Health Service Advisory Committee Research Articles

Landscape of Spinal Muscular Atrophy Newborn Screening in the United States: 2018-2021.

Newborn screening (NBS) programs identify newborns at increased risk for genetic disorders, linking these newborns to timely intervention and potentially life-saving treatment. In the United States, the Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state NBS programs to screen. ACHDNC updated the Recommended Uniform Screening Panel to include Spinal Muscular Atrophy (SMA) in July 2018. As of June 2021, 34 state NBS programs had fully implemented SMA newborn screening, and at least 8 programs were pursuing implementation. This article will review current SMA screening processes, considerations, challenges, and status.

Expanding Newborn Screening for Pompe Disease in the United States: The NewSTEPs New Disorders Implementation Project, a Resource for New Disorder Implementation.

Public health programs in the United States screen more than four million babies each year for at least 30 genetic disorders. The Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state newborn screening (NBS) programs to screen. ACHDNC updated the Recommended Uniform Screening Panel (RUSP) to include Pompe disease in March 2015. To support the expansion of screening for Pompe disease, the Association of Public Health Laboratories (APHL) proposed the Newborn Screening Technical assistance and Evaluation Program (NewSTEPs) New Disorders Implementation Project, funded by the HHS’ Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB). Through this project, APHL provided financial support to 15 state NBS programs to enable full implementation of screening for Pompe disease. As of April 27, 2020, nine of the 15 programs had fully implemented Pompe disease newborn screening and six programs are currently pursuing implementation. This article will discuss how states advanced to statewide implementation of screening for Pompe disease, the challenges associated with implementing screening for this condition, the lessons learned during the project, and recommendations for implementing screening for Pompe disease.

Newborn Screening: Beyond the Spot.

The newborn screening paradigm of testing all newborns in the United States for treatable conditions within the first few hours of birth has proven to be a remarkable success story in the realm of public health by reducing neonatal and childhood morbidity and mortality. The Newborn Screening Saves Lives Act of 2007 and its successor, the Reauthorization Act of 2014, legislated the establishment of a Department of Health and Human Services Advisory Committee to make recommendations around newborn screening and a methodology to establish and add new conditions to a Recommended Uniform Screening Panel (RUSP) which currently includes 34 core conditions. In spite of the absence of a federal mandate that requires each of the states in the U.S. to screen for the disorders on the RUSP, most state public health laboratories have adopted the conditions on this panel. Moreover, the evolution of the evidence-based review process for adding new conditions to the RUSP has led to improvements in incorporating the public health impact and feasibility and implementation considerations. The cooperation between the federal partners who support implementation and rollout of state-based screening programs, develop technical standards and proficiency materials for laboratories, review and approve new technology platforms, and promote research to develop new assays and treatments for screenable disorders, points to the success of the newborn screening enterprise nationwide. As new technologic advances are made in the realm of genomic sequencing, the potential for incorporating these technologies holds great promise for newborn screening, but the ethical ramifications must be carefully considered to avoid harming the existing trust in the program.

Evaluating Harms in the Assessment of Net Benefit: A Framework for Newborn Screening Condition Review.

The Department of Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children ("Advisory Committee") makes recommendations to the HHS Secretary regarding addition of new conditions to the national Recommended Uniform Screening Panel for newborns. The Advisory Committee's decision-making process includes assessing the net benefit of screening for nominated conditions, informed by systematic evidence reviews generated by an independent Condition Review Workgroup. The evidence base regarding harms associated with screening for specific conditions is often more limited than that for benefits. The process for defining potential harms from newborn screening reviewed the frameworks from other public health evidence-based review processes, adapted to newborn screening by experts in systematic review, newborn screening programs and bioethics, with input from and approval by the Advisory Committee. To support the Advisory Committee's review of nominated conditions, the Workgroup has developed a standardized approach to evaluation of harms and relevant gaps in the evidence. Types of harms include the physical burden to infants; psychosocial and logistic burdens to families from screening or diagnostic evaluation; increased risk of medical treatment for infants diagnosed earlier than children with clinical presentation; delayed diagnosis from false negative results; psychosocial harm from false positive results; uncertainty of clinical diagnosis, age of onset or clinical spectrum; and disparities in access to diagnosis or therapy. Estimating the numbers of children at risk, the magnitude, timing and likelihood of harms will be integrated into Workgroup reports to the Advisory Committee.

Science, politics, and the end of the lifelong gay blood donor ban.

Science, politics, and the end of the lifelong gay blood donor ban.

In This Issue

In This Issue

A framework for key considerations regarding point-of-care screening of newborns

Newborn screening is performed under public health authority, with analysis carried out primarily by public health laboratories or other centralized laboratories. Increasingly, opportunities to improve infant health will arise from including screening tests that are completed at the birth centers instead of in centralized laboratories, constituting a significant shift for newborn screening. This report summarizes a framework developed by the US Secretary of Health and Human Services Advisory Committee on Heritable Disorders in Newborns and Children based on a series of meetings held during 2011 and 2012. These meetings were for the purpose of evaluating whether conditions identifiable through point-of-care screening should be added to the recommended universal screening panel, and to identify key considerations for birth hospitals, public health agencies, and clinicians when point-of-care newborn screening is implemented.

Weighing the Evidence for Newborn Screening for Hemoglobin H Disease

To conduct a systematic review to assist the United States Secretary of Health and Human Services Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) to determine whether Hemoglobin H screening should be included among the core recommended conditions for newborn screening. We identified 21 articles in MEDLINE from 1989 to March 2010 that provided evidence regarding screening, treatment, and outcomes associated with Hemoglobin H disease. In California, newborn screening has identified 9 cases per 100 000 of deletional hemoglobin H disease and 0.6 cases per 100 000 of nondeletional hemoglobin H disease. Five cases of hemoglobin Bart's hydrops fetalis syndrome were also identified in over ten years of screening for Hemoglobin H disease. Although Hemoglobin H disease is associated with a wide range of morbidity, no studies were found that evaluated the benefits of early identification and treatment. The SACHDNC found the data insufficient to recommend that states adopt newborn screening for Hemoglobin H disease.

“Jasper’s Basic Mechanisms of the Epilepsies” Workshop

SummaryIn 1969, H.H. Jasper, A.A. Ward, and A. Pope and the Public Health Service Advisory Committee on the Epilepsies of the National Institutes of Health (NIH) published the first edition on Basic Mechanisms of the Epilepsies (BME). Since then, basic and clinical researchers in epilepsy have gathered together each decade to assess where epilepsy research has been, what it has accomplished, and where it should go. In 1999, the third edition of BME was named in honor of H.H. Jasper. Projected for publication in 2011, the fourth edition of Jasper’s BME will (1) synthesize the role of interactions between neurons, synapses, and glia in the initiation, spread, and arrest of seizures; (2) examine the molecular, cellular, and network plasticity mechanisms that subserve excitability, seizure susceptibility, and ultimately epileptogenesis; (3) provide a framework for expanding the genome of rare mendelian epilepsies and understanding the complex heredity responsible for common epilepsies; (4) explore cellular mechanisms of the two main groups of presently known Mendelian epilepsy genes, namely ion channelopathies and developmental epilepsy genes; and (5) for the first time, describe the current efforts to translate the discoveries in epilepsy disease mechanisms into molecular and cellular therapeutic strategies in order to repair and cure the epilepsies. For an expanded treatment of this topic see Jasper’s Basic Mechanisms of the Epilepsies, Fourth Edition (Noebels JL, Avoli M, Rogawski MA, Olsen RW, Delgado‐Escueta AV, eds) published by Oxford University Press (available on the National Library of Medicine Bookshelf [NCBI] at http://www.ncbi.nlm.nih.gov/books).

Sex, Sin, and Science: A History of Syphilis in America

At of end his book, John Parascandola writes, “It is my hope that the reader ... acquired a broader appreciation of disease as a social as well as a medical construct and of the way in which social and cultural factors influence our understanding of and reaction to any given disease.” The social context of syphilis is nicely summarized by the title, Sex, Sin, and Science: A History of Syphilis in America. Because syphilis is sexually transmitted, it is often considered as a moral issue, and thus people who have syphilis have sinned. This perception is both absurd and insightful. Parascandola’s history of syphilis is compelling from the beginning. “Because many believed that the disease first made its appearance in the French troops besieging Naples, it was often called (especially by the Italians) morbus gallicus (‘French disease’) ... The French, on the other hand, preferred to call it the ‘Neapolitan disease’ blaming it on the city of Naples.” Syphilis was so sinful that it could not be discussed by name. “This continued hesitancy to discuss sexual matters is reflected in the terminology used in newspapers and other public media of the early twentieth century.” “Social evil” meant prostitution. Syphilis and gonorrhea were “social diseases,” and the effort to combat them was the “social hygiene” movement. We learn that in 1911 California became the first state to require physicians to report cases of venereal disease and that, to assure confidentiality, reporting was done by number rather than by name. Some of those involved in the social hygiene movement were more interested in preventing sex than in preventing disease. A Public Health Service (PHS) advisory committee recommended changing an educational film so that “‘some attention be given to the influence of moral standards on the spread of disease’ because if no reference was made to moral issues, it might appear to some that the PHS was ‘condoning sexual promiscuity.’” There was fear that penicillin might offer “complete freedom to indulge in licentiousness...” or “if extramarital sex did not lead to significant illness, only a ‘few intangibles of the spirit’ would remain to guide people into moral paths.” Parascandola notes, “Social hygienists had always been at least as interested in moral as in health issues, and so their fight would not end with the defeat of venereal disease.” Parascandola’s book informs readers that in 1953, “the Eisenhower administration proposed eliminating the PHS venereal disease program because its job was essentially done.” But syphilis came back, along with gonorrhea, herpes, chlamydia, and AIDS. There is considerable scientific evidence that HIV causes AIDS. Nonetheless, just as with syphilis, others think the cause is sin. Absurd. Yet the social construct Parascandola describes remains so pervasive that it continues to affect us all.

Premature death among state mental health agency consumers: assessing progress in addressing a quiet tragedy

Ronald W. Manderscheid, Ph.D., has served as the Director of Mental Health and Substance Use Programs at the Global Health Sector of SRA International since 2006. Concurrently, he is Adjunct Professor at the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, a Member of the Secretary of Health and Human Services Advisory Committee on Healthy People 2020, and President-Elect of the American College of Mental Health Administration. Dr. Manderscheid serves on the boards of the Employee Assistance Research Foundation, the Danya Institute, and the Public Manager.

Government panel focuses on top priorities for guiding genetic testing policies

Ensuring the clinical utility of genetic testing and understanding issues surrounding public access to this technology were among the priorities targeted for more in-depth study by a Department of Health and Human Services advisory committee. The Advisory Committee on Genetics, Health, and Society met July 7–8 in Washington, D.C., to continue working toward a final report on policy needs for the growing field of genetic and genomic testing. Mike Leavitt, secretary of Health and Human Services, said this committee can help develop information needed for policies that strike a balance between meeting consumer needs and imposing regulatory restrictions. “I think it is often the case that consumers are underestimated in terms of their capacity to sort through these things,” he said. “I think there is often a sense of well-intended protection that we want to provide that sometimes can constrain progress. Somebody needs to be pushing the envelope a little, and at the same time you have to have the brake on to keep us on the road.”

M.D.s May Soon Be Free of Current E&M Guidelines

Back to table of contents Previous article Next article Government NewsFull AccessM.D.s May Soon Be Free of Current E&M GuidelinesMark MoranMark MoranSearch for more papers by this authorPublished Online:2 Aug 2002https://doi.org/10.1176/pn.37.15.0002Ten years of making—and remaking—the federal government’s guidelines for how physicians must document “evaluation and management” of patients for Medicare payment could be unmade entirely.That’s if the government heeds its own broad-based advisory committee on regulatory reform urging that the “E&M” documentation guidelines be scrapped.The Department of Health and Human Services (HHS) Advisory Committee on Regulatory Reform recommended dumping the guidelines at a recent meeting in Denver. The 21-member committee has five physicians, including Nancy Nielsen, M.D., vice speaker of the AMA’s House of Delegates, as well as administrators of the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration).The recommendation awaits action by HHS Secretary Tommy G. Thompson.The guidelines for evaluation and management of patients are part of the government’s resource-based relative value scale for determining physician payment under the Medicare program and have been the object of heated controversy. Physician groups hailed the recommendation as long overdue.“The AMA has repeatedly informed HHS and the Regulatory Relief Advisory Committee that physicians identify E&M documentation guidelines as the single, largest paperwork burden imposed by the Medicare program,” the AMA said following the committee’s recommendation.Chester Schmidt, M.D., chair of APA’s Committee on RBRVS, Codes, and Reimbursement, echoed that view.“This is a very positive development,” he said. “The reason this panel is backing off is the very intense pressure that has been brought to bear to change the documentation requirements. Physicians believe that the guidelines are not clinically relevant and that they are merely a means for the government to do audits and to find fault, resulting either in civil or criminal actions [against doctors] because of documentation deficiencies.”Schmidt added, “The outcry from all specialties has consistently been that the E&M coding guidelines are not clinically relevant, are onerous, and impose on physicians extra paperwork for which there is no reimbursement.”Psychiatrists use the E&M codes for inpatient and partial hospitalization, consultation, nursing home visits, and some office visits. Especially controversial are the guidelines for determining the level of “medical decision making,” which is one of the three E&M components, along with history taking and examination. The guidelines for that component use a four-by-four grid designed to produce a numerical approximation of medical decision making.Schmidt has called the system so complex “it bears no resemblance to the actual practice of medicine.”Douglas L. Wood, M.D., chair of the advisory committee and a physician at the Mayo Clinic, summed up the view that the decade-long effort to revise or improve the guidelines has been exhausted.“The documentation guidelines that have been used are unworkable, and I think 10 years of effort to try to find one that works is a pretty strong statement that there is something fundamentally difficult or fundamentally impossible about trying to create documentation guidelines for evaluation and management services,” Wood said, according to transcripts of the advisory committee meeting in Denver.“The fact that no other commercial insurer uses them should be a pretty strong statement that they’re probably not applicable anyway,” Wood said. “And indeed, there is now and has been an adversarial environment that’s based on fraud and abuse actions and the actions of Medicare carrier medical directors.”The transcript of the Denver meeting is posted on the Web at www.regreform.hhs.gov/sacrr5_16.htm. ▪ ISSUES NewArchived

Violence and aggression in A&E: Recommendations for action

The problem of violence and aggression in health care settings has become a high-profile issue. Following the release of figures issued by the Health Services Advisory Committee (HSAC) which show nursing as the most dangerous profession in the UK, Frank Dobson, Health Secretary, urges health service managers to do everything they can to reduce violence. Violence is defined as any incident which puts a health care worker at risk and includes verbal abuse, threatening behaviour or assault by a patient or member of the public. It is suggested that most violent incidents within the hospital setting contain an intentional and, therefore, aggressive element. The theoretical background to the concept of aggression is explored to pinpoint its causes and identify the factors which originate its potential for harm. An analysis of the Accident and Emergency (A & E) environment with the conflicting demands of its workload highlights its potency for the creation of violent and aggressive behaviour towards its staff. In order to minimize its detrimental effects, this paper examines various approaches towards counteracting violence and aggression. It concludes that these methods fall into five major categories and details recommendations for action within these areas. The HSAC (1997) declares that it is possible to reduce the risk of violence by proactive management, underpinned by positive commitment from senior managers and staff at all levels.

Cardiopulmonary resuscitation training for family members of patients on cardiac rehabilitation programmes in Scotland

Existing cardiopulmonary resuscitation (CPR) training programmes have failed to reach those most likely to witness a cardiac arrest, such as families of cardiac patients. In 1993, the Scottish Health Service Advisory Committee suggested that CPR training could be offered as part of cardiac rehabilitation programmes. A survey was carried out to identify the current extent and nature of such training and factors influencing its provision. Questionnaires were mailed to all the 45 Scottish cardiac rehabilitation programmes on the British Heart Foundation’s register. A 93% response rate was achieved. Only 37% of programmes provided information to families about attending a CPR course and 37% actually provided CPR training The numbers trained by these programmes were very small. Hospital programmes were significantly more likely than community programmes to provide CPR training (χ2=6.65, P<0.01) as were those which included an exercise component (χ2=7.63, P<0.01). Reasons for not providing training ranged from lack of resources and lack of staff training, to not having considered it. CPR training is provided as part of cardiac rehabilitation programmes to a limited extent. Ways of recruiting and increasing the number of family members of cardiac patients who are trained in CPR need to be found.

Intravenous immune globulin shortage: experience at a large children's hospital.

The current shortage of immune globulin for intravenous use (IVIG) is being attributed to several events, including an increase in off-label use, and intense Food and Drug Administration (FDA) scrutiny of product lots and manufacturing facility upgrades that result in temporary production halts.1 Additionally, there has been an increase in product recall or failure to release product because donors at risk for Creutzfeldt-Jakob disease have been identified.2 Although transmission of Creutzfeldt-Jakob disease by blood products has not been established, the FDA has recalled IVIG lots with perceived risk of contamination. This shortage has caused sufficient concern among patients and their providers to capture congressional attention.2 During a recent meeting of the Health and Human Services Advisory Committee on Blood Safety and Availability, it was recommended that a systematic appraisal of off-label uses of IVIG be undertaken.3 This may assist in alleviating product shortages by discouraging use in inappropriate patient populations and by establishing priorities among approved indications. Another recommendation from that meeting was to sell product directly to hospitals and pharmacies, eliminating product handling and potential price gouging by third-party suppliers. Meanwhile, the shortage of IVIG nationwide continues and most tertiary care hospitals, especially those caring for seriously ill children, are affected. Texas Children's Hospital (TCH) is a 456-bed freestanding pediatric teaching institution affiliated with Baylor College of Medicine in Houston, Texas. Our medical staff provides primary care yearly for approximately 200 infants and children requiring administration of IVIG for serious or life-threatening medical conditions. These include primary immunodeficiency …

Reply

Letters to the EditorReply Muhammad Yousuf, MBBS, MRCS, MRCP Dib Abdulaziz Al-Saudi, MBBS, MSC Riaz Ahmad Sheikh, and MBBS, MD Mohammad Shafi LoneMBBS, MD Muhammad Yousuf Department of Medicine, King Abdul Aziz Hospital, Madinah Al-Munawarah, Saudi Arabia Search for more papers by this author , Dib Abdulaziz Al-Saudi Department of Medicine, King Abdul Aziz Hospital, Madinah Al-Munawarah, Saudi Arabia Search for more papers by this author , Riaz Ahmad Sheikh Department of Medicine, King Abdul Aziz Hospital, Madinah Al-Munawarah, Saudi Arabia Search for more papers by this author , and Mohammad Shafi Lone Department of Medicine, King Abdul Aziz Hospital, Madinah Al-Munawarah, Saudi Arabia Search for more papers by this author Published Online:1 Jul 1996https://doi.org/10.5144/0256-4947.1996.480bSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: We thank Dr. F. Jamal for her interest in our paper. We were not able to carry out microbiological studies to determine the etiology of pneumonias among Haj pilgrims and in our paper have already suggested the need for further study to find out the factors and microorganisms responsible for pneumonias in both Makkah and Madinah. We foresee that pneumonias may become an interesting problem in the coming Haj seasons, which will fall in the relatively cooler months of the year, and such a study would help improve the management of pilgrims with this infection.Study based on sputum culture will, however, be technically quite difficult among pilgrims because of the problems of obtaining a good sample due to the language barrier, particularly in Turkish, Nigerian and Indonesian pilgrims who cannot speak English or Arabic. Evaluation of these cases by transtracheal aspiration (TTA), blood culture and serology may yield better information.1We agree with her that the availability and success of 23-polyvalent pneumococcal vaccine makes it particularly worthwhile to determine the proportion of cases caused by Streptococcus pneumoniae and characterize the strains implicated by serotyping and antibiotic sensitivity testing. We concur with her observations that Streptococcus pneumoniae can be the major cause of community-acquired pneumonias in old patients and an important cause of death,2–4 and the recommendations to vaccinate this high-risk group with polyvalent pneumococcal vaccine are worth consideration. However, Haj pilgrims constitute a special group of patients. Most of them are from Asia or Africa. They usually develop pneumonia after their stay in Haj camps of Mina and Arafat and not while living in the community. They have diabetes mellitus as the third common co-morbid illness. For these reasons, causative microorganisms responsible for their pneumonias may well be different from European or American studies of community-acquired pneumonias. Pneumococcal vaccine is not yet recommended for the general public by the Public Health Service Advisory Committee on Immunization Practice of the Centers for Disease Control.5 Furthermore, the efficacy of the vaccine is more in females as compared to males,6 whereas males constitute most of the pilgrims. Also, efficacy of the vaccine depends on the serotype, which varies with the age of the patient, hospital type and source of isolate7 and this information may be vital in pilgrims who may benefit from such vaccination.Keeping the above factors in mind, we recommend that pending the results of microbiological study in pilgrims with pneumonia, polyvalent pneumococcal vaccination can be recommended in high-risk cases, i.e., those with COPD, bronchial asthma and age above 60 years. Those who cannot afford the vaccine may take prophylactic antibiotics before they move to Mina or Arafat, as has been recommended earlier.8ARTICLE REFERENCES:1. Ostergaard L, Andersen PL. "Etiology of community-acquired pneumonia. Evaluation by transtracheal aspiration, blood culture or serology" . Chest. 1993; 104: 1400–7. Google Scholar2. Ortqvist A, Hedlund J, Grillner L, et al. "Etiology, outcome and prognostic factors in community-acquired pneumonia requiring hospitalization" . Eur Respir J. 1990; 3: 1105–13. Google Scholar3. Pachon J, Prados MD, Capote F, et al. "Severe community-acquired pneumonia. Etiology, prognosis and treatment" . Am Rev Respir Dis. 1990; 142: 369–73. Google Scholar4. Moine P, Vercken JB, Chevret S, Chastang C, Gajdos P. "Severe community-acquired pneumonia. Etiology, epidemiology and prognostic factors. French study group for community-acquired pneumonia in the intensive care unit" . Chest. 1994; 105: 1487–95. Google Scholar5. Requejo HI. "Polyvalent pneumococcal polysaccharide vaccine: a review of the literature" . Rev Hosp Clin Fac Med. 1993; 48: 130–8. Google Scholar6. Gable CB, Holzer SS, Englehart L, et al. "Pneumococcal vaccine. Efficacy and associated cost savings" . JAMA. 1990; 264: 2910–5. Google Scholar7. Hager HL, Wooley W, Berk SL. "Review of recent pneumococcal infections with attention to vaccine and nonvaccine serotypes" . Rev-Infect Dis. 1990; 12: 267–72. Google Scholar8. Yousuf M, Zafar M, Maqbool M. "Medical problems of Pakistani pilgrims in Saudi Arabia" . Pak J Med Res. 1993; 32: 172–5. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 16, Issue 4July 1996 Metrics History Published online1 July 1996 InformationCopyright © 1996, Annals of Saudi MedicinePDF download

Management of health and safety in the health services: information for directors and managers30 pp Management of health and safety in the health services: information for directors and managers £7.50 . 0 7176 0844 1 0717608441 Health Services Advisory Committee

Management of health and safety in the health services: information for directors and managers30 pp Management of health and safety in the health services: information for directors and managers £7.50 . 0 7176 0844 1 0717608441 Health Services Advisory Committee

Antibody responses of healthy infants to a recombinant hepatitis B vaccine administered at two, four, and twelve or fifteen months of age

Hepatitis B vaccine was administered to healthy infants on two investigational schedules that fall within ranges recommended by the U.S. Public Health Service Advisory Committee on Immunization Practices and by the American Academy of Pediatrics Committee on Infectious Diseases. A month after receiving vaccine at 2, 4, and 12 or 15 months of age, 98% and 100% of the children had >10 mIU antibodies to hepatitis B surface antigen per milliliter, with geometric mean titers of 1358 mIU/ml and 3424 mIU/mL, respectively. (J P EDIATR 1994;125:67-9)

Mental Health Services in Army Primary Care: The Need for a Collaborative Health Care Agenda

Epidemiologic studies have shown that more than half of mentally ill patients in the United States receive their psychiatric care exclusively in primary care settings. This fraction may be even higher in the military due to concern over possible occupational repercussions resulting from use of specialty psychiatric care and specialist shortages. Collaboration between generalists and mental health care specialists could potentially improve mental health care delivery and reduce psychiatric disability for a large segment of the Army population who have a psychiatric disorder but may not seek specialty care. Collaborative efforts can reinforce military generalists' essential gate-keeping function, thereby decreasing unnecessary medical utilization and health care costs. The authors review the problems associated with mental health care delivery in primary care and provide examples of collaborative models previously studied or currently being explored. A four-part Army Primary Care-Mental Health Services Agenda is proposed, consisting of: (1) coordinated research including primary care-mental health services research and community-based epidemiologic studies; (2) formation of a primary care-mental health services advisory committee for aiding with policy and program development; (3) graduate and continuing medical education in primary care-mental health services emphasizing interdisciplinary collaborative skills; and (4) clinical implementation of feasible collaborative interdisciplinary mental health care models adapted to the range of unique Army primary care settings. The main goal of the Army Primary Care-Mental Health Services Agenda is to improve access to Army mental health care in the most efficacious and cost-effective way and to help minimize the organizational impact of disability related to psychosocial distress.