At the time of this writing, the population of the United States is 313.9 million. Remarkably, around 30% of these Americans have a diagnosable psychiatric disorder at a given point in time (Kessler, Berglund, et al., 2005). Around 50% will experience a diagnosable disorder at some point in life (Kessler, Demler, et al., 2005). Reflect for a moment on this point—That is a lot of people! So what happens to all of these people? Figure 1.1 offers some clues.

As shown in Figure 1.1, only about 20% of those with a diagnosable problem receive care from a specialty MH or substance abuse clinic, while 21% are treated in PC. The majority, around 59%, receive no care at all (Wang et al., 2005). These basic statistics upend the notion many have about where and how MH problems are treated in this country. Most people with problems seek no care, and many who do seek care simply go to the family doctor; few will ever see a therapist’s couch.

Primary care providers see the full spectrum of psychiatric disorders, from depression to substance abuse to psychosis. They prescribe around 60% of psychotropic medications (Mark, Levit & Buck, 2009; Mojtabai, 2008). They regularly handle chronic psychiatric problems as well as acute flare-ups (e.g., a suicidal patient). Because they provide care across the life span, PCPs also treat child behavior problems (e.g., ADHD) in addition to the problems of adults and older adults. Of course, they must do all of this while also tending to the medical needs of their patients. A PCP must truly be a generalist! For all of these reasons, PC has earned the label of the country’s “de facto mental healthcare system” (Regier et al., 1993).

Thus, one reason to integrate MH services into PC is to help meet the demand for care there. Another reason lies with the 59% of people who seek no care. An interesting point is that approximately 80% of adult Americans will visit PC in the course of a year (National Center for Health Statistics 2012b). Among American children, the number is about 93% (National Center for Health Statistics 2012c). Thus, many if not most of these undiagnosed people will most certainly enter the PC system. They might only seek help for a sore throat or a work physical, rather than for psychiatric or substance abuse problems. However, the point is that they do enter PC.

Most of the time, these patients pass in and out of the clinic without the psychiatric problem being detected. For example, patients with alcohol dependence receive appropriate assessment and referral in PC only about 10% of the time (McGlynn et al., 2003), and depression goes undetected 30–50% of the time (Simon, Von Korff & Barlow, 1995). However, a PC clinic with good screening protocols, behaviorally savvy clinicians, and a robust behavioral health staff might be able to detect and treat problems that may otherwise go unnoticed. Thus, a second reason to integrate is to increase a clinic’s ability to identify and provide MH care to patients who would otherwise slip through the cracks of a broken system.

Yet, improving care for psychiatric problems is not the only reason to integrate a clinic. Behavior interferes with health in many ways, and the consequences show up in PC patients in many ways. To illustrate this, we often have new behavioral health consultants (BHC; we explain this term later in the chapter) trainees review the daily patient schedule of a PCP, with the goal of finding possible behavioral components to the problems patients are presenting with that day. For example, the patient seeing the PCP for headaches might be stressed or skipping meals; the patient presenting with stomach pain might be drinking alcohol to excess; the patient complaining of dizziness might be having panic attacks. There is even a behavioral component to the common cold, in that frequent hand washing helps prevent it! The point is that health and behavior are so intertwined that it can be difficult to find any medical problem that does not involve behavior in some way. A behavioral influence is most notable in four types of patient concerns: (1) lifestyle-based somatic complaints, (2) subthreshold syndromes, (3) preventive care, and (4) chronic disease management. We describe these concerns in detail below.

Irritable bowel syndrome, tension headaches, insomnia, and chronic pain are a few examples of lifestyle-based somatic complaints. In a classic study of these complaints, researchers demonstrated that, of the 14 most common complaints in a PC clinic, 84% had no clear organic etiology over a 3-year follow-up period (Kroenke & Mangelsdorff, 1989). In other words, these symptoms were likely the result of stress and/or lifestyle. Because these conditions are experienced as physical symptoms, patients often view them as medical problems and thus seek help from a PCP rather than a MH provider (Bray et al., 2004; Patterson et al., 2002). Obesity is another lifestyle-based somatic issue that PCPs confront almost hourly. On rare occasions, patients seek help specifically for obesity, but much of the time it is a problem that never even gets discussed (Greiner, Born, Hall, Hou & Kimminau, 2008).

The second category of subthreshold syndromes includes marital conflict, domestic violence, bereavement, and other life stressors. These are problems that do not meet the “threshold” of a DSM diagnosis, but are nonetheless problems that may take a significant expenditure of PCP time and energy. For example, conservative estimates indicate 12–23% of patients in family medicine have experienced intimate partner violence in the last year (Cronholm, Fogarty, Ambuel & Harrison, 2011), and such patients utilize 1.3–2.6 times as much health care (Ulrich et al., 2003).

Behavioral issues also arise in patients with chronic diseases, the major causes of morbidity and mortality in the world in both developed and developing countries (Heron, 2010). Primary care systems have historically focused mostly on treating acute problems, but chronic conditions are the fastest growing part of PC (Patterson et al., 2002). More than 75% of healthcare costs are now attributable to chronic conditions (see Web Link 1). This rise is due to several factors, including an aging population; an increase in conditions such as diabetes, lipid disorders, and obesity; and medical advances that allow people to live longer with diseases that would have been fatal in earlier years. The trend toward more chronic disease means that PCPs must more often help patients learn to manage them. They must counsel patients on how to cope with a chronic condition, educate family members, motivate patients to make changes, and teach them skills for managing it. Unfortunately, estimates suggest that up to 60% of patients with chronic disorders adhere poorly to treatment (Dunbar-Jacob & Mortimer-Stephens, 2001).

The challenge of responding to all of these behavioral issues in PC may be reason enough to integrate services. Yet, there is another reason why integration is so crucial: PCPs simply cannot do it alone. Primary care is a very busy place and a very stressed system.