This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Rural Models for Integrating Primary Care and Mental Health Services

Primary care has become the hope of this decade for more effective and less expensive personal health care. The primary care physician may be a general internist, general pediatrician or family practitioner but the concept often focuses on the new specialty of family practice. There has been an impressive increase in the number of young physicians entering this field. A large proportion (20–40%) of patients of the primary care physician have diagnosable psychiatric illness. Recent surveys found that 58% of all visits for mental disorder were made to primary care physicians instead of psychiatrists. Family practitioners do not refer most of these patients to psychiatrists because of dissatisfaction with the lack of collaboration, slow responsiveness in terms of seeing the patients, failure to receive reports and lack of demonstrated effectiveness of psychiatric treatment. Often the family practitioner will treat psychiatric problems himself or will refer to a non-psychiatric mental health practitioner (psychologist or social worker). This paper reviews the interaction of psychiatrists with primary care physicians. It suggests a curriculum for post-graduate and continued medical education about psychiatric illness and discusses styles of more effective collaboration between primary care doctors the psychiatrists. It describes the present and potential difficulties caused by the diversion of hopes for behavioral medicine to become a discipline wherein physicians treat those behavioral disorders which influence physical health. Instead the behavioral scientist may see this new field as a pathway into the hospital from which to seek active medical staff membership and independent admission and treatment privileges. Hopefully, these “turf” and economic issues will get worked out as psychiatrists reaffirm their medical identities, participate with other physicians in hospital staff activities and alter their practice styles so as to contribute to the overall health care of our total society. To do otherwise would deprive patients of needed psychiatric skills.

Primary care and psychiatry

This study identified the health resources that rural consumers in DHHS Region V indicated they would use for mental health problems. Data were collected by survey research methods from a probability sample of 3057 rural residents. The study found that rural residents prefer to use primary care givers for mental health problems except in the case of serious mental illness.

Resources Rural Consumers Indicate They Would Use For Mental Health Problems

The subject of rural mental health has received increased attention over the past two decades. Numerous studies have revealed unique problems and assets particular to rural communities. To receive federal funding, mental health needs of a particular area must be demonstrated, yet the government has never prescribed just how needs assessments should be accomplished. Largely due to a lack of direction, many approaches and instruments have been used with varying degrees of success. This lack of consistency makes the comparison of studies very dificult. In order to serve these areas better, a reliable method for assessing mental health needs requires development. In general, there are five busic approaches that can be used in assessing mental health needs: key informant, community forum, social indicators, rates-under-treatment, and survey. lke nature of needs assessment combined with the particular needs and characteristics of rural communities made these five approaches more or less desirable. In order to evaluate each approach critically, a number of criteria were selected from the literature and then systematically applied to each approach. Each approach was then evaluated from the perspective of the appropriateness of its utilization in a rural community. It is recommended that before undertaking a comprehensive mental health needs assessment, the nurse planner first evaluate the agency’s request for a needs assessment. It is essential to determine how specific the needs assessment information should be.

Assessing Mental Health Needs in the Rural Community: A Critique of Assessment Approaches

Frontier areas (defined as six or fewer persons per square mile) are at the extreme end of the urban-rural continuum. Whereas they occupy almost half of the land mass of the United States, they constitute only about 2 percent of the population. Exigencies of harsh climate and vast distances make the delivery of health and human services even more difficult than in other rural areas. This paper describes several innovative models for delivering mental health services to the persistently and seriously mentally ill in rural areas.

Michael E. Samuels

Papers

Need for mental health services in federally funded rural primary health care systems.