ACU Column 15.4 (November 2004): Connected Separateness or Separate Connection: Envisioning Body with Mind

Consumers, including those who are poor and underserved, do not experience mental and physical health separately, although the dualism of the health care systems for primary care and mental health suggests that they do. Few consumers seeking health care services, whatever their socioeconomic circumstances, do so because they themselves recognize that they suffer from a mental disorder, a substance use disorder or even one of the ubiquitous problems of living that increase stress, anxiety and other negative feelings that give rise to deleterious behaviors (such as increased drug use, overeating, excessive shopping, inappropriate acts of violence). In contrast, lay people quite commonly self-diagnose and seek out health care services, motivated by physical discomfort or concerns about illness or by physical situations such as pregnancy; accidents and injuries; sexually transmitted diseases; headaches, stomach aches, and other assorted pains; and complications from diabetes, liver and kidney disease and hypertension.

Approximately 37 million Americans 15 years old or older, or 15% of the population, have some sort of physical, mental, or emotional disability, making this one of the largest minorities in the country.¹ (In fact 15% is probably lower than the actual percentage but it is the confirmable number given the paucity of the data and difficulties associated with epidemiological research.) An overwhelming 70% of the total U.S. population at some point in their lives will endure a condition lasting at least 6 months that interferes with activities of daily living, qualifying them as disabled.² Unfortunately, our current health care system, in both its organization and financing, legitimizes the medicalization of these conditions, relegating problems associated with mental health to a lesser status. Meanwhile, the current U.S. health care system, having shifted its focus from infectious disease to chronic disease and behavioral disorders, engages in an unending discussion of how to integrate primary care and mental health, without emerging with significant changes to the medical model.

Providers, policymakers, and administrators, as well as consumers, must realize that the stigma associated with mental disorders, emotional problems, and even the normal sequellae to bereavement, physical relocation, marriage, divorce or separation, financial difficulties, weather-related disasters, and job loss is an impediment to positive outcomes including resiliency and wellness, self-care, and disease management for chronic conditions. In studies, conferences, and articles, health professionals implore the primary care and mental health systems to integrate rather than remaining separate. Federal efforts to promote these connections can be traced at least as far back as 1967, when community and migrant health centers were founded and to 1973, when federally qualified health maintenance organizations were first formed.³ Despite these efforts and the existence of some excellent models and programs where attention to body with mind is paramount, requests for integration continue to pour out, as is evident in the final report of President Bush's 2003 Commission on Mental Health.⁴ Significantly, the authors of that report note, "Primary care providers may lack the necessary time, training, or resources to provide appropriate treatment for mental health problems. (page 21)"⁴

Experts and practitioners in behavioral medicine and public health typically welcome the opportunity to integrate psychosocial with biomedical approaches to health and illness. Such opportunities arise during primary prevention encounters and the attendant attempts to change factors influencing health or well being, especially lifestyle and attitudes, beliefs, and moods that influence adaptation to stressors or illness. However, with the exception of behavioral medicine, a discipline whose intervention techniques ultimately are based on learning theory,⁵ few physicians or other primary care providers are interested in or profess to have the time to impart strategies to enhance mental health, prevent mental disorders or teach disease management techniques to treat mind with body.

Health care is evolutionary. The emergence of managed care shifted the spotlight to primary care. In the early 1990s, the Institute of Medicine (IOM) appointed an expert Committee to assess the opportunities and challenges for primary care.⁶ One central characteristic of primary care is noted in the IOM report: "Primary care does not consider mental health separately from physical health. (page 81)"⁶ While many...