Mental Health Integration Program Research Articles

Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges.

Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective. In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care. As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

Increasing Depression Treatment for Safety‐Net Patients: A Five‐Year Evaluation of Integrated Mental Health Services in Primary Care across Los Angeles County

Research ObjectiveSocioeconomic disparities in mental health care use can be mitigated by interventions to systematically improve disease diagnosis and treatment. Beginning 2010, Los Angeles County Departments of Health Services (DHS) and Mental Health (DMH) collaborated to increase access to effective mental health treatment. Implemented in staggered fashion among select safety‐net clinics, the Mental Health Integration Program (MHIP) embedded behavioral health specialists to co‐manage primary care patients (e.g., psychiatric consultation support for medication prescription, brief problem‐focused psychotherapy). This study examined whether clinic MHIP implementation was associated with higher treatment initiation (medication receipt and/or specialist follow‐up [for psychotherapy]) in safety‐net clinic sites.Study DesignThis retrospectively cohort study examined 33,537 primary care patients who were newly diagnosed with depression from June 30, 2009 to July 1, 2014 (n = 39,066 person‐years), using merged medical and pharmacy records from DHS and DMH. Patients were seen in one of 19 clinics that were either: (1) before, (2) after, or (3) had never implemented MHIP. We followed patients for 90 days after a new diagnosis, defined as having no diagnoses in the prior year. Then, we determined whether patients received antidepressant medication (prescription filled per pharmacy records) and/or mental health specialist follow‐up (completed referral documented in medical records). In multilevel regression models, we used MHIP implementation status to predict odds of treatment initiation, controlling for time and patient demographic and clinical characteristics (e.g., comorbidity).Population Studied255,840 safety‐net patients seen in LA County.Principal FindingsIn 30.1% of episodes, primary care patients received any treatment within 90 days of a new depression diagnosis (38.7% [after] vs 36.2% [before] vs 25.0% [never implemented MHIP in clinic]). 27.9% received medication within 90 days, while only 3% reached specialists. In multivariate analyses (n = 30,347 person‐years), we found that there was 2.35‐times odds of treatment initiation among patients in clinics after MHIP implementation (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.18–2.55; p < 0.001), compared to patients in clinic before implementation. This program effect was driven by medication treatment (OR = 2.42; CI = 2.24–2.63; p < 0.001), as opposed to specialist follow‐up (OR = 1.14; CI = 0.88–1.47; p = 0.32). Odds of treatment initiation were higher among minority (Asian > Latino > Black) than White patients, Spanish‐ than English‐speaking patients, and uninsured than insured patients in the study sample.ConclusionsCollaboration between two large, distinct health systems and its resulting integrated care programs were associated with greater odds of treatment initiation among patients newly diagnosed with depression, compared to patients in clinics before implementation or in clinics that did not implement. Findings suggest potential positive effects of targeted outreach (to minority and Spanish‐speaking patients) and possible leakage of insured patients to private sectors for depression treatment.Implications for Policy or PracticeThis evaluation is one of few to document effects from widescale implementation of integrated mental health care, in particular within the country's second largest public health system. Observed mental health integration programs may need further innovation to address current access gaps in mental health specialty care, such that evidence‐based psychotherapy options are also available to safety‐net primary care patients.Primary Funding SourceDepartment of Veterans Affairs.

Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System.

Beginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications. The aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation. This retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics. 9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety, <1% alcohol, and substance use disorders). Odds of visits being associated with psychiatric diagnoses were 9% higher [95% confidence interval (CI)=1.05-1.13; P<0.0001], and 10% higher for diagnoses that were new (CI=1.04-1.16; P=0.002), after MHIP implementation than before. This appeared to be fueled by increased visits for depression post-MHIP (odds ratio=1.11; CI=1.06-1.15; P<0.0001). MHIP implementation was associated with more psychiatric diagnoses coded in safety-net primary care visits. Scaling up this effort will require greater attention to the notable differences across patient populations and languages, as well as the markedly low coding of alcohol and substance use services in primary care.

Measurement-based care implementation in a Veterans Affairs primary care-mental health integration program.

Measurement-based care (MBC) in behavioral health is the systematic use of validated measurement tools to guide clinical decision making and collaborative treatment planning. Although benefits of MBC for clinicians and patients have been supported by research, it appears to be underutilized in clinical settings. This study examined the effectiveness of a MBC implementation plan informed by the theory of planned behavior in a large, integrated primary care program at a Veterans Affairs hospital over 18 months. Multiple methods, including self-report clinician data and aggregated clinic data, were used to examine change in clinician MBC-related behaviors over time. Results demonstrated both an increase in symptom measures administered per clinical encounter and per individual patient treated. Additionally, the ratio of individuals receiving at least one symptom rating measure to total number of patients treated decreased over time, demonstrating increased use of MBC by integrated primary care clinicians. Survey data demonstrated upward trends in administering measures at initial assessment and at treatment termination, and clinician attitudes toward MBC were generally positive. Results corroborate the theory of planned behavior as a model in which to guide systematic MBC implementation. MBC implementation challenges and recommendations are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Supplemental Material for Measurement-Based Care Implementation in a Veterans Affairs Primary Care–Mental Health Integration Program

Supplemental Material for Measurement-Based Care Implementation in a Veterans Affairs Primary Care–Mental Health Integration Program

The Learning Curve After Implementation of Collaborative Care in a State Mental Health Integration Program.

This study examined organizational variability of process-of-care and depression outcomes at eight community health centers (CHCs) in the years following implementation of collaborative care (CC) for depression. The authors used 8 years of observational data for 13,362 unique patients at eight CHCs that participated in Washington State's Mental Health Integration Program. Organization-level changes in depression and process-of-care outcomes over time were studied. On average, depression outcomes improved for the first 2 years before improvement slowed, peaking at year 5. Significant organization-level variation was noted in outcomes. Improvements in depression outcomes tended to follow process-of-care measures. Findings suggest that it may take 2 years after implementation of CC to fully observe depression outcome improvement at an organization level. Substantial variation between organizations in depression outcomes over time suggests that sustained attention to processes of care may be necessary to maintain initially achieved gains.

Joint Report Provides ‘How-to’ Guidance for Implementing Collaborative Care

Joint Report Provides ‘How-to’ Guidance for Implementing Collaborative Care

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder.

This study aimed to describe the characteristics of primary care patients with bipolar disorder enrolled in a statewide mental health integration program (MHIP). With the Composite International Diagnostic Interview (Version 3.0) and clinician diagnosis, 740 primary care patients with bipolar disorder were identified in Washington State between January 2008 and December 2011. Clinical rating scales were administered to patients at the time of enrollment and during treatment. Quality-of-care outcomes were obtained from a systematic review of the patient disease registry and compared with a previous study of patients with depressive symptoms in an MHIP. Descriptive analysis techniques were used to describe patients' clinical characteristics. Primary care patients with bipolar disorder had high symptom severity on depression and anxiety measures: Patient Health Questionaire-9 (mean±SD score of 18.1±5.9 out of 27) and the seven-item Generalized Anxiety Disorder scale (15.7±4.7 out of 21). Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Only 26% of patients were referred to specialty mental health treatment. Patients with bipolar disorder had a greater amount of contact with clinicians during treatment compared with patients with depressive symptoms from a prior study. Primary care patients with bipolar disorder enrolled in MHIP had severe depression, symptoms of comorbid psychiatric illnesses, and multiple psychosocial problems. Patients with bipolar disorder received more intensive care compared with patients with depressive symptoms from a prior study. Referral to a community mental health center occurred infrequently even though most patients had persistent symptoms.

Bipolar Patients in Integrated Systems May Need More-Intensive Care

Back to table of contents Previous article Next article Professional NewsFull AccessBipolar Patients in Integrated Systems May Need More-Intensive CareMark MoranMark MoranSearch for more papers by this authorPublished Online:12 May 2014https://doi.org/10.1176/appi.pn.2014.5b12AbstractFederally qualified primary care clinics, as well as primary care clinics where both uninsured and Medicaid patients are treated, are likely to have a significant percentage of patients with bipolar illness.Primary care patients with bipolar disorder may require more-intensive services—including direct psychiatric care—than is currently provided in a collaborative care primary care model.That’s the finding from the study “Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder,” published April 15 in Psychiatric Services in Advance.“Primary care patients with bipolar disorder experienced persistent depressive and anxiety symptoms despite higher-intensity collaborative care treatment, but they were infrequently referred to a community mental health center,” the researchers stated. “Successful treatment of bipolar disorder in primary care may require additional clinical interventions aimed at either further improving the care delivered to patients in primary care or through more effective referrals to community mental health centers.”The authors were Joseph Cerimele, M.D., Ya-Fen Chan, Ph.D., Lydia Chwastiak, M.D., Marc Avery, M.D., Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., of the University of Washington, who have pioneered the development of collaborative care models integrating behavioral and general medical care. Key PointsBottom Line: Primary care patients with bipolar disorder may require more intensive care, or better outreach with specialty mental health clinics, than is currently provided in a collaborative care system.Only about one-third of primary care patients in a statewide mental health integrated care program who had bipolar disorder and baseline PHQ-9 scores of 10 or more experienced significant clinical improvement in depressive symptoms.More than half of the patients reported concerns about housing, and 15 percent reported homelessness, while 22 percent reported lack of a support person.Only one-third of the patients were referred to a specialty mental health clinic.They identified 740 primary care patients with bipolar disorder in the statewide mental health integration program (MHIP) between January 2008 and December 2011 using the Composite International Diagnostic Interview and clinician diagnosis. The MHIP uses collaborative care based on the IMPACT model (Improving Mood–Promoting Access to Collaborative Treatment), which was developed at the University of Washington to improve recognition and systematic treatment of patients with psychiatric disorders in primary care settings.Primary care patients with bipolar disorder had high symptom severity on both depression and anxiety measures using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder scale. Only about one-third of patients with bipolar disorder with baseline PHQ-9 scores of 10 or more experienced significant clinical improvement in depressive symptoms (with a PHQ score of less than 10 or a reduction in PHQ-9 score by 50 percent or more) during the time from initial MHIP assessment until treatment in MHIP or until the study ended.Psychosocial problems were common, with approximately 53 percent reporting concerns about housing, 15 percent reporting homelessness, and 22 percent reporting lack of a support person. Yet only 26 percent of patients were referred to specialty mental health treatment. The average time from initial assessment to psychiatric consultation was 5.7 weeks among patients with bipolar disorder.Wayne Katon, M.D., says integration of psychiatrists, on site or by telemedicine, may be necessary for the care of bipolar patients in collaborative care systems.Courtesy of Wayne Katon, M.D.Katon, vice chair of the Department of Psychiatry at the University of Washington, told Psychiatric News that the study indicates that these patients may need more-intensive care than is currently provided in a collaborative care model, in which a care manager, supervised by a psychiatrist, provides the direct patient care.“The importance of this article is that the U.S. federally qualified primary care clinics, as well as many primary care clinics that treat both uninsured and Medicaid patients, are likely to have a significant percentage of patients with bipolar illness, especially bipolar II illness,” Katon said. “This article emphasizes that despite the fact that only about one-third improve with treatment in these clinics, few are being referred to community mental health clinics or actually attend when referred. These clinics already had integrated collaborative care—that is, the use of a care manager supervised by a psychiatrist—so the inference is that these patients may need more-intensive psychiatric treatment, which could occur if psychiatrists are integrated into the clinics either in person or via telemedicine. Alternatively, the clinics need to establish better links with community mental health.” ■“Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder” is posted here. ISSUES NewArchived

Leveraging Integrated Care Principles in Community Mental Health Centers

Leveraging Integrated Care Principles in Community Mental Health Centers

Psychiatric Consultant Helps Shape Care of Wide Range of Patients

Psychiatric Consultant Helps Shape Care of Wide Range of Patients

Collaborative Care: An Integral Part of Psychiatry’s Future

Collaborative Care: An Integral Part of Psychiatry’s Future

Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. Observational analysis of data collected from a patient registry. Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50% reduction in PHQ-9 score and PHQ-9 score < 10). SI was common (45.2%) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4%) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

Initiation of Primary Care—Mental Health Integration Programs in the VA Health System

Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program. To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white. Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

PRACTITIONER APPLICATION: Cost and Quality Impact of Intermountainʼs Mental Health Integration Program

PRACTITIONER APPLICATION: Cost and Quality Impact of Intermountainʼs Mental Health Integration Program

Cost and Quality Impact of Intermountainʼs Mental Health Integration Program

Most patients with mental health (MH) conditions, such as depression, receive care for their conditions from a primary care physician (PCP) in their health/medical home. Providing MH care, however, presents many challenges for the PCP, including (1) the difficulty of getting needed consultation from an MH specialist; (2) the time constraints of a busy PCP practice; (3) the complicated nature of recognizing depression, which may be described with only somatic complaints; (4) the barriers to reimbursement and compensation; and (5) associated medical and social comorbidities. Practice managers, emergency departments, and health plans are stretched to provide care for complex patients with unmet MH needs. At the same time, payment reform linked to accountable care organizations and/or episodic bundle payments, MH parity rules, and increasing MH costs to large employers and payers all highlight the critical need to identify high-quality, efficient, integrated MH care delivery practices. Over the past ten years, Intermountain Healthcare has developed a team-based approach-known as mental health integration (MHI)-for caring for these patients and their families. The team includes the PCPs and their staff, and they, in turn, are integrated with MH professionals, community resources, care management, and the patient and his or her family. The integration model goes far beyond co-location in its team-based approach; it is operationalized at the clinic, thereby improving both physician and staff satisfaction. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes. The MHI program is financially sustainable in routinized clinics without subsidies. MHI is a successful approach to improving care for patients with MH conditions in primary care health homes.

The behavioral health laboratory: Building a stronger foundation for the patient-centered medical home.

The Veterans Health Affairs is in the process of implementing a new model for the delivery of primary care: The Patient-Centered Medical Home (PCMH). One critical challenge of any PCMH model will be the integration of basic mental health treatment into primary care. Such a mental health integration program must be flexible enough to incorporate new evidence-based treatments as patient demographics and health care needs evolve over time. This paper summarizes the Behavioral Health Laboratory (BHL) care management model, a program already in place in more than 20 Veterans Affairs facilities along with private sector insurance providers, as ideally suited to fill this role in the PCMH. The BHL uses a platform of standardized, software-aided mental health assessments and clinical care managers to deliver evidence-based treatments for depression, anxiety, and substance abuse in primary care settings. The authors review this comprehensive program of screening, assessment, treatment, and referral to specialty care when needed. The BHL program is consistent with the guiding principles of the Patient-Centered Medical Home: applying chronic illness disease management principles to provide more continuous, coordinated, and efficient primary care services to patients with diverse needs. Just as importantly, the authors review how this standardized platform for delivering integrated mental health services provides the flexibility to incorporate novel interventions for a changing population.

The patient experience with the mental health system: a focus on integrated care solutions.

To discuss the benefits of working with a multidisciplinary team from the patient and family perspective. According to patients and their families, stigma is the primary barrier hindering treatment for depression and is followed by a web of access to care, mental health parity, and medication issues. The Mental Health Integration program strives to eliminate these barriers by emphasizing consumer- or patient-driven treatment, family support, and community-based solutions. Working with a recovery model--"You are not alone, treatment works, recovery is possible, and there is hope"--the National Alliance on Mental Illness brings the family and consumer voice into the Mental Health Integration program, with the intention of effecting more widespread impact.

Is the Far West Mental Health Integration Project Making a Difference? The General Practitioner Perspective

This paper reports on the evaluation of an Australian Government and NSW State funded Mental Health Integration Project in remote far western NSW. The project was part of the Mental Health Integration Program, developed from the Second National Mental Health Plan. The project implemented a model of community-based mental health services and used innovative financing arrangements to allow the provision of community-based specialist mental health teams to remote communities and to recruit visiting psychiatrists to support the local primary care providers. The evaluation strategy included a survey of general practitioners (GPs) in the Upper Western Sector and Broken Hill, designed to investigate their level and type of contact with psychiatrists and community-based specialist mental health care teams, their perceptions about the impact of the new services, and their interest in further professional development in mental health care.The project has shown that visiting specialists can be deployed in a primary care setting with a focus on meeting the needs of local GPs, primary health care staff and their patients.

Lessons from the National Mental Health Integration Program

Three projects were funded under the national Mental Health Integration Program (MHIP) in 1999, each of which employed a different model aimed at improving linkages between disparate parts of the mental health system. A national evaluation framework guided local evaluations of these projects, and this paper presents a synthesis of the findings. For providers, the projects improved working relationships, created learning opportunities and increased referral and shared care opportunities. For consumers and carers, the projects resulted in a greater range of options and increased continuity of care. For the wider system, the projects achieved significant structural and cultural change. Cost-wise, there were no increases in expenditure, and even some reductions. Many of the lessons from the projects (and their evaluations) may be generalised to other mental health settings and beyond.