Why Pursue Mental Health Integration?

It is the right thing to do: The NCCBH vision statement provides the foundation for our work: We are committed to creating and sustaining healthy and secure communities, achieved through a system that holds the needs of consumers paramount, regardless of their ability to pay.

Vital to this commitment is a network of organizations and advocates promoting services of unparalleled value.

NCCBH members primarily serve public sector consumers, those with severe and persistent mental illness or serious emotional disturbance-the needs of this population are often overlooked in primary care and integration planning. We must assure that their needs as well as the needs of the broader community are appropriately addressed.

Many people in the broader community now receive their behavioral healthcare in a primary care setting, and the gap between the medical and behavioral healthcare systems must be bridged: As noted by Robin Dea and many other commentators, there is:

“evidence that many, if not most, people coming into primary care are being treated for psychosocial problems, not organically based medical disease . . . evidence of medical cost offsets from treating behavioral health problems presenting as physical health problems in the primary care setting . . . the assumption that if adequate detection of early stage psychiatric illness took place in primary care, there would be some prevention of patients going to more severe episodes of major psychiatric illnesses . . . and primary care is where most people who have behavioral health problems are in fact seen.”

Some of the important findings from the research field include:

-The Epidemiologic Catchment Area (ECA) Study and articles based on this survey data, reported the finding that about 50% of care for common mental disorders was delivered in general medical settings. However, many subsequent studies have shown that these disorders may be undiagnosed or under-treated.

-Screening systems, treatment guidelines and provider education in primary care are necessary but not sufficient steps to ensure a difference in outcomes.

-Collaborative and stepped care has been shown to achieve outcomes that are better than “usual care”.

There is the opportunity for quality improvement of care within the primary care and specialty behavioral healthcare settings: Studies have shown that many people with depression stop taking their medications before the minimal time required to effectively treat an episode of depression. Patients at Group Health Cooperative who initiated medications for depression with their primary care physician and received targeted stepped up care and relapse prevention support were significantly more likely to adhere to adequate dosages of medication and to demonstrate a greater decrease in depressive symptoms.

Application of research findings such as these through adoption of evidence-based practices in both primary care and specialty behavioral health (BH) settings will result in better outcomes for consumers.

With the publication of Priority Areas for National Action: Transforming Health Care Quality, the Institute of Medicine’s 2003 follow up to Crossing the Quality Chasm: A New Health System for the 21st Century, a major opportunity and challenge has appeared for the public mental health system.

The Quality Chasm recommended the systematic identification of priority areas for national quality improvement; Priority Areas proposes twenty areas for transforming health care nationally. Included in this list are major depression (screening and treatment) and severe and persistent mental illness (focus on treatment in the public sector).

Their inclusion as priority areas, as well as the findings in the Interim Report from the President’s New Freedom Commission on Mental Health, with its observation that the system is “fragmented and in disarray-not from lack of commitment and skill of those who deliver care, but from underlying structural, financing and organizational problems” suggests that the time for new strategies is at hand.

Many people being served by public behavioral health services need better access to primary care: A rationale less frequently articulated for integration is that the specialty BH system, especially the public sector focusing on the severe and persistent mentally ill adult population (SPMI) and seriously emotionally disturbed (SED) children, serves a disabled consumer population with healthcare needs that are frequently under-addressed due to difficulties in obtaining medical services.

Most state Medicaid waivers related to coverage for physical healthcare have focused on enrollment of the TANF population into Medicaid managed care plans, leaving the disabled Medicaid population unable to adequately access care, or in better situations, reliant on “safety net” providers-community health centers (CHCs) or county delivered health services.

Community health centers serve people who need better access to behavioral healthcare. These “safety net” providers serve a broader scope of patients than just the Medicaid population. But many states have implemented mental health Medicaid waivers that focus the public mental health system on the SPMI/SED and Medicaid populations, with minimal levels of support for non-SPMI/SED or uninsured populations. Often there is not a good match of target populations between the two systems. If the Medicaid mental health program also has a highly managed service authorization and payment methodology, there may be additional barriers to reimbursement for mental health services.

This has led to frustration for “safety net” healthcare providers because they have difficulty obtaining behavioral health services for their non-SPMI/SED or uninsured patients. In a recent survey of CHC medical directors, 80% indicated that cost is the main barrier to behavioral health care for their uninsured populations. The recent financing and development of behavioral health services in CHCs addresses this frustration and is just the latest in a series of efforts to acknowledge that a large proportion of the population gets their behavioral health services in primary care.

Because behavioral health clinicians are a resource for assisting people with all types of chronic health conditions: Yet another reason for integration is the potential contribution of BH clinicians regarding behavioral and lifestyle change: providing interventions targeted at better management of chronic disease, supporting and “leveraging” the time of primary care providers through disease management programs.

Disease management activities focus on several areas: early identification of populations at-risk for costly chronic disease (e.g., asthma, diabetes), care interventions that utilize evidence-based practices, education-intensive orientations that focus on both patient and provider, care management and a coordinated approach across multidisciplinary treatment teams, and a method for systematic data collection that measures clinical and cost-effectiveness. Large organized healthcare systems, such as Northern California Kaiser-Permanente, implement their major disease management programs with specifically assigned nurses as care managers and educators.

However, many physicians in individual or group practices do not have access to this level of support unless they are in the network of a health plan with active disease management programs. In markets where primary care and multi-specialty groups have accepted accelerated risk, disease management approaches will be especially value-added.

We are in a time of significant public policy activity regarding financing of the national healthcare system and the uninsured population. As we approach the 40th anniversary of the founding of the community mental health center movement, the dialogue has returned us to our public health beginnings-serving the needs of a population.

The Health Resources and Services Administration (HRSA) Primary Care Integration Initiative is currently being implemented across the country. The HRSA initiative includes: identification of system issues related to integration and the development of related strategies; development of a service manual for CHC behavioral health services; development of BH intervention models for CHCs; and grants for establishing BH services in existing CHCs.

Newly funded CHC sites will be expected to provide dental, mental health and substance abuse services, either directly or by subcontract arrangements. CHCs are in the process of decision making about building their own BH services or contracting for BH services, as they prepare their grant applications. (The NCCBH website, www.nccbh.org, has a Primary Care Integration Resource Center with more details about the HRSA process.)

At the same time that HRSA is putting new BH resources into CHCs, reports are emerging from many states indicating that the public mental health system is funded at somewhere around half the level that is needed. In the private sector, the relentless downward pressure on behavioral health PMPMs has also reduced overall system resources, shifting cost from the private sector to the public sector.

Reports such as these were released prior to the current fiscal crisis in state Medicaid programs; rather than addressing the shortfalls, there are significant new reductions in BH services in many states. And, the implementation of managed care methods for Medicaid have made it difficult for some community based BH providers to continue to enact their mission of serving the needs of the population, regardless of ability to pay.

The implications for system-wide duplication and competition for the scarce resources of BH staff and funding, as well as the opportunity to improve consumer access to both health and behavioral healthcare services, suggests that collaboration is a priority at the national, state and local levels. Good public policy will work at sustaining, supporting and requiring collaboration between the two “safety net” systems of community mental health centers and community health centers.

The conceptual model proposed in this paper can become the basis for HRSA grantees to work with their partners in the public mental health system to fully define working relationships and collaboration on behalf of consumers of care.

In summary, the reasons for integration are grounded in the desire to improve access to both primary care and behavioral health services; ensure that there are evidence-based practices as well as consistent communication and coordination of clinical activities (especially medication management-a key concern of consumers) among the providers serving any single individual; wed the skill sets of primary care physicians and BH clinicians in order to better manage chronic health issues; and, participate in and shape the public policy debate regarding how services should be organized, delivered and financed in ways that ensure that needs of public sector SPMI/SED consumers and the broader community alike are met.

By: Linda Rosenberg

About the Author:

Bipolar affective disorder is also referred to as manic-depression disorder, which is a form of a mental illness wherein the patient displays sudden and intense mood swings that are uncontrollable and can be dangerous for the individual as well as those around him/her. It can begin with the patient feeling happy, cause the person to feel utterly depressed the next moment and swing back to a cheerful mood within minutes; it can also stay for months in a mood cycling motion of manic-depressive or mixed episodes.

Timely diagnosis and clinical therapy is very important to educate patient and family besides any bigger support group around the individual about the condition, the ways in which it can manifest itself, the danger to the person and how best to control and treat it.

Best treatment options for bipolar affective disorder include regular therapy, combined with medication and teaching the patient more about the disorder and tools that are effective in controlling it, including reading a handbook on the subject and learning how to use a workbook on bipolar disorder.

Among the latest in the line of many new medications to treat bipolar affective disorder are Aripiprazole or Abilify, atypical anti-psychotic that has been approved for treatment of manic and mixed bipolar disorder episodes since 2004, which benefits the patient by shutting down the brain’s dopamine receptors so they behave more normally and thus, result in mood stabilization and the popular, Celexa. The latter is mainly an antidepressant that has been used by medical experts for a long time but witnessed more beneficial value over the last few years when treating patients with bipolar affective disorder.

Other effective and latest medication in the market for treating bipolar disorder includes Geodon, also an anti-psychotic that is a mood stabilizer with no fear of weight gain, working much like Zyprexa that has a few minor side effects of which weight gain is fortunately, not one; Wellbutrin, (may also be packaged as Zyban) are other helpful medication used initially as an anti-smoking drug but which has shown marked benefit for bipolar patients. To its advantage is the fact that patients using Wellbutrin can effectively manage weight as it neither induces weigh gain or loss!

Even though bipolar disorder cannot be cured completely, with timely diagnosis, proper counseling and the benefit of new-age medicines, much of the mental health of the patient can be improved as research is constantly being conducted to improve and upgrade the benefits of each drug proven effective in controlling bipolar affective disorder – so do consult a doctor and the psychiatrist before undertaking any sort of medication for bipolar disorder treatment.



By: Abhishek Agarwal

About the Author:

Bipolar Disorder is better known by its former name, Manic Depression; a mental illness where a person manifest mood swings which presents itself in cycles where one switches between depressed, manic and a normal mood. In the U.S.A. over two percent of people are known to suffer from this illess, where thirty percent of all hospitilisations are for psychiatric patients in a single year.

Psychiatrists and psychologists have not come up with the actual cause of Bipolar Disorder as of yet. Researches have, however, made steady progress in understanding the brain and how it functions, the actual causes of many mental illness including Bipolar Disorder. This illness is currently understood to be caused by many factors which include biological, emotional, environmental and physical reasons.

It has been discovered that some bipolar patients have additional brain cells which is one theory for a biological cause. Research shows that those with Bipolar had thirty percent more brain cells which send signals to others than is normal. There is still speculation as to whether it is the brain cells which are responsible for regulating our moods, our responses to pleasure and also our responses to stress.

The disorder tends to run in families, although some that are diagnosed have no family history of the illness. This points to the nature of hereditary as being one of the causes of this mentall illness, so genetics could actually be a cause.

What has received lots of attention is the neurotransmitter system as being one of the causes of Bipolar Disorder. For decades, researchers have shown a link between neurotransmitters and mood disorders. A chemical imbalance in the brain of these neurotransmitters such as dopamine, norepinephrine and seratonin, that is any high or low levels can create this disorder. When an imbalance in levels between other neurotransmitters occurs this creates sensitivity or illness. This imbalance is also known to be hereditary.

Psychologists widely believe that the biological causes which trigger bipolar only makes a person more prone and increases the likelihood of getting disorder, and not necessary cause it. Once a person comes across situations such as environmental factors, a sudden tragedy or a difficult childhood, which could trigger the illness, the biological tendencies come into action and Bipolar develops. Such triggers could be from child abuse, rape, sexual abuse, a death in the family, being in a controlling relationship, or living in violent environment. Mood cycling in relation to Bipolar Disorder works in the same way. Triggers from emotional situations, the environment, stress or tragic circumstances could start mood changes between manic and depressive episodes.

Alcohol and drug abuse can be a cause of this illness, as the effects can trigger mood changes. These cases are difficult for a doctor to determine when the actual bipolar started, whether it was before or after the abuse. When someone suffers from a mood disorder they may turn to alcohol or drugs to get rid of these bad feelings – they can escape from it all. Continuous research is done to find answers and infomation which can be collated from areas like genetics, neurology, psychology and psychiatry so we can gain more knowledge about all the mental illness including Bipolar. Technology is always advancing so it may soon come to light, the answers to all these theories. Until then we must wait for an answer so that better and more successful treatment becomes available, and maybe, even a cure.



By: Abhishek Agarwal

About the Author:

Music is often dubbed as the universal language. And rightly so. It’s a language that doesn’t need interpreters. Irrespective of the lingual, social, and cultural background of a person music never fails to strike the chord within. Words fall short in the description of this divine gift of God that the human race has been blessed with. A person who is averse to the effects of music is sometimes not even considered to be a human! Such is the power of music. It’s the uniting bond for the people. Be it happiness, sadness, anger, exasperation, love, friendship, madness music is for every occasion. It can be a man’s best friend when the whole world proves to be inadequate for him. Music can be the best companion at times when one seeks some peace of mind in tranquility.

Music can also be healing. Many a times music lightens up a dampened mind. It’s almost therapeutic. Even plants and animals are sensitive to music. It has been proved that plants grow well when music is played in the vicinity. Even animals develop fondness for music. Music pacifies hyperactive minds. Music instills calmness in a person and the list can go on. The facets and the benefits of music are actually endless. It is really surprising that in certain beliefs music is thought to be a sin!

Music is now discovered to have wonderful effects on a depressed mind. Here I do not mean minds that are temporarily disturbed or depressed over an issue but the ones who are inflicted by the mental disorder named depression. Depression is seen to be bowing down to the unseen powers of music. Depression patients are having results when they are given music therapy. Results of a survey conducted to the effect authenticated the conclusion.

The survey was conducted on two groups of depressed people. One group received depression cure and the other group was completed by music therapy apart from depression treatment. The group that received music therapy was found to heal quicker and better than the other group. It was always known that music is soothing to the senses, but it has been proved now that this oldest art form is medicinal for clinical depression.

Apart from music patients are prescribed depression pills. You can buy xanax like depression pills even online. But xanax online like all its counterparts has side effects that you need to be aware of. Xanax warnings must be read well before taking the medicine. Another point to be remembered is that, always follow the usage you have been prescribed or you might run the risk of developing Xanax addiction.



By: Denzing Jones

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