Integrating Behavioral Health and Primary Care

Especially in recent months, the charged debate over whether and how to pay for American health care has overshadowed practical discussions of how to deliver better, more efficient care. In this book, the editors provide convincing evidence that health systems integrating the treatment of general medical and mental illness—built around a common framework of interdisciplinary, team-based, and patient-centered care—are doing just that.

The national shortage of psychiatrists results in primary care physicians most often treating patients with psychiatric illness, but primary care and internal medicine specialists receive modest training in psychiatric diagnosis and management. In addition, psychiatric comorbidities promote worse outcomes due to patient nonadherence, personality disorder–induced countertransference, provider burnout, somatization-driven procedures and tests, and iatrogenic cardiometabolic illness. Experienced in the study of these challenges, editors Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein have compiled a text written by interdisciplinary practitioners to help physicians and health administrators develop locally tailored models for integrated care. Each chapter is written and edited by psychiatrists, internists, and mental health clinicians, ensuring relevance and accuracy.

The book opens with examples of successful existing models, including the Veterans Health Administration, Cherokee Health Systems, and the Canadian health care system, accompanied by an overview of effective screening and handoffs, personnel organization, and financial frameworks. The next section uses a concise, directive approach toward diagnosis, treatment, and behavioral management for disorders of anxiety, mood, psychosis, somatization, eating, personality, and substance use. Many chapters are summarized by “key points” to guide the reader and provide evidence-based treatment algorithms and recommendations for when to consult a psychiatrist. The third section describes the role of the psychiatrist in other specialty clinics, such as the management of psychogenic nonepileptic seizures in the neurology clinic and chronic pain in the pain management clinic. The book concludes with a section on psychosocial interventions appropriate for the primary care setting.

A major strength of this text is its clinical relevance and ease of use for the primary care physician. Especially helpful is the chapter on personality disorders, which describes common phenomena like countertransference reactions in physicians and clinic staff, and importantly, unsafe care practices. The chapter emphasizes early identification and consistent limit setting, along with nonpunitive relationships, as essential in the navigation of these challenging cases. It also recommends a team-based approach to care, a model similar to dialectical behavioral therapy for borderline personality disorder, to help maintain attachment to the clinic rather than individuals and to prevent provider burnout.

The book’s examples of adaptable, successful integrated care systems are well suited to the needs of health system administrators and primary care practice managers who seek to improve the outcomes and efficiency of their own systems. The authors also show how improved outcomes and greater efficiency are being achieved with interspecialty colocation and telehealth (i.e., the application of telecommunications technologies to support the long-distance delivery of clinical care).

Compiled to serve more as a reference guide than a progressive narrative, the book often repeats content and concepts between chapters. Psychiatrists who practice outside of integrated care settings will find less clinical utility in the approach and level of detail to most psychiatric diagnoses and their management. In addition, some medication recommendations and psychotherapeutic techniques seem outside the expertise and experience of many primary care providers and are provided without references for further guidance and context.

These considerations aside, the editors have delivered a strong and clear text that advances a coherent conceptual framework for the delivery of integrated care. The collected authors convey innovative practices through tangible examples and offer practical clinical tools for primary care and behavioral health care providers alike. The result is a timely and instrumental guide to creating the next generation of American health care.