Editorial Article

Integration of Behavioral and Physical Health Care and a Role for Precision Psychiatry in U.S. Primary Care and Public Health Settings

Dr. David Keleti
Clinical Outcomes Corporate Medical Management AmeriHealth Caritas Family of Companies, 200 Stevens Drive Philadelphia, PA, USA
*Corresponding author:

David Keleti, Clinical Outcomes Corporate Medical Management AmeriHealth Caritas Family of Companies, 200 Stevens Drive Philadelphia, PA, USA, Email: dkeleti@gmail.com

"Integrated primary care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place." Alexander Blount, Ed.D. Director, Center for Integrated Primary Care.

Mental and behavioral disorders (the latter including substance use disorders, SUDs [1] are a public health concern affecting hundreds of millions of people worldwide, only a small percentage of whom receives the most basic treatment [2]. Individuals with severe and persistent mental illness (SPMIs) die an average of 25 years earlier than the general population, with significantly higher mortality rates resulting from comorbid diseases like coronary heart disease (CHD), pneumonia, influenza, and chronic lower respiratory diseases [3]. Behavioral health disorders are primary drivers of medical utilization and cost; 75% of patients with depression cite physical complaints as their reason for seeking health care [4]. Therefore, the cost of health care services for psychologically distressed patients is double that of non-distressed patients with the same degree of medical severity [5], with 80% of this differential attributable to increased utilization of medical, not behavioral health services [6]. The frequency of physical diseases is strongly associated with the presence of SPMI, including human immunodeficiency virus, obstetric complications, stroke, myocardial infarction, hypertension, cardiovascular diseases, obesity, metabolic syndrome, and hyperlipidemia [7]. Additional studies have shown that diabetes, CHD, and rheumatoid arthritis are risk factors for comorbid depression [8-10]. Furthermore, an increasing number of patient-reported physical symptoms is associated with greater likelihood of a mental diagnosis [11]. Even the consumption of psychotropic medications by individuals with SPMI may be associated with increased risk of medical co-morbidities like diabetes, obesity, and hypercholesterolemia [3,12].

Medicaid, a U.S. government-funded insurance program providing health care coverage to low-income Americans, is the single largest payer for mental health services in the United States and is playing a greater role in reimbursement of SUDs services [13]. Medicaid beneficiaries are disproportionately affected by behavioral-physical health comorbidities, with significantly poorer ratings of their health compared to those without behavioral health complications [14]. Over half of disabled beneficiaries with psychiatric conditions also had claims for diabetes, cardiovascular or pulmonary disease [15]. Medicaid beneficiaries with mental illness also have significantly more provider visits, monthly filled prescriptions, inpatient and emergency room claims than both individuals without mental illness or the uninsured [14,16].

Unlike those who are institutionalized, individuals with SPMIs living in communities nationwide—especially those with co-occurring SUDs—have difficulties accessing comprehensive healthcare services, often relying on emergency room care. This practice often results in discontinuous care, misdiagnosis, polypharmacy, and excessive burden on the hospital system. Disparities impacting mental health include higher rates of tobacco use, inactivity, alcohol consumption, intravenous drug use, unsafe sexual behavior, poor nutrition, homelessness, poverty, trauma, incarceration, unemployment, and social isolation [3,17]. These impactable risk behaviors dramatically affect the utilization of public health services nationwide.

In the United States, behavioral health has traditionally been managed in isolation from physical health, such that separate institution, provider, and payer systems exist, with minimal intercommunication. This siloed approach toward health care is being re-evaluated in favor of more holistic, collaborative and integrated approaches to managing behavioral and physical health.

Primary care is the de facto mental health system in the United States, although most primary care physicians (PCPs) lack the capacity and expertise to effectively manage such care. Astonishingly, up to 60% of patients (and up to 92% of the elderly) with psychological problems are solely treated in primary care settings, whereas only 20% are treated in the specialty mental health system [18-20]. About 70% of all primary care visits have psychosocial drivers of medical care use, including behavioral disorders, alcoholism and drug addiction, inadequate social support, poor coping skills, and stressful environments [21,22]. Non-psychiatric PCPs prescribe about 80% of antianxiety and 65% of antidepressant medications, as well as 20% of pharmacy-filled antipsychotics [23]. In recent years, antidepressants are increasingly prescribed in primary care in the absence of a psychiatric diagnosis [24].

Unfortunately, less than 13% of patients with behavioral health disorders and less than 5% with SUDs receive minimally adequate treatment in primary care [25]. Furthermore, positive outcome rates for patients receiving behavioral health care in traditional primary care settings are only slightly better than those observed under spontaneous recovery [19,26]. Consequently, three-quarters of patients discontinue taking their prescribed psychotropic medications over the course of a year [27], and 33%−50% of patient referrals from primary to specialty behavioral health care are no-shows [28]. Despite these considerable challenges—and because two-thirds of PCPs report being unable to access outpatient behavioral health care for their patients [29]—addressing some behavioral health conditions in the primary care setting remains a most promising touch point for implementing integrated care strategies.

Integrated care is the systematic coordination of physical health care and behavioral healthcare at a primary point of service, an approach that is both holistic and seamless from the patient’s view. Barriers to implementing integrated care systems are extensive [30], with increasing complexity apparent at higher levels of integration. For the successful implementation of an integrated care program, we must become familiar with established integrated concepts and care models.

Four concepts common to most integrated care models are: the health home, the health care team, stepped care, and four-quadrant clinical integration. The health home is a single site where members are provided comprehensive and continuous medical care (“one-stop shopping” for health care services). It consists of five functional elements: comprehensive care, patient-centeredness, coordinated care, accessible services, and quality and safety [31]. The health care team—often consisting of a registered nurse, care manager, behavioral health practitioner, and auxiliary staff—jointly shares responsibility with the PCP in managing patient care [32]. The stepped care model is based on delivering the minimally necessary, maximally effective and cost efficient care to a patient with non-acute illness. In this model, the patient is escalated through increasingly intense services only if his functioning does not improve under the usual course of care. A patient with a behavioral health condition may first receive basic education or referrals to self-help group before being progressively escalated to 1) clinicians providing psychosocial interventions; 2) behavioral health practitioners applying specific practice algorithms; and finally 3) referral to specialty care [32]. The four-quadrant clinical integration model is a conceptual framework identifying populations best served in primary care versus specialty behavioral health. Patients are classified into one of four quadrants based on their axis position of low-to-high risk/complexity of their physical health issues (abscissa) against their behavioral health issues (ordinate). Patients in the low behavioral/low physical health quadrant are best served in a primary care setting, whereas those in the high behavioral/high physical health quadrant are best served in specialty behavioral health integrated with primary care. Patients in the high behavioral/low physical health quadrant are best served in specialty behavioral health programs with linkages to primary care. Patients in the low behavioral/high physical health quadrant are best served in a primary care or medical specialty setting with occasional referrals to short-term specialty behavioral health care [33]. Many traditional integrated care models are built upon these concepts, a few of which are described below.

The Chronic Care model (CCM) was developed in the early 1990s by Dr. Edward Wagner (Director of the MacColl Institute for Healthcare Innovation and the Improving Chronic Illness Care program) to address the unmet needs of chronically ill patients [34-36]. By 2030, half of the US population is projected to have one or more chronic conditions [37]. The CCM follows an organizational approach for delivering population- and evidence-based care for people with chronic diseases in a primary care setting. Six key elements of healthcare support high-quality chronic disease care: the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Within each of these elements, “change concepts” are applied as principles to direct improvements in care redesign. For example, incentives based on quality of care can help drive an organization to provide higher-quality care [38]. In 2003, updates to the change concepts included patient safety, cultural competency, care coordination, community policies, and case management [39]. The CCM has strongly influenced the development of other widely used practice models like collaborative care and disease management. The Collaborative Care model, developed in the late 1990s by Drs. Wayne Kayton and Jürgen Unützer (AIMS Center at the University of Washington), is perhaps the most widely implemented integrated care model to treat common mental health conditions requiring systematic follow-up. Collaborative care is defined by five core principles: 1) patient-centered team care; 2) population-based care monitored by a tracking registry; 3) treatment-to-target strategies using validated treatment methodologies; 4) evidence-based care; and 5) accountable care [40]. Trained PCPs and embedded behavioral health staff provide evidence-based medication and/or psychosocial treatments, supported by regular psychiatric case consultation, follow-up, and treatment adjustment for refractory patients. This model has been validated in more than 80 randomized controlled clinical trials internationally, including the IMPACT-D trial for late-life depression [41,42] and several meta-analyses [43-45], demonstrating substantial evidence for improved outcomes compared to usual care in patients with depression or anxiety.

The Systems of Care model was first described by Drs. Beth Stroul and Robert Friedman (Georgetown University Center for Child Development) in 1986 as “a comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of severely emotionally disturbed children and adolescents [46].” Child and adolescent psychiatrists serving patients with complex behavioral health needs interface regularly with multiple social service agencies, so a “wraparound,” family-centered approach facilitates coordination of mental health/substance abuse (MH/SA) services, child welfare, developmental disabilities, juvenile justice, and primary health care [47]. The American Academy of Child and Adolescent Psychiatry has compiled several Systems of Care resources on their website [48], currently the default model in health service delivery for children with serious emotional disturbances. For example, PerformCare New Jersey System of Care program registers, authorizes, and coordinates services (e.g., psychiatric screening services, family support organizations, etc.) for children, adolescents, and young adults experiencing emotional, behavioral, and developmental challenges [49].

The Primary Care Behavioral Health (PCBH) model was first described in 1998 by Dr. Kirk Strosahl (Mountainview Consulting) [50,51]. This model innovated the role of the behavioral health consultant (BHC) embedded in the primary care setting, who collaborates with the PCP to optimize delivery of behavioral health services to primary care patients. Upon completion of the doctor’s appointment, the PCP may initiate a “warm handoff” of the patient to the BHC for brief, low-intensity behavioral health consultations. The BHC has a variety of additional roles, like teaching self-management skills relating to diet and exercise to patients with diabetes or CHD and performing psychotherapy with patients suffering from anxiety or depression. The addition of BHC expertise to a primary care practice expands the availability of behavioral health services to a larger population, allows the triaging and monitoring of high-risk patients, and improves provider-patient communication. A controlled randomized study reported positive short-term outcomes, including marked improvements in depressive symptom reduction, coping skills, adherence to relapse prevention plans and medication regimens, and patient-reported satisfaction [19]. The Three Component model (3CM) was developed by the MacArthur Foundation Initiative on Depression and Primary Care based on the work of Drs. Allen Dietrich (Dartmouth University) and John W. Williams, Jr. (Duke University) investigating the most effective elements of depression management in primary care settings [52]. The model’s three components consist of a PCP, a care manager, and a mental health specialist (MHS), all of whom work collaboratively to provide patient care. First, the care manager telephonically contacts the patient within one week following the initial office visit, and performs monthly follow-ups to evaluate the patient’s treatment response. After communicating the facts with the team, the MHS provides treatment suggestions for effective depression management and follow-up care. The effectiveness of the program was validated by the RESPECT clinical trials, demonstrating improved outcomes of 3CM support versus usual care in patients with depression [53] and posttraumatic stress disorder [54]. The 3CM model also had a formative impact on several well-established integrated health systems like Intermountain Healthcare, MaineHealth, and Colorado Access.

The most established clinical trials concerning integrated care treat depression and anxiety in a primary care setting. IMPACT and PROSPECT evaluated the effect of collaborative care management on late-life depression (the latter also investigated suicidal ideation) [41,55,56]. The CALM study evaluated the impact of collaborative care management, including the use of cognitive behavioral therapy and/or medication, on multiple anxiety disorders (panic, generalized anxiety, social anxiety, and/or posttraumatic stress disorders) [57,58]. The RESPECT-D trial evaluated the impact of the 3CM on major depressive disorder or dysthymia in primary care [53]. Clinical outcomes uniformly reported improvements in functionality and quality-of-life measures compared to usual care.

Several studies have evaluated the impact of integrated care on patients with behavioral health and comorbid chronic illnesses. TEAMcare and PATHWAYS examined the integration of CCM and collaborative care principles to concurrently manage diabetes and/or CHD with comorbid depression in primary care [59,60]. Coincident with the added functional impairment and greater medical symptom burden associated with comorbid depression, diabetes-/CHD-related complications like heart attack, stroke, amputation, or blindness can also trigger depressive episodes [61]. TEAMcare participants exhibited improved depression scores, as well as improved glycemic control (HbA1c), LDL-cholesterol control, systolic blood pressure, and pharmacotherapy initiation and adjustment over usual care patients at 6- and 12-months follow-up [59,62]. Improvements in depression scores, but not medical outcomes, were sustained at 18- and 24-months follow-up [63]. PATHWAYS participants exhibited improved depression scores—especially those with two or more diabetes-related complications—but not improved HbA1c control compared to usual care patients at 12-months follow-up [60,64]. Few collaborative care studies reported on medical outcomes, fewer still reported significant reductions in corresponding clinical measures [65,66] and none reported sustained reductions in major adverse cardiac events [67]. Other studies have examined alternative integration models. PCARE evaluated the impact of adding a primary medical care nurse into community mental health settings (reverse colocation, described below). PCARE participants exhibited significant improvements in Framingham Cardiovascular Risk Scores and SF-36 Mental Component Summary Scores, as well as receipt of more recommended preventive services [68]. PRISM-E compared the impact of random assignment to a MH/SA specialist co-located in the primary care practice (integrated care) versus direct referral to specialty care (enhanced referral) for older adults with depression, anxiety, or alcohol abuse [69]. Older PRISM-E participants (including those at risk for alcohol abuse) were more likely to access integrated behavioral health treatment in primary care at a faster rate, and show more significant reductions in overall drinking and binge drinking episodes, than referral to MH/SA clinics [70,71], although reductions in depression severity at 6-month follow-up were greater for the enhanced referral cohort [72].

Integrated behavioral care is practiced on a continuum, based on the level of collaboration between medical and behavioral health professionals. In 1996, Dr. William J. Doherty (University of Minnesota) and colleagues published the Levels of Systemic Collaboration Model to describe five levels of primary care-behavioral healthcare collaboration: 1) minimal collaboration; 2) basic collaboration at a distance; 3) basic onsite collaboration; 4) close collaboration in a partly integrated system; and 5) close collaboration in a fully integrated system. As the level of integration increases, the practice becomes better equipped to manage patients of increasing physical and behavioral health complexity [73].

In 2010, the Milbank Memorial Fund published an eight-level classification system for practice models: 1) improved collaboration between separate physical and behavioral health providers; 2) medically provided behavioral health care (PCPs delivering behavioral health services, receiving consultative support from a behavioral health professional); 3) Colocation (behavioral health staff working in a medical care setting); 4) disease management (staff providing interventions to manage chronic disease burden); 5) reverse colocation (physical health staff working in a mental health setting); 6) unified primary care and behavioral health (staff supporting the full integration of clinical, administrative, and financing services); 7) primary care behavioral health (using an epidemiological, public health approach to service the entire primary care population, emphasizing brief, focused interventions.); 8) collaborative system of care (hybrid integrated/semi-integrated model with collaborative system of wraparound services) [74]. In the Milbank continuum, healthcare delivery may be coordinated, but provided separately (models one and two) or at the same location (model three). Models four and five are partly integrated, models six and seven are fully integrated, and model eight (a hybrid model) may be partly or fully integrated.

A comprehensive collective history of behavioral health-physical health integration practice is well beyond the scope of this editorial. However, the findings of several reports and analyses are illuminating.

In 2008, the Agency for Healthcare Quality and Research released a meta-analysis of published integrated MH/SA-primary care programs, identifying 33 trials of integrating behavioral health practitioners into primary care [75]. These studies tended to show positive outcomes resulting from integrated care for symptom severity, treatment response, and remission when compared to usual care, despite wide variations in levels of provider integration and integrated processes of care. The report concluded that integrated care enlists strong evidentiary support, especially regarding depression, but no clear patterns emerged correlating improvement in outcomes with increasing levels of provider integration or integrated processes of care. Put bluntly, fully integrated models do not appear to offer superior clinical outcomes in head-to-head comparisons with partially integrated or collaborative care models. This author compiled a comprehensive list of systematic reviews and meta-analyses (SR/MAs) to develop a profile of the common elements associated with behavioral health-physical health collaboration and integration strategies published during the past 25 years [76]. The list was updated in 2016. The resulting metareview retrieved 266 SR/MAs referencing more than 4,000 unique integrated/collaborative care studies (including an estimated 1,500 non-US studies) covering a range of patient populations, health conditions, and treatment models (Table 1).

A majority of SR/MAs examined studies performed in primary care/general practice settings (57%), followed by community, residential or home care (12%). A plurality of SR/MAs examined studies targeting major depressive disorders (35%), followed by mental illness associated with comorbid chronic diseases and/or SUDs (17%). A plurality of these studies was performed in adults (45%) or the elderly alone (13%). A plurality of these studies also focused on psychosocial interventions (e.g., counseling, cognitive behavioral therapy; 32%), alone or in conjunction with pharmacotherapy (9%), followed by collaborative care/shared care (20%), multiple interventions and multilevel complex care (16%), and integrated care with multidisciplinary teams (12%). Studies in secondary and tertiary care settings, as well as those focusing on adolescents and populations with eating disorders or SPMIs (like schizophrenia and bipolar disorder) were underrepresented in the existing research.

Several common themes were evident across the various behavioral health-physical health integration models reviewed. First, an assortment of clinical staff provides behavioral health support. Integrated provider systems included some combination of a psychiatrist or clinical psychologist, therapist, behavioral health-trained clinical nurse, care manager, social worker, and/or community navigator. Second, integrated behavioral health-physical health models have documented clinical improvements mostly in major depression and anxiety, including primary and secondary outcomes (e.g., symptom reduction, medication adherence), as well as operational measures (e.g., targeted referrals and patient engagement). More recent individual studies (not captured in this metareview) have also reported concomitant improvements in short-term medical outcomes relating to diabetes, cardiovascular disease, and physical functioning [59,65-67,77]. Third, risk behaviors may be more effectively managed in clinical or community settings, depending on the specific behavior and the population. For example, smoking cessation interventions may be more effectively managed in primary care, whereas diet and exercise interventions may be more appropriately managed in a community setting. Fourth, although integrated care models have reported superior outcomes to traditional care, higher levels of integration are not by themselves associated with further improvements in depression-, anxiety-, or SUD-related clinical outcomes.

Common elements have been identified in successful integrated primary care programs, but no best practices have been definitively validated as significant predictors for promoting positive health outcomes. Rather, successful strategies implement multifaceted, system-level interventions, including those that incorporate clinician education, nurse case management, and consultation-liaison interaction between primary and secondary care. Simple guideline implementation and educational strategies alone are generally ineffective. Counseling and some forms of brief psychological treatment are broadly effective for a wide range of generic psychological conditions presenting in the primary care setting. There was little evidence to support greater long-term effectiveness of any one psychosocial treatment over another, although the best quality evidence supported motivational interviewing for short-term SUD improvements. Looking ahead, improved stratification of behavioral health-physical health integration and collaboration models will aid in determining the relative successes of different integration approaches.

Table 1: Metareview of Systematic Reviews and Meta-analyses (SR/MA).

Delivery Setting

%SR/MA

BH-PH models/interventions

%SR/MA

Primary care/general practice

57%

Psychosocial interventions

32%

Community services/residential/home care

12%

Collaborative care (US)/shared care (UK)

19%

Outpatient hospitals/clinics

7%

Pharmacotherapy

10%

Psychiatric inpatient/mental health or substance abuse clinic

5%

Psychosocial interventions + pharmacotherapy

9%

Secondary  and tertiary care

4%

Screening/assessment

9%

Inpatient hospital/trauma center

3%

Integrated BH-SUD treatment

8%

Nursing home/hospice/long-term care facility/care home

2%

Integrated care/multidisciplinary teams

12%

U.S. Veteran Affairs

1%

Disease management/chronic care model

5%

School

<1%

Multiple (≥3 settings)

7%

Intersectoral communication/shared decision-making

5%

Unspecified

2%

Conditions

%SR/MA

Cost/expenditures of BH-PH programs

5%

Major depression

35%

Major anxiety

4%

Case/care management (including assertive and intensive community treatment)

4%

Mild-to-moderate depression/anxiety

2%

Perinatal/postnatal depression

2%

Linkages/referrals

4%

Substance use disorder (SUD)

5%

Community outreach (including community health workers/navigators)

3%

Post-traumatic stress disorder

2%

Eating disorders

2%

Somatoform disorder

1%

Patient health education/coaching

2%

Autism/special needs

1%

Dementia

1%

Guided self-management

2%

Bipolar disorder

1%

Behavioral health training in primary care

2%

Schizophrenia

1%

Multiple SPMIs

11%

Psychiatric consultation/consultation-liaison in primary care

2%

SPMI with comorbid disease/SUD

17%

General/unspecified

16%

Stepped care

1%

Population

%SR/MA

Colocation

1%

Adults only (≥16 years)

45%

Guidelines and algorithms

1%

Elderly only (≥55 years)

13%

Patient-centered medical homes

1%

Adult + Elderly

6%

Peer support

<1%

Maternal/Pregnancy

5%

Wraparound services

<1%

Children + Adolescents

3%

Multiple (>4 models, including multilevel complex initiatives)

16%

Adults + Adolescents

3%

Adolescents only

<1%

Unspecified

1%

Families

1%

No intervention

<1%

Veterans

1%

 

All age groups

9%

Unspecified

15%

The aforementioned integrated care models are rarely fully implemented due to operational, logistic, and budgetary constraints. Indeed, integrated care practices are as varied as the communities they serve (readers are invited to consult the references below for specific practice models). In this section, we will limit ourselves to outlining one example in the health plan sphere.

Aetna is a U.S.-based managed health care company with a membership of over 18 million individuals and a network of over 1 million health care professionals. In 2005, Aetna invited the PCPs in its network to participate in the Depression in Primary Care Program, designed to train physicians to improve the care of depression in a PCP setting [78,79]. The basic collaborative care model consisting of three primary components: 1) PCPs screen for depression using the patient health questionnaire 9 (PHQ-9) assessment; 2) Aetna care managers telephonically contact participating patients at 1, 4, and 8 weeks post-treatment to inquire about their status and address any problems they encounter; and 3) behavioral health referrals are facilitated by care managers at the physicians’ behest. Additional offerings include psychiatric consultation to PCPs and a PCP incentive system with a reimbursement that was $15 more per screening in addition to their office visit fee.

Major barriers for practices in implementing this program included identifying the minority of Aetna members within a given practice, the need to change the PCP practice workflow to administer the PHQ-9 assessment, and the requirement to submit a special claim form to Aetna using an Aetna-specific billing code for the screening. Of the 5,000 practices that were approached to sign up with the program, about half initially agreed to participate, but PCP participation slowed considerably thereafter [75].

By 2006, evidence of a significant favorable impact by improved PHQ-9 scores was limited to a small subset of Aetna members who had very high risk of medical care and depression, and who were already engaged in an active case management program. A decrease in medical costs (primarily in inpatient care) and an increase in pharmacy costs was observed with a net savings of about $136–$201 per member per month [75]. These favorable results informed the development of additional integration initiatives, like the Medical Psychiatric Case Management program to treating members with chronic medical disorders and comorbid depression [80].

The ‘Precision Medicine Initiative,’ launched by President Obama in 2015, allocated $215 million for precision medicine research and development [81]. Although primarily directed toward federal sponsorship of cancer research, the announcement spurred interest in applying precision medicine strategies to non-oncology fields, including behavioral health.

Patients with behavioral health conditions are often treated pharmacologically in a trial-and-error manner. For example, patients with depressive and anxiety disorders commonly take selective serotonin reuptake inhibitors as first-line therapy for six-to-eight weeks before a determination is made whether the medication is effective [82]. If the regimen is not effective, providers will adjust doses or prescribe alternate medications. This cycle may be repeated multiple times, resulting in months of ineffectual treatment and delays before a patient’s condition is effectively managed. The STAR*D study followed patients with non-psychotic major depression for six years through a sequence of treatment regimens, reporting that only 37% achieved remission on first-line treatment with selective serotonin reuptake inhibitors, while another 16% withdrew due to drug intolerance [83]. An understanding of individual mental health pharmacogenomics profiles of patients with specific mutations may allow clinicians to more accurately predict the most effective medications at proper doses administered earlier during disease progression, thereby dramatically shortening treatment timelines and improving effectiveness of personalized care plans [84].

The Research Domain Criteria by the National Institute of Mental Health is a neurobiology-based research framework aimed at classifying mental illnesses, integrating various levels of information to improve our understanding of the underlying bases of human behavior [85]. Besides genomic data, the development of diagnostic categories also includes biological, psychological, and sociocultural variables. Investigators expect that some mutations will be identified and precision-medicine-guided treatments will be advanced for subpopulations with brain disorders possessing strong genetic components like autism, schizophrenia, bipolar disorder, and obsessive-compulsive disorder. However, since only a subset of screened patients will possess such biomarkers, precision medicine is unlikely to be a panacea for treating all mental illnesses. Rather, it will help clinicians identify genetic risk factors that contribute to the patient’s overall risk profile; a databank that will include his symptomology, physiology, cognitive assessments, environmental exposures, social supports, and sociocultural background [86,87]. As Dr. Jeffrey Lieberman of Columbia University has stated, precision medicine “offers the possibility of ‘peeling the onion,’ dissecting psychiatric disorders into much more precise categories that pertain to that individual,” and moving from trial-and-error to evidence-based treatment strategies [88].

Preparations are already underway to capitalize on advances in precision psychiatry in the private sector. 2bPrecise LLC, subsidiary of the healthcare information technology company Allscripts, is a precision medicine platform developer with offerings that combine genomic and clinical data for statistical analysis and pattern detection. The Holston Medical Group, one of the largest multi-specialty providers in the southeastern US and a leader in electronic health record integration, partnered with 2bPrecise to deploy its precision medicine platform to improve behavioral health care at their patient’s point of service, especially for patients with opioid addiction [89].

At first glance, the integrated care and precision psychiatry strategies appear widely divergent. Integrated care seeks to consolidate the management of physical health and behavioral health conditions into a unifying treatment program, whereas precision psychiatry seeks to isolate the genetic basis for mental illnesses. However, a purely genetic approach to precision psychiatry is unlikely to be impactful at the population level, even in SPMIs with a strong genetic component. Rather, genetic data will be only one of a number of biological, psychological, and sociocultural variables comprising a patient medical profile. As integrated care programs proliferate and existing practices mature, clinicians will accumulate more knowledge concerning the interplay between physical health and behavioral health conditions, as well as how they are most effectively managed. The hope is that precision psychiatry will then take medicine to the next level of patient care with targeted behavioral pharmacological and psychosocial therapies.

The author would like to thank Jasmine Vickers and Lauren Murski for their assistance in preparing the meta review statistics, as well as Caryn Frankovitz and Katey Weaver for their thoughtful comments on the manuscript.

The views and opinions expressed in the article are those of the author and do not necessarily reflect the views and opinions of AmeriHealth Caritas.

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Citation: Keleti D (2017) Integration of Behavioral and Physical Health Care and A Role For Precision Psychiatry In U.S. Primary Care and Public Health Settings. J precision Med and Public Health 1:e006.

Published: 26 September 2017

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