Ms. F is a 44-year-old Caucasian woman who was seen in an academic internal medicine clinic for treatment of uncontrolled type 2 diabetes mellitus. The integrated mental health team had noticed from their database that Ms. F’s PHQ-9 depression screening scored above 20 on her last two visits, signaling that perhaps she was experiencing moderate to severe depressive symptoms. However, the team saw that she was not receiving any evidence-based treatment for depression, neither medication nor brief therapy. The behavioral health care manager assigned to the internal medicine clinic contacted internal medicine resident Dr. C to offer assistance. Dr. C had already received extensive training from the consulting psychiatrist and care managers about diagnosing and treating depression, had confidence in prescribing and managing antidepressant medications, and knew how to access brief evidence based-psychotherapies that were being provided in primary care and in the community. Dr. C indicated that he had already diagnosed Ms. F as suffering from a major depressive episode when she had a PHQ-9 score of 21 at a previous visit. He remembered that she was very tearful when he had warned her about the high likelihood of diabetic complications if she did not adhere to the recommended diet, exercise, and medications. However, he stated that Ms. F had minimized her depressive symptoms and had blamed her tearfulness on the clinic staff who she claimed “just want to run my life.” Ms. F also refused both treatment with an SSRI and a referral to brief individual therapy.

The care manager placed the patient on his caseload and made several attempts to reach her by phone for a consultation. Although unsuccessful in his initial attempts to contact her, he continued to follow the case in the electronic medical record. At a subsequent meeting he informed the other behavioral health care managers and the team psychiatrist that Ms. F had an appointment in the internal medicine clinic the following day. At the beginning of the clinic, the internal medicine team also had a “team huddle.” The care manager attended this meeting, and was asked to provide suggestions on several of the patients who were discussed, including Ms. F.

When it came time to discuss Ms. F, Dr. C was given an opportunity to express his frustration with trying to treat Ms. F’s diabetes in the setting of significant non-adherence to recommended medications and dietary restrictions. Her last hemoglobin A1c value was 11.4. Her body mass index was 42, and she seemed to still be gaining weight, despite repeated “dire” warnings about impending complications of her uncontrolled diabetes. The care manager normalized the frustration Dr. C was feeling, and presented a brief description of motivational interviewing as a possible alternative approach with this patient. He then described how motivational interviewing not only has strong outcomes in many cases, but how this type of approach also helps to “liberate” the provider from at least some of the frustration that invariably comes with treating patients who are non-adherent.

With the support of the care manager, Dr. C was able to see Ms. F and show her empathy and compassion. This prompted Ms. F to then apologize for her past behavior, including all the obstacles that she faced in coming to the clinic. This then allowed Dr. C to point out that he notices that Ms. F is trying very hard to make her appointments and that he was curious about what motivates her to come in at all. Ms. F then explained how she values being strong and independent, and that she wanted to make it to appointments to prove that she was capable of doing so. She stated that she often feels lonely and doesn’t have many friends, but that she liked coming to the clinic and wanted to feel accepted by clinic staff, including by her doctor. Dr. C thanked Ms. F for sharing this with him and offered to partner with her in meeting her goals. He expressed understanding of how difficult it must be for Ms. F to feel judged by clinic staff and of her desire to connect with people who accept her. Dr. C then told Ms. F about the “healthy choices” group, and that he thought that this might be a place where Ms. F could come to connect with other people with health struggles like hers, without being judged. Ms. F was interested, and Dr. C then called in the care manager, who told Ms. F more about the group and connected with Ms. F on a personal level.

Ms. F attended the “healthy choices” group later that week. She was able to commit to a seemingly small dietary change, eating only one dessert with dinner instead of her usual two to three, which she expressed a high degree of confidence that she could attain. She was very proud to report to the group the following week that she had been successful. The group encouraged her and she began to feel close to several members. She began to reveal more details about her obstacles to change, including being a victim of sexual assault. After attending the “healthy choices” group for several weeks in a row, Ms. F agreed to participate in a support group for people with posttraumatic stress disorder at the community mental health center that was also co-led by one of the care managers.

At her 3-month follow-up appointment with Dr. C, Ms. F’s BMI had dropped to 39 and her hemoglobin A1c had dropped to 10.2. However, she continued to have significant depressive symptoms, with a PHQ-9 score of 18, and hypertension, with blood pressure of 154/91. At that point, Ms. F agreed to initiate sertraline to assist in the treatment of her depression. She also agreed to take lisinopril and metformin, which she previously had resisted. The integrated mental health team maintained close contact with Ms. F during the initiation of sertraline, inquiring about any side effects or any other obstacles to adherence. Ms. F tolerated 50mg of sertraline with very few side effects, but her level of depressive symptoms was still quite high. At the recommendation of the consulting psychiatrist, passed on via the care manager, Dr. C increased the sertraline dose to 100mg. Ms. F saw a partial response, with a PHQ-9 score of 12 after 1 month at this dose. Dr. C then increased the sertraline dose to 150mg. By the next 3 month follow-up visit, Ms. F had a PHQ-9 score of 7. More remarkably, she had a hemoglobin A1c of 8.4, a BMI of 36, and BP of 133/86.

Our population is growing rapidly, and with a geriatric population outpacing all other demographics we will see nearly one in five US residents aged 65 and older by 2030. Between 2010 and 2050, the US population is projected to grow from 310 million to 439 million, an increase of 42 %. The nation will also continue to become more racially and ethnically diverse, with the minority population projected to become the majority by 2042. (US Department of Commerce Economics and Statistics Administration 2010). With this growth comes an expanding need for care with a diminishing set of resources including financing, providers, and infrastructure. The largest component of this growing burden stems from chronic diseases such as diabetes and heart disease which are worsened by health characteristics like obesity and hypertension, and can be directly linked to ongoing health behaviors such as unhealthy diet, lack of exercise, poor sleep habits, and nicotine and alcohol use.

Mental illnesses and substance use disorders are very prevalent and are responsible for a significant amount of disability and mortality, either directly, or indirectly through poor medical health and decision making. In the population there is a 5–10 % prevalence of major depression, with up to three times that percentage having significant subsyndromal symptoms. In hospitalized patients this number is as high as 25 % (Barkin et al. 2000). Patients who have chronic medical illnesses have even higher risks of mental illnesses (such as major depressive disorder) and their complications (such as suicidal ideation) (Wells et al. 1988; Druss and Pincus 2000). In addition, mental illnesses, substance use disorders, and psychosocial factors can significantly complicate other medical illnesses. Mental illnesses, such as major depressive disorder, are associated with increased disability, reduced adherence to medical treatments, and worsened medical outcomes (Katon 1996). Early identification and effective treatment of mental disorders and other psychological factors affecting medical illness can dramatically reduce the costs, disability, and suffering associated with medical illnesses.

However, many people who suffer from mental illnesses and substance use disorders are not properly diagnosed, and those who are diagnosed often do not receive effective treatment. There are many factors that contribute to this unfortunate reality, including lack of awareness of mental illness and the availability of effective treatments, ineffective screening programs for mental illnesses, inadequate access to mental health treatment (due to shortages of trained mental health providers and limited insurance coverage of mental health services), isolation of mental health systems from other systems of care, and the stigma against mental illness which often makes people reluctant to discuss their mental health concerns or seek treatment. While mental health treatments for individual patients have advanced considerably in the last several decades, relatively little attention has been paid to translating these advances into advances for the mental health of large populations, until more recently. And unfortunately, the USA is currently ranked last in the quality of care outcomes in nearly every category of mental health and medical treatment in the developed world despite care being ranked as one of the most expensive health care systems globally (Kane 2013).

As health systems adapt to more effectively and efficiently serve the health needs of entire populations, there is a growing recognition of the importance of more systematic approaches to the identification and treatment of mental illnesses and substance use disorders at the population level. The patient-centered medical home (PCMH) and the Accountable Care Organization (ACO) are examples of health care delivery models designed to provide high-quality, cost-effective care to entire populations. These models effectively link a primary care “hub” to acute care and specialty care supports and provide incentives for prevention, early intervention, and proactive management of chronic illnesses at the most cost-effective level of care possible. Managing chronic illness at the most cost-effective level of care usually means avoiding unnecessary hospitalizations and specialty referrals and implementing standardized disease screening¹ and management protocols to increase the likelihood of efficient delivery of quality care. In these models, common, uncomplicated illnesses must be managed by primary care providers (not by specialists and not in acute care settings) whenever possible. This frees up the much fewer specialist physicians, psychiatrists in particular, to treat the more serious and emergent cases while the primary care doctors treat the simpler and more routine symptoms. This is particularly timely as experts and officials predict that the nation’s psychiatric workforce will be short more than 22,500 physicians by 2015 (Iorfino 2013).

While outpatient psychiatric consultation-liaison services in the USA and the UK have been available since the first half of the twentieth century (Dolinar 1993), the vast majority of consultation-liaison psychiatry services have historically been oriented toward the highest levels of medical care (Mayou 1989), such as tertiary care inpatient medical/surgical hospitals and less commonly subspecialty outpatient consultation clinics (e.g., HIV psychiatry, perinatal psychiatry, and psycho-oncology clinics). This new model focuses on the general outpatient setting where the majority of patients are seen for more routine care and maintenance of the chronic conditions that will often lead to the need for treatment in this higher level of care. This provides a primary (prevention) or secondary (early treatment) level of preventive care rather than tertiary (minimizing consequences) at best (Centers for Disease Control and Prevention 2013).

Indeed, there have been a number of significant barriers to integration, including the following: inability of general medical patients to identify the psychiatric nature of some symptoms; reluctance of patients to seek or health care providers to recommend mental health care due to stigma; limited training of medical providers in mental health; lack of time to address mental health concerns (in addition to other general medical concerns) in the relatively brief general medical clinical encounter; and restrictions on insurance coverage for mental health services, particularly those provided in general medical settings and/or by general medical providers (Unutzer et al. 2006). However, the increased interest in integrated care (IC) and population health with PCMHs and ACOs, has sparked a renewed interest in the integration of mental health into overall health care, and particularly integration into primary care and other outpatient medical clinics. Integrated care answers each of these barriers in turn with specifically designed and targeted solutions. It is also constructed to change and adapt to apply to the diverse and the rapidly changing medical delivery environment.

The concept of a health care system caring for the “whole person,” including mental health needs, is not a new one. In fact, the delivery of care was historically far more all-encompassing, and in much of the world remains that way for reasons of culture, economy, or necessity. Treatment in many developing countries as well as much more rural areas in the industrial world have physicians that provide care from medical, to mental, to dental and surgical. Many deeply held cultural and spiritual beliefs specifically focus on the mind–body connections and can be seen to dominate the fields of traditional medicine practices that many people will turn to long before seeking care from more “western” approaches even in large US cities. These include: homeopathy, ayurveda, acupuncture, spinal manipulation, hypnosis, and traditional Chinese medicine (Turner 2013). When medical care involves these “eastern” techniques in practice, this is often labelled as “alternative, complementary, or integrative (not to be confused with integrated).”

There is a broad lexicon in the medical literature that expresses this general concept of combined care. This lexicon includes phrases such as “medical-mental health integration” or “collaborative care,” “shared care,” “co-located care,” “primary care behavioral health,” “integrated primary care,” and even “behavioral medicine.” In some ways, this divergent lexicon was beginning to become an obstacle to advancing research into and effective implementation of integration of behavioral health services into systems of general medical care due to the misclassification of different levels of integration in the research literature. In addition, because of the growing enthusiasm for integrated care, there was a temptation for programs to simply declare themselves “integrated,” without performing the work necessary to achieve this distinction. In short, intervention was needed to prevent the integrated behavioral health landscape from becoming one in which “anything goes” (Peek 2013).

As a result, the Agency for Healthcare Research and Quality (AHRQ) convened an expert consensus panel to help provide a common integrated care lexicon. While many different models of integration are available and useful, the consensus panel defined the core concept of behavioral health and primary care integration as:

“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization” (Peek 2013).

This restates what is known as the Alma-Ata Declaration from the International Conference for Primary Health Care in September 1978. The Declaration of Alma-Ata begins by stating that health:

which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal …

It goes on to call for all governments, regardless of politics and conflicts, to work together toward global health. Those who ratified the Declaration of Alma-Ata hoped that it would be the first step toward achieving health for all by the year 2000. In 2008, the World Health Organization (WHO) revisited the topic and released a 200 page report on the application of integrated care in vastly different populations across the globe and detailed the planning, implementation, and the successes and failures of many of these different strategies. These were largely successful and increased the number of patients successfully treated by orders of magnitude (2008).

The AHRQ consensus panel went on to define the key functions of integrated behavioral health care.

The key functions included:

Finally, the AHRQ consensus panel defined the supports necessary for these functions to become sustainable on a meaningful scale. These supports included: