. Professional Psychology: Research and Practice. 2017;48(3):139-148.
20 Ramanuj 2019 - Ramanuj, P., Ferenchik, E., Docherty, M., Spaeth-Rublee, B., & Pincus, H. A. (2019). Evolving models of integrated behavioral health and primary care. Current Psychiatry Reports, 21(1), 4.
21 Witzeman 2024 - Witzeman, K. A., Lieberman, A., Beckman, E. J., Ross, K. V., & Coons, H. L. (2024). Integrated care for persons with persistent gynecologic conditions. Clinical Obstetrics & Gynecology, 67(1), 247–261.
22 Peterson 2017 - Peterson M, Turgesen J, Fisk L, McCarthy S. Integrated care in rural health: Seeking sustainability. Families, Systems, & Health. 2017;35(2):167-173.
23 AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care.
24 SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources.
25 PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF).
26 AIMS-Collaborative care - University of Washington. Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS).
27 OLoughlin 2019 - O’Loughlin, K., Donovan, E. K., Radcliff, Z., Ryan, M., & Rybarczyk, B. (2019). Using integrated behavioral healthcare to address behavioral health disparities in underserved populations. Translational Issues in Psychological Science, 5(4), 374–389.
28 Ahad 2023 - Ahad, A. A., Sanchez-Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), e39549
29 NLM-Psychiatric timeline - National Library of Medicine (NLM). Timeline of early psychiatric hospitals & asylums. Early American psychiatry: Diseases of the mind. National Institutes of Health.
30 PBS American Experience-Mental illness - American Experience. A brilliant madness timeline: Treatments for mental illness. PBS Wisconsin.
31 CSP-Mental illness - Concordia University St. Paul (CSP). (2020, July 13). A history of mental illness treatment: Obsolete practices.
32 Heboyan 2021 - Heboyan, V., Douglas, M. D., McGregor, B., & Benevides, T. W. (2021). Impact of mental health insurance legislation on mental health treatment in a longitudinal sample of adolescents. Medical Care, 59(10), 939–946.
33 Carlo 2020 - Carlo, A. D., Barnett, B. S., & Frank, R. G. (2020). Behavioral health parity efforts in the U.S. JAMA, 324(5), 447.
34 Sugarman 2023 - Sugarman DE, Busch AB. Telemental health for clinical assessment and treatment. BMJ. 2023;380:e072398.
35 APA-Stigma - American Psychiatric Association. (2024). Stigma, prejudice and discrimination against people with mental illness.
36 Manderscheid 2024 - Manderscheid, R. W., & Ward, A. (2024). Looking toward the future of integrated care: History, developments, and opportunities. The Journal of Behavioral Health Services & Research, 51(4), 609–617.
37 RGC-State of integrated primary care - Westfall, J. M., Jabbarpour, Y., Jetty, A., Kuwahara, R., Olaisen, H., Byun, H., Kamerow, D., Guerriero, M., McGehee, T., Carrozza, M., Topmiller, M., Grandmont, J., & Rankin, J. (2022). The state of integrated primary care and behavioral health in the United States 2022. Robert Graham Center.
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