Many Areas of the United States Lack Integrated Behavioral Health in Primary Care

Kenny Lin, MD, MPH
Posted on June 19, 2023

A Graham Center Policy One-Pager in the June 2023 issue of AFP overlaid the geographic locations of integrated behavioral health clinics in primary care over a color-coded map of U.S. counties’ percentages of residents reporting poor mental health. In an ideal world, these clinics, which are associated with better health outcomes, higher patient satisfaction, and lower costs, would cluster in regions with greater mental health distress. Unfortunately, the Graham Center analysis found that the opposite was frequently the case, with such clinics “notably lacking in … rural Kentucky, Louisiana, Tennessee, and West Virginia.”

What factors could account for this apparent mismatch between integrated behavioral health supply and demand? A recent Health Affairs Forefront article noted that obstacles to widespread adoption include an ongoing debate about the need for high fidelity to the evidence-based Collaborative Care Model, which can be difficult to implement, and inadequate fee-for-service payment relative to costs of practice redesign and ongoing services. Successful efforts to improve behavioral health integration in Rocky Mountain Health Plans, Blue Cross Blue Shield of Michigan, Rhode Island, and Minnesota have relied on multiple approaches customized to primary care structures and community needs.

A 2022 study in the Journal of General Internal Medicine examined characteristics of integrated behavioral health associated with primary care clinician confidence in managing depression in a network of community health centers (CHCs) in 10 midwestern states. Primary care clinicians reported more confidence when their CHCs had depression tracking systems, when they were satisfied with the accuracy of depression screening, when they had access to behavioral health treatment plans, and when they cared for more patients with depression. In contrast, clinicians working at CHCs with more patients living below the poverty line had lower confidence in prescribing antidepressants, whereas those at CHCs with more Black patients had lower confidence in diagnosing depression.

Integrated behavioral health clinics may or may not provide treatment for persons with opioid use disorder or other substance use disorders, even though these commonly co-occur with mental health problems. In a Substack post, Ben Miller explained that shared vulnerability, dual diagnosis, and bidirectional influence support pairing mental health and addiction treatment. Obstacles to concurrent treatment in primary and specialty care settings include societal stigma, diagnostic classification systems, health system fragmentation, and different treatment philosophies.

AFP provides a wealth of clinical resources for family physicians on depression and bipolar disorder, anxiety disorders, and substance use disorders. Clinicians and practice managers can also find practical information on behavioral health collaboration and integration in an FPM topic collection.