Mind and body: We can’t treat primary care and mental health as disconnected systems

In 1954, Dr. Brock Chisholm, the first director-general of the World Health Organization, declared, “There is no health without mental health.” While we have certainly made great strides in behavioral care in the seven decades since Dr. Chisholm’s statement, it often seems as though we have not yet taken his words to heart. Mental health and physical health remain distinctly siloed, with little limited interaction between those treating the mind and those treating the body. 

This fragmented approach is adversely affecting patient well-being. Indeed, people with chronic illnesses are more likely to experience depression, while people with depression are also more likely to develop chronic illnesses. For instance, we know that people with diabetes are up to three times more likely to have anxiety or depression, and yet just one-quarter of diabetes patients with depression are ever diagnosed or receive treatment for their mental health conditions. 

Research also shows that people with mental health conditions are less likely to seek medical care. There is a need to more tightly align primary care and mental health services within our health care system. 

That alignment begins with how we train medical and behavioral health students. There is a strong need for more interprofessional education and practice (IPE). 

Our current approach has helped fears around mental health stigma continue to flourish. One study found that three-quarters of people with mental illness feel as though stigma has not improved over the past decade. 

About 80 percent reported that their fear of being stigmatized or discriminated against prevented them from living their best lives, including seeking help for their mental health. Patients are worried that if they disclose their mental health concerns to doctors, they will not have their symptoms taken seriously when they are seeking care for non-mental health concerns. 

Unfortunately, those fears are not unfounded. People with histories of mental illness do report receiving worse care for their physical health problems, thanks in large part to a phenomenon known as diagnostic overshadowing, in which medical professionals mistakenly attribute physical symptoms to a patient’s mental illness.

Beyond combating stigma, improving the integration of behavioral care and primary care can also help greatly expand access to mental health services. As a recent report from the Brookings Institution notes, specialty behavioral health providers remain uncommon in low-income neighborhoods, communities of color, and rural areas in the United States. 

Conversely, there are about 230,000 primary care practices in locations across the country. At the urging of the U.S. Preventive Services Task Force (USPSTF), a growing number of primary care physicians have begun screening for depression and anxiety through the use of a simple questionnaire. 

“There are a lot of patients who come to primary care who may be experiencing symptoms but don’t bring them up,” Michael Silverstein, vice chair of the task force, told the Washington Post. “So it’s about finding people and alleviating that burden earlier rather than waiting for them to come to their doctors with signs or symptoms.”

Screening represents a critical first step, but other efforts are now going even further. This month, a bipartisan group of lawmakers introduced legislation to improve mental health care for seniors on Medicare by integrating behavioral health services into their primary care. Community Health Systems, the largest provider of general hospital health care services, recently announced it was rolling out tools for offering virtual mental health services at its 700 affiliated primary care providers. 

M Health Fairview, a partnership between the University of Minnesota and Fairview Health Services, now co-locates mental health and primary care practitioners within the same office, removing a significant barrier to finding behavioral care. If a doctor identifies a patient who is struggling with their mental health, they can simply walk the patient down the hallway and introduce them to their colleague. In this case, those colleagues are master’s and doctorate-level mental health clinicians. It’s helping to plug gaps in care while training the next generation of behavioral health experts to think of the link between mental health and primary care as second nature. 

At the John F. Kennedy School of Psychology and Social Sciences, where I serve as dean, students receive experiential training in primary care settings, ensuring they graduate as well-rounded health professionals with an acute understanding of how behavioral and physical health must be approached in tandem. 

Our students who chose our Integrated Healthcare concentration have the opportunity to receive coursework on the theoretical and research aspects of integrated healthcare and then they receive practical training at their practicum and externship sites where they are able to apply the theoretical constructs. 

One of the most unique features of our students’ training is a course in health sciences where they are taught the core principles of interprofessional education and practice with nursing, physical therapy, physician assistant, podiatric medicine, and social work students. This allows them to gain a greater appreciation of how other health care professional approach the treatment of patients and how behavioral health and physical health can be integrated to provide a more comprehensive and, in many cases, a more cost-efficient approach to treating patients and most importantly, lead to a better clinical outcome for patients. 

Colleges can help improve this connection by providing students with practicum, internship opportunities and program concentrations that integrate these two closely-linked disciplines.

Better integrating behavioral and physical health care can help to improve patient outcomes, decrease health care costs, and dismantle the pervasive stigma surrounding mental health. And slowly, but surely, our system of health care education is finding ways to ensure that mental health is treated as an indispensable component of human health that it truly is.

Alvin McLean, PhD, is dean of the JFK School of Psychology and Social Sciences at National University.

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