Debunk caricatures of behavioral healthcare

Just recently, I had the occasion to meet with a large gathering of professional representatives from a disability group outside the behavioral health and intellectual/developmental disability communities. An estimated one-third to one-half of persons with this disability also experience a comorbid mental health condition, typically depression.  What shocked me was the belief shared by almost all in the room that virtually all persons in this disability group who have a mental health condition should be seen by a psychiatrist. Clearly, this belief is almost a caricature that flies in the face of today’s actual mental health practice.

At a national level, data show that about three-quarters of all behavioral healthcare today occurs in primary care settings, such as physician offices adn clinics. Only one-quarter occurs in specialty settings, such as individual and group practices, behavioral health clinics and specialty hospitals. We also know that peer support is growing rapidly in these specialty settings and that consumer-operated service programs are becoming much more prevalent. Finally, a very small fraction of behavioral healthcare now occurs in jails and prisons, which together represent an emerging care sector.

Behavioral health also is in the midst of a workforce crisis. As a result of the Affordable Care Act (ACA), an estimated 25 million more Americans have health insurance today. About 8 million of these newly insured persons have one or more behavioral health conditions. Yet, no parallel expansion has occurred in the behavioral health workforce. Simultaneously, providers of baby boomer age are beginning to retire in large numbers.

Appropriate sources of care

All of these factors point to the need for us to develop much greater clarity on appropriate sources of behavioral healthcare and to communicate these both within the field and within the broader disability communities. Toward that end, here are several principles that can serve to foster further framing of this very important issue:

• For persons with serious behavioral health conditions, such as schizophrenia or life-threatening addictions, care always should be provided by well-trained specialty providers who have prior experience in addressing these complex conditions. Because such conditions almost always are accompanied by serious physical disorders, specialty care for these persons should be provided through integrated care arrangements where necessary primary care also is available.
• For persons with less serious conditions, such as simple depression or anxiety, or early substance use, care should be provided by well-trained specialty or primary care providers. To assure that primary care providers offering such care are able to address refractory cases, ongoing consultation-liaison with specialty providers always should be available to them.
• In all instances, peer consultation and support should be available to persons receiving care. The availability of peers will help to assure that every effort is made to promote self-determination of one’s life and self-management of one’s behavioral health conditions, with the goal of full recovery.
• To assure that these services are provided not only to those who reside in our urban centers, but also to our rural citizens, modern telecommunication technology, i.e., high speed internet,  should be available to those residing in counties of all sizes. This will permit direct telemedicine if no providers are available and expert telehealth consultation if available rural providers need additional support. Telemedicine has advanced far in the past decade, and it should be fully utilized where necessary.

When we peered into the future in 2014, we foresaw that up to nine of every 10 cases of behavioral healthcare would be seen in primary care settings by 2024. We also concluded that behavioral healthcare would evolve into a specialty, much as heart care is today. Both of these predictions underline the urgency of further work on the principles outlined above. There are huge opportunities for behavioral health to work closely with primary care; we should seize them as quickly as possible. This work will help us dispel prevalent caricatures of behavioral healthcare.