Abstract
Introduction
Depression is the most common mental illness in the United States. Of the 6.6% of Americans estimated to suffer from major depressive disorder each year, only 51.2% are currently receiving treatment, and only 21.7% of these being adequately treated. 1 The overall goal of this research was to improve the recognition, treatment, and/or referral of persons with depression who present in primary care practices, including Federally Qualified Health Centers, by examining the impact of integrated mental health services into primary care. A broad search of the literature on different approaches to the integration of primary care and depression screening, treatment, and payment demonstrated that sufficient evidence exists to support integration. Despite the prevailing consensus as to its value, there is not widespread adoption of integrated care models. Thus, the objective of this article is to examine the barriers to the adoption of depression and primary care models in the United States.
The Case for Integrated Depression Care
The primary goal of integration is the provision of comprehensive care. 2 Three models prevail. Integration can consist of mental health care delivery becoming ingrained in primary care protocols, the co-location of mental health specialists within primary care settings, and team approaches involving mental health providers lending their expertise to primary care providers.
A significant body of evidence supports the value and efficacy of early and continuing access to depression treatment. Although studies show that most persons with depression seek care through their primary care providers, collaborative care models for that care are not the norm.3,4 Earlier access to treatment is desirable, and prompt treatment can result in decreased length of depressive episodes. 5 Significant differences in access to treatment and treatment uptake also exist among racial and ethnic groups6-8 and populations with varying insurance status. 9 These issues of disparate access and outcomes are particularly critical to timeliness of treatment initiation. To reap maximum benefits from treatment, patients must not only enroll early but also remain actively engaged in their treatment protocols. Nonadherence to treatment is high among patients being treated for depression, and nonadherence can result in an increased likelihood of future depressive episodes. 10 Outcomes vary based on race and the presence of comorbidities, with possible additional variation due to gender 11 and age. 12 Thus, one goal of depression care interventions is to increase access and adherence to the treatment protocol.
The chronic care model involves the implementation of a well-planned course of action designed through the collaboration of care providers and patients, relying heavily on evidence-based medicine, community support, and patient ownership. 13 This model has been successfully implemented for depression care. 14 Effective therapies for depression often require multispecialty treatment, and collaborative care has been shown to improve outcomes in patients with major depressive disorder.15,16 Collaborative care models show improved outcomes when compared with usual care.17,18
Methods
As a first step in the project, we conducted scoping searches, broad searches of the literature, to identify related research. The goals of these initial searches were to assist in defining the scope of the project and help formulate the approach to the literature review. The scoping searches were carried out in the Medline, Cochrane, and PsycInfo bibliographic databases. The team also searched Google for grey literature (ie, resources not traditionally indexed by commercial publishers), tracked citations, and consulted with experts and authors.
These searches revealed recent literature that evaluated the impact of different approaches to the integration of primary care and depression screening, treatment, and payment. Examples include work by Butler et al, 19 Compton, 20 Jacob et al, 21 Thota et al, 22 and Unützer and Park. 23
Since evidence already exists to support integration of depression services into primary care, our goal was to determine key barriers. We conducted searches to explore, describe, and categorize barriers to integrated care for depression. The article offers an exploratory analysis of the literature so that future research can be conducted in this area and is neither meant to be a systematic review nor meant to be a review article.
To inform our search strategy, we used some core definitions for integrated care models. Although there are several terms used, 2 the most common, “integrated care delivery,” describes any practice delivered by a trained medical professional with the intention of improving patient health status. This is a broader perspective than the definition of integration introduced by Shortell et al, “. . . the extent to which patient care services are coordinated across people, functions, activities, and sites over time,” 24 as it relates to depression care. SAMHSA (The Substance Abuse and Mental Health Services Administration) also provides a definition of integrated care: “the systematic coordination of general and behavioral healthcare . . . for people with multiple healthcare needs.” 25
The initial literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on a previously existing search conducted by Butler et al
19
in their systematic review of integrated care for depression. The search combined MeSH terms with targeted keywords. The MeSH terms included
The results were reviewed and filtered. Results that fell into the following criteria were excluded (
Barriers to Integrated Depression and Primary Care.
Findings
The literature revealed multiple barriers to the integration of depression care and primary care. By virtue of being part of a special or vulnerable population, patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party. In other cases, the barriers are “at the margin” and with identification and study, could be removed or attenuated at low human and economic cost.
Vulnerable Populations
Many barriers to integrated depression care exist for those in vulnerable populations. In this article, we will use the Bioethics Research Library at Georgetown University’s Bioethics Thesaurus Database definition of vulnerable populations, “persons who may be compromised in their ability to give informed consent or who are frequently subjected to coercion in their decision making,” including children with other health issues, the elderly, and racial and ethnic minorities. 65 Providers treating children with life-threatening conditions such as HIV may treat mental health needs as a secondary concern and focus their attention on the child’s physical condition. 29 Staff with specialized training in a physical condition may also lack sufficient knowledge about how to provide mental health care. 29 Because children with serious physical illnesses may have negative feelings toward medical facilities, they may be uncomfortable receiving mental health care is such settings. 29 Family medicine physicians and pediatricians report that they feel less competent caring for children with autism than for children with other chronic medical conditions. 31 Among elderly patients, the difficulties of diagnosis can make initiation into treatment, whether integrated or not, a challenge as many older adults present depression with a variety of somatic symptoms. 39
Patient and Family Factors
There are patient and family sociodemographic factors that make the delivery of integrated depression and primary care more challenging. As noted earlier, children, young people and the elderly face multiple primary care providers who are not always connected easily with mental health specialists. 28 Other research has shown that collaborative care management may produce positive outcomes that are indifferent to age. 66 The separation of primary care and elder care management, particularly psychiatric management, and the separation of pediatrics from general primary care and specialized mental health care result in a lack of access and coordination that prevents optimization of treatment.67,68 Racial and ethnic disparities and providers’ lack of cultural competency can also stand in the way of integration. Ethnic minorities may struggle to gain access to managed mental health care, and ethnic and racial minority patients are less likely to use mental health care services at all or as much as whites. 39 A lack of cultural competence among mental health care providers and payers can also serve as a barrier to integrated depression care; to facilitate culturally competent care, both providers and managed care gatekeepers must be sensitive to patients’ cultural needs. 47
Comorbidities
The presence of patient comorbidities can also serve as a barrier to the success of integrated care. Persons with severe mental illness face more barriers to receiving any form of medical care than does the general population, and these barriers become even greater for older patients. 42 Many children with mental illness also have physical comorbidities. 43 Many people with mental illness also struggle with substance use. Substance abuse treatment is not a mandated Medicaid coverage area, making payment for integrated care involving depression and substance abuse even more problematic than integrated care for depression alone. 44
Provider Factors
Success requires investment by both patients and providers in integrated models of care. Many providers have expressed doubts about their ability to implement collaborative care models within their own practices. 39 Relationships between primary care physicians and mental health specialists can also stand in the way of successful integration. Primary care physicians and mental health specialists are often unable to spend sufficient time building relationships and communicating with one another, resulting in a lack of understanding of one another’s viewpoints on patient care; integrated care may not be collaborative care if providers lack opportunities to communicate effectively.48,50 Primary care physicians may also be asked to expand their scope of practice when initiating integrated care, which could prove a barrier if physicians are wary of such significant change. 45
Financial and Cost Barriers
Some of the largest barriers to integrated depression care are financial. Some practices do not have the financial resources to hire or train necessary staff,32,45 while the inability to bill for care delivered over the phone or for collaborative meetings among staff members and low reimbursement levels for care management prevent integration from becoming a financially attractive option for many. 45 Additionally, capitated and fee-for-service 40 payments can serve as disincentives for treatment of depression within the primary care setting. 19 Particularly in the case of carve-outs, primary care providers have financial disincentives to engage in collaborative care, as they may lose reimbursement for depression related services to a mental health provider. 55 Regulations regarding the timing of billable visits and amount of reimbursement for these visits are prime barriers to effective adoption of integrated care models.54,69
Organizational and Societal Barriers
A wide array of organization and societal barriers also stands in the way of more integrated depression care delivery. Societal and cultural factors influence generalized stigma and specific cultural attitudes toward depression. 69 A study of physical and behavioral health centers receiving public funding found that these facilities identified many structural issues as key barriers to integration. These barriers included provider shortages, provider’s lack of time, lack of adequate provider education, lack of reimbursement for certain services involved in integrated care models, barriers to communication, and billing restrictions to be major obstacles to integrated care. 54 The primary organizational barriers identified in this review are the current physician training system, the shortage of time within primary care practices, and billing regulations. Current physician education strategies regarding integration have not been shown to improve patient outcomes, 61 and many primary care physicians may not have sufficient training to effectively treat mental illness. 54 Because primary care visits are often highly time-limited, it can be difficult for primary care physicians to effectively screen for and treat depression.54,56 Time can also be a barrier among specialty mental health providers. 67 In currently integrated practices, physicians have cited the lengthy waiting period for an appointment and the lack of full-time collocated mental health clinicians that contributes to this wait time as barriers to the model’s success. 49 Furthermore, the lack of combined medical records or billing codes for integrated care serve as barriers among community-based providers. 60
Once integrated systems have been established, lack of consensus 69 and barriers to quality improvement may still exist. These barriers can include lack of staff willingness to implement changes, lack of provider time, lack of support for improvement initiatives among management, and difficulties recruiting and retaining staff. 58
Conclusions
Previous research indicated that depression and primary care models are practical, feasible, and effective. By asking the question, “Why are they not fully adopted?” we hoped to identify those barriers acting individually and in combination that reduce their spread into the US health care system. By recognizing that integrated depression and primary models are successful, and identifying the factors that reduce their adoption and spread, this article hopes to clarify the evidence, and help systems and providers move toward better care and health improvements. It is our additional hope that practicing clinicians will find this review to be an efficient source of information regarding the challenges they will face should they choose to implement an integrated model of depression care within their own practices.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
This work was funded by The Center for Healthcare Research and Transformation.