Integration of Physical and Behavioral Health

This week I gave a talk at  a conference held by the The Center for Public Service Psychiatry in Pittsburgh. There were many psychiatrists, residents, nurses and primary care physicians in the audience. I had the opportunity to share some of my thoughts on the seemingly inexorable trend of integrating physical health and behavioral health services.  Here are some of the concerns that I outlined in my talk.

We are concerned about the early morbidity and mortality of people diagnosed with mental disorders.  People are developing preventable chronic diseases and are dying younger than Americans who are not diagnosed with mental illness.  The opportunity that emerges from this tragedy is the integration of physical health and behavioral health services and a commitment to serving the whole person.  There is no doubt that attending to the whole person, preventative screening, early detection, access to quality medical care and active whole health supports are going to help people manage their conditions more effectively and live longer lives.  That's a good thing.  But as a person in recovery, I have concerns.  

1. I am worried that integrated health and behavioral  health services will mean that psychiatric disability is placed squarely within the jurisdiction of physical medicine, as just another disease among diseases.
2. I am concerned that in everyday practice, integrated care will mean that  psychiatric medication will be the only treatment offered.
3. I am concerned that when those of us with psychiatric disabilities receive integrated services, focus will shift back to symptom reduction, stabilization and mere maintenance in the community.
4. I am concerned that the promise of recovery will be lost and that return to work, school and community will be replaced by a focus on management of "meds, money and manners" leading to more people living out their lives in handicaptivity.
5. I am also concerned about diagnostic overshadowing in medical settings where too often, our bodily complaints are seen as being "all-in-your-head". 
6. I am concerned that other evidence based practices such as supported employment, strengths based case management, and cognitive behavioral therapy will be even harder to access in integrated care systems.  I'm concerned that with integrated care we will forget that poverty is a significant risk factor for co-morbidity and early mortality.  I fear we will forget that getting a job with health insurance and rising out of poverty is one of the most powerful things we can do to improve access to quality medical care.
7. And finally, I am concerned that passive consent for treatment will continue to predominate and that top-down medical decision making will replace shared decision making and informed medical consent.

I have a vision about what needs to happen to address these concerns.  My vision is that integrated health and behavioral health services will only be an improvement in care if mental health service users become activated, empowered, informed experts in the management of our healthcare.  Integration will only result in an improvement in care if practitioners are trained to collaborate with activated users of health services.  This will require deep changes in the healthcare infrastructure as well as how clinical work is conducted.

In the rest of my talk, I went on to discuss the importance of shared decision making and the role of peer practitioners in decision support centers in healthcare clinics.  More on that later...