People with co-existing physical and mental health problems face many challenges when it comes to accessing health care and face significantly higher costs than the regular person. People with long-term physical health conditions (LTCs) such as diabetes and cardiovascular diseases are more likely to experience mental health problems. The NHS costs associated with mental health in this segment of the population are between £8 billion and £13 billion annually, thus representing a large welfare burden. People with comorbid physical and mental disorders are also less likely to be employed.1
Traditionally, delivery of primary care and mental health treatments has been separate, however, research suggests that integrating behavioral health with primary care and medical services is not only effective in reducing patient mental health symptoms, but is also associated with improved patient satisfaction with care, quality of life, and adherence to treatment.2 Integrated healthcare models have also been associated with reductions in healthcare costs3, and healthcare utilisation (e.g., significantly fewer emergency departments and office visits).4 Although the benefits of integrated care models for providers are less explored in literature, a recent study5 suggests that providers within these models experience an increased sense of support, reduced stress, and increased confidence in managing behavioral health conditions. Moreover, integrated behavioural health models can save providers’ time; for example, a comparison between pediatric clinics with and without integrated behavioral health showed that pediatricians are more time-efficient during routine medical visits in the clinics with integrated behavioural health.6
Types of integrated behavioural healthcare
There are different levels of integrated healthcare; for example, collaborative care models usually target mild to moderate mental health issues and refer to management of mental health issues within primary care contexts. Examples of collaborative care models are Improving Mood-Promoting Access to Collaborative Treatment7 in the US and Improving Access to Psychological Therapies8 in the UK. IAPT is an example of a stepped care model, where people with depression and anxiety within NHS are offered treatment either at Step 2 or Step 3 depending on their needs and symptom severity. At step 2, clients are recommended low-intensity CBT-based treatments such as guided self-help, internet-delivered CBT, or group CBT, while at step 3 they are recommended high-intensity CBT such as face-to-face interventions. Overall, integrated care models can increase access to care where there’s limited specialised behavioral health services or other barriers to accessing traditional behavioral healthcare. They also have the potential to meet the needs of individuals struggling with co-morbid LTCs and mental health issues.
A recent paper focused on evaluating a new Integrated-IAPT service developed by NHS England for individuals with LTCs that have co-morbid anxiety or depression9. This segment of population has generally been under-represented in IAPT due to physical and mental healthcare issues being managed separately. The authors evaluated the impact of this new service on 1,096 patients in three English counties between March 2017 and January 2018. Data was collected on secondary health care utilization costs (emergency department visits, outpatient, and inpatient admissions), depressive symptoms (PHQ-9), anxiety symptoms (GAD-7), and employment status (self-report). Overall, findings suggested that the Integrated-IAPT was effective in reducing depressive and anxiety symptoms, that there was a decrease in health costs for the Integrated-IAPT sample compared to controls, and that unemployed patients who received Integrated-IAPT were more likely to find a job. It is noteworthy that the reduced secondary healthcare costs were mainly due to reduced inpatient and emergency room admissions, but not outpatient, and that this drop in secondary healthcare costs was steepest for individuals with cardiovascular comorbid problems.
It’s also interesting that most participants received face-to-face or telephone interventions, while only 3 individuals received it via telemedicine. Evidence-based internet-delivered CBT interventions (iCBT) such as SilverCloud Health’s programmes for depression and anxiety have been proven to be effective in reducing symptoms, and cost-effective. iCBT has also been integrated with IAPT and has the potential to reach even more people in contexts such as Integrated-IAPT where more individuals with LTCs could be assisted in managing mental health symptoms. It could also further reduce healthcare costs and facilitate finding employment.
The need for further evaluation and adaptation to real-world settings
Despite the benefits of integrated care, adoption of these models has been slow, mainly due to implementation challenges in large health systems and difficulties with scaling small research trials models to real-world health systems.5 There is a need to systematically evaluate and improve integrated healthcare models as they expand to real-world settings and larger health systems. Integrated care models are not limited to collaborative care, they range from integrating behavioural health into primary care (e.g., for management of mild to moderate symptoms of depression, anxiety or substance abuse) to integrating primary care into behavioural health (e.g., incorporating primary health in centers for people with severe mental issues).
A recent paper10 focused on four large-scale programmes in the US (Primary and Behavioural Health Care Integration, Certified Community Behavioral Health Clinic, Medicaid Health Homes, and Patient-Centered Medical Home) that either incorporate primary health into behavioral health or are comprehensive, multi-targeted models. There is overall a lack of understanding of what the core elements of these programs are and how to successfully adapt these models to local contexts.10 The authors suggest these national programs have several core common features such as multidisciplinary teams, population health management, referral processes, sustainability strategies, ongoing care management, and coordination of care mechanisms.
Authors explain that integrated care models can be shaped from bottom-up or top-down and that depending on the context/practice setting, different elements of integrated care may be prioritised; however, providers, payers, researchers, and policymakers can use these existing initiatives and the identified common features to understand, adapt, and advance comprehensive models of integrated care.10 The paper also identifies a few areas of improvement across these initiatives such as addressing social determinants of health and leveraging health IT. Leveraging existing technologies, including digital mental health platforms and other telehealth services can increase access to care, enhance the patient experience, and possibly reduce costs.
In the era of precision medicine where the goal is tailoring treatment so that each patient receives exactly the care, they need, integrating care for physical and mental health is essential. Not only can it remove barriers to accessing treatment and improve the overall health of individuals with LTCs and co-morbid mental health issues, but it can also lower overall costs associated with the treatment of these disorders and social welfare due to unemployment. SilverCloud Health will continue to be at the forefront of these efforts and leveraging iCBT has the potential to further enhance the positive findings from integrated care research studies. Read our blog to learn more about SilverCloud research on the effectiveness of their programs in individuals with LTCs.
1. Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., & Galea, A. (2012). Long-term conditions and mental health: the cost of co-morbidities.
2. Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., ... & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, (10).
3. Jacob, V., Chattopadhyay, S. K., Sipe, T. A., Thota, A. B., Byard, G. J., Chapman, D. P., & Community Preventive Services Task Force. (2012). Economics of collaborative care for the management of depressive disorders: a community guide systematic review. American journal of preventive medicine, 42(5), 539-549.
4. Thapa, B. B., Laws, M. B., & Galárraga, O. (2021). Evaluating the impact of integrated behavioral health intervention: Evidence from Rhode Island. Medicine, 100(34).
5. Prom, M. C., Canelos, V., Fernandez, P. J., Gergen Barnett, K., Gordon, C. M., Pace, C. A., & Ng, L. C. (2021). Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations. The Journal of Behavioral Health Services & Research, 48(3), 346-362.
6. Lancaster, Blake 2020 On the Clock: How Integrated Behavioral Health Providers Save Pediatricians Time International Journal of Integrated Care, 21(S1): A245, pp. 1-8, DOI: doi.org/10.5334/ijic.ICIC20352
7. Unützer, J., Katon, W., Callahan, C. M., Williams Jr, J. W., Hunkeler, E., Harpole, L., ... & IMPACT Investigators. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. Jama, 288(22), 2836-2845.
8. Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International review of psychiatry, 23(4), 318-327.
9. Toffolutti, V., Stuckler, D., McKee, M., Wolsey, I., Chapman, J., J. Pimm, T., ... & M. Clark, D. (2021). The employment and mental health impact of integrated improving access to psychological therapies services: Evidence on secondary health care utilization from a pragmatic trial in three English counties. Journal of Health Services Research & Policy, 1355819621997493.
10. Goldman, M. L., Scharf, D. M., Brown, J. D., Scholle, S. H., & Pincus, H. A. (2021). Structural Components of Integrated Behavioral Health Care: A Comparison of National Programs. Psychiatric Services, appi-ps.