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Nearly every major policy statement on mental health in the last decade, ranging from the Surgeon General?s Report to the President?s New Freedom Commission on Mental Health, has begun with the tenet that mental health is central to overall health and more recent reports have added a corollary-physical health is central to mental health. Improving the treatment of mental and substance use disorders in primary care settings and improving the medical care of people with serious mental health (MH) and substance use (SU) disorders served in behavioral health (BH) settings has been a growing area of focus over the last decade. The goal of achieving quality of services and outcomes on both sides of the primary care/behavioral health interface is gaining long overdue attention and emphasis. This paper seeks to review the history, structure, and current developments of care at the primary care/behavioral health interface. It focuses on care in the public sector, where high rates of comorbidity, regulatory burdens, and lack of resources create particular challenges in providing care at that interface. There are two sides to the primary care/behavioral health interface-the first is the presence of people in primary care that need MH/SU services. By 2003, 54% of people with mental health issues were served in the general medical only sector rather than within or in combination with the specialty mental health sector. Mood disorders are the seventh most costly health conditions in the United States, but rank second in the most disabling health conditions, reflecting both a high burden and potential under-funding of those conditions in the United States.1 Many initiatives have focused on treating depression because of the broad scope of the problem (more than 19 million Americans each year), the degree to which it has been under-recognized and under-treated in primary care settings, and the growing understanding of the impact of depression on other chronic health conditions. The other side of the interface is the issue of primary healthcare for people served in specialty mental health settings. Recent reports demonstrate that people with serious mental illness die, on average, 25 years earlier than their age cohorts in the general population. This is a serious public health problem for the people served by public mental health systems. 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases.2 Many of the risk factors for these "natural causes" of chronic disease/death, such as smoking, obesity, and inadequate medical care, are modifiable. We know the successful models of care for addressing MH/SU issues in primary care and have promising models for addressing the healthcare needs of people with serious mental illness. We know that providing stepped care according to specific program models will result in improved outcomes for those served. We know that both public and private policy and financing mechanisms function as barriers to implementing what is known clinically. Improving care at the primary care/behavioral health interface will require that the MH/SU and medical systems of care begin to more fully embody the tenets noted above and create a health system that is person-centered. Moving from today?s fragmented, disease-focused system to this sort of person-centered system will require work by multiple stakeholders in these systems and, as with any collaborative endeavor, some degree of sacrifice and loss of control. However, moving towards a more collaborative system of care will ultimately yield gains to consumers, communities, and society that far outweigh these sacrifices. Linda Rosenberg leads the National Council for Community Behavioral Healthcare in treating children, adults and families with mental illnesses and addiction disorders across the country. She holds faculty appointments at several schools of social work. http://www.thenationalcouncil.org/
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mental health, substance use, Surgeon General, public mental health,
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