Report of a Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care

National Library of Medicine Cataloging in Publication

Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care (2000 : Atlanta, Ga.)

Report of a Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care : held on November 30-December 1, 2000, at the Carter Center, Atlanta, Georgia. — Rockville, MD : U.S. Dept. of Health and Human Services, Public Health Services, Office of the Surgeon General ; Washington, D.C. : For sale by the Supt. of Docs., U.S. G.P.O., 2001.

Includes bibliographical references.

1. Delivery of Health Care, Integrated / congresses. 2. Mental Health Services / congresses. 3. Primary Health Care / congresses. 4. United States. I. United States. Public Health Service. Office of the Surgeon General.

02NLM: W 84 AA1 S961r 2001

Suggested Citation

Department of Health and Human Services (DHHS). Report of a Surgeon General’s working meeting on the integration of mental health services and primary health care; 2000 Nov 30–Dec 1; Atlanta, Georgia. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.

This publication is available on the World Wide Web at http://www.surgeongeneral.gov/library.

For sale by the Superintendent of Documents, U.S. Government Printing Office,

Internet: www.bookstore.GPO.gov Phone: Toll Free 1 (866) 512-1800; DC area (202) 512-1800

Fax: 1 (202) 512-2250 Mail: Stop SSOP, Washington, D.C., 20402-0001

A groundbreaking meeting was held November 30 – December 1, 2000, to advance the integration of mental health services and primary health care. The meeting was an outgrowth of the U.S. Surgeon General’s landmark report on mental health.1

That report’s single recommendation was to encourage people to seek help for mental illness. It found that a startling majority of adults and children with mental illness do not receive any services. The report featured primary care as one of the prime portals of entry into treatment—especially for those reluctant to access, or unaware of their need for, mental health services. Primary care was also seen as an opportune site for emphasizing wellness and prevention of mental illness. Yet few programs nationwide are expressly organized to integrate mental health services and primary health care—and even fewer have been evaluated fully.

The meeting2 was designed to set a blueprint for the future. Its specific objectives were to forge consensus among diverse participants on core principles and on a national action strategy for the integration of mental health services and primary health care.

Participants invited to the meeting represented a cross-section of consumers and families, insurers and health care systems, researchers and other experts, clinicians, and representatives from foundations and government (Appendix A). These groups are key to launching a new public/private approach.

This meeting report covers Surgeon General David Satcher’s remarks, the format of the meeting, its highlights, and, finally, the core principles and national action strategy generated and voted upon by participants. The report does not include activities that have occurred since the Carter Center Meeting.

Brief Summary of Dr. Satcher’s Remarks

The meeting opened with an eloquent speech from Dr. David Satcher. He began by noting, in particular, the diversity of the participants including business, health care systems, consumers, families, and foundations, as well as government agencies. He was particularly impressed with the balanced presence of primary care and mental health experts who were well established in their fields. These experts included “real world” and “front line” people who would be key to helping solve some of the unfortunate barriers within our current health care system. He then challenged the participants to think beyond each of their individual perspectives and consider ways to overcome barriers between primary care and mental health. He noted that many golden opportunities exist for integrating mental health services and primary care.

He presented his thoughts regarding the highlights of the Millis report on the role of primary providers (Millis, 1966). That report identified a number of roles for primary care providers. They included providing first contact of care, providing comprehensive care, providing the coordination and integration of care, and providing community leadership.

Dr. Satcher acknowledged, as a family physician, both the frustrations and opportunities presented to the primary care provider on a daily basis. As the Surgeon General he pronounced the evidence in 1999 in Mental Health: A Report of the Surgeon General and the need to create a system of care that not only treats illness but also promotes health. He named building a balanced community health system as one of his top three national priorities. A balanced community health system balances health promotion, disease prevention, early detection, and universal access. This system concept would require a partnership between primary care and mental health and between public health and medicine.

Primary care offers golden opportunities as a point of first contact with patients and their families, in which a meaningful relationship can be established to educate and motivate patients, as well as to detect health condi

1 U.S. Department of Health and Human Services (DHHS). Mental Health: A Report of the Surgeon General. Rockville, MD: Author, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

2 Sponsored by the Assistant Secretary for Health/Surgeon General of DHHS.

tions. A “balanced partnership” provides an opportunity for the coordination and integration of patient care. This is actualized by involving the health team and the family and targets continuity of care, which ensures comprehensive high-quality care.

Dr. Satcher addressed specifically the lack of time in primary care that providers have to adequately attend to the many responsibilities that our health care systems require of them. He urged primary care providers to remember that they are not alone. In fact, he challenged the primary care provider to be the quarterback of the health care team that collaboratively makes the system work for the patients and their families. He spoke of our negligence of the health care system for not engaging the potential resources available within families. Not only is family involvement therapeutic for the patient, but it is the key to sustaining continuity of care and providing high-quality care.

He then encouraged providers to act as responsible community leaders who educate, motivate, and mobilize the public regarding the definition of mental health as stated in Mental Health: A Report of the Surgeon General. He went on to define mental health as a person’s ability to function and to be productive in life; to adapt to changes in his/her environment; to cope with adversity; and to develop positive relationships with others. He emphasized that without good mental health one cannot have good health and well being. Therefore the primary care and mental health partnership is crucial for overall balanced health.

The good news in the mental health report, he indicated, is that we have the ability, perhaps 80 to 90 percent of the time, to treat mental disorders with a range of different treatments. However, the bad news is that less than half who suffer each year seek treatment. And many who make contact with the health system don’t necessarily make contact with the mental health system because they are experiencing mental illness, because they are unaware, or because of the stigma surrounding mental illness. Others have trouble because of barriers associated with the health care system itself.

Dr. Satcher moved on to ask what is the vision for the future and what is the task ahead. He then pointed out that Mental Health: A Report of the Surgeon General devoted an entire chapter to laying a vision for the future. He went on to identify the eight courses of action in that chapter to include the following:

l Our work should be based on the best available science so that we may prevent disease and promote good mental and physical health. Thus,

we must continue and enhance mental health research, especially prevention and promotion.

l We must acknowledge and find ways to overcome the barriers of stigma.

l We need to build public awareness regarding mental health and effective treatments.

l We must address the serious shortage of mental health providers and the lack of training available for many community helpers who could potentially impact a person’s health.

l We need to ensure the delivery of state-of-the-art treatment which means moving front-line knowledge to front-line care so that primary care providers have access to knowledge, technology and teams of experts to support their work with their patients and families.

l We need to tailor treatment to age, gender, race, and culture.

l We need to facilitate entry into treatment.

l We need to remove the financial barriers that create complexity and restrictions within our health care system.

Dr. Satcher ended with a quote from John Gardner, Secretary of Health, Education, and Welfare in the 1960s, “Life is full of golden opportunities carefully disguised as irresolvable problems.”

Meeting Format

The conference agenda was structured around formal presentations, question-and-answer sessions, and small breakout groups for detailed deliberation. Panel presentations and question-and-answer sessions furnished a common understanding of the nature of the problem, some “real world” programs, the hurdles and opportunities programs face, and findings from research.

Dr. Satcher’s speech was followed by a state-of-the-art review of practice and research findings gathered from structured interviews. The structured interviews had been conducted before the meeting by consultant and meeting organizer Brenda Reiss-Brennan, President of Primary Care Family Clinics, Inc. Over 90 interviews were completed of attendees and nonattendees from a diverse group of experts representing business, foundations, federal agencies, consumers and families, research, employers, economists, epidemiologists, providers, health care consultants, and payors. Ms. Reiss-

Brennan gave an overview of her findings about participants’ level of interest in the process of integration3 and their rationale for developing systemic approaches to promoting healthy families and communities.

The interviews indicated that clinical research knowledge appears to be directing the field toward integration and economic knowledge appears to be directing the field away from integration. In the middle of this quality gap, being squeezed to maximum capacity, are providers of care and their patients and families, who attempt to negotiate major health disabilities in stressed environments. This current nonintegrated process of care creates costly burdens for the health care system, the family, and the community.

Interviews revealed consensus among participants to build collaboration and commitment among stakeholders that result in strong leadership, mobilization of successful implementation strategies, and demonstration of affordable, evidence-based integrated care.

After plenary and panel presentations, participants were divided into five breakout groups, covering seminal issues of design, training, economics, research, and quality. The breakout groups were charged with developing ideas for core principles and action steps, and then bringing those ideas forward for general discussion by all participants.

A reporter from each breakout group presented their group’s priorities when participants reconvened in a general session. With the aid of a professional facilitator to guide the discussion and build consensus, participants separately voted on their top core principles and action steps.

Meeting Highlights

Nature of the Problem

Every year, about 20 percent of U.S. adults and children have a mental disorder. Despite an array of effective known treatments, the majority of those with mental disorders do not receive treatment and thus needlessly suffer from distress and disability. Mental disorders are highly disabling, ranking second only to cardiovascular conditions as a leading cause of worldwide disability by the World Health Organization (Murray & Lopez, 1996). Moreover, these disorders impose substantial cost burden to patients, their families, and communities at large. That burden is reflected in lost productivity and

premature death and in the amount of medical and community resources expended.

The prevalence of mental disorders in primary care is somewhat higher than that in the population. About 25 percent of people receiving primary care have a diagnosable mental disorder (Olfson et al., 1997), most commonly anxiety and depression. Depression occurs in about 6 to 10 percent of primary care patients (Katon & Schulberg, 1992). Older adults are particularly vulnerable in an unintegrated system because many of them are treated in primary care for a variety of health conditions, and depression may go undiagnosed and untreated. Low-income minority populations face similar identification barriers because primary care services are often cost prohibitive and difficult for them to access.

Major depression is one of the more prevalent conditions observed in the primary care setting afflicting an estimated 5 to 9 percent of presenting patients. Such prevalence coupled with evidence that most depressed patients receive mental health care from primary care physicians (Coyne et al., 1994; Reiger et al., 1993; Rost et al., 1998) has prompted much attention in the field.

Mental disorders frequently co-occur with other mental or somatic (physical) disorders. Estimates of this “comorbidity” range from about 20 to 80 percent of primary care patients (Sherbourne et al., 1996; Olfson et al., 1997). Comorbidity adds to disability and contributes to morbidity and mortality.

There are a number of barriers to effective diagnosis and treatment of mental illness in primary care. Overwhelming societal stigma is partly to blame for patients resisting diagnosis, resisting treatment altogether, or not adhering to treatment recommendations (DHHS, 1999). Primary care providers vary in their capacity to recognize and diagnose disorders, and, if they do so correctly, they may not adequately treat or monitor patients. Some estimates are that about half of those with mental disorders go undiagnosed in primary care (Higgins, 1994). Finally, mental health services—in either primary care or through referral to specialty care—are often difficult to access, fragmented, or poorly financed. Thus, the integration of mental health services and primary health care faces broad-sweeping attitudinal, educational, organizational and financing problems. These problems stem in part from the historical separation of mental health from the mainstream of medicine (DHHS, 1999).

Opportunities

Primary care holds a myriad of opportunities to engage patients in need of mental health care. These opportuni

3 Participants spent a significant amount of time discussing integration but were unable to reach a consensus on a definition for integration.

ties range from health promotion to disease prevention and treatment.

As a first point of patient contact with the health care system, primary care is often closer to home or work and more affordable than specialty care. It offers the possibility of cost-effective treatment, particularly with less severe mental disorders. Primary care also has the potential for early identification of symptoms and for coordination and continuity of care for both mental and somatic disorders. This is highly important given the frequency of comorbidity and the long-term nature of many mental disorders. Further, a focus on mental health within primary care underscores a message of the Surgeon General’s report: Mental health is fundamental to overall health.

Primary care is not only where individuals receive care; it is where family members do too. By establishing relationships with the family, primary care providers have the advantage of tapping the family as a source of support. These relationships with the family are key for children and older people with mental disorders.

Perhaps most importantly, primary care is where many consumers prefer to receive mental health services (Annexure et al., 1997). Primary care is often perceived by consumers as less stigmatizing than the specialty mental health sector.

Most of these opportunities for integrating mental health care have yet to be realized, with the exception of one mental disorder: depression. Research and practice on prevention, diagnosis, and treatment of depression in primary care have been proceeding for more than a decade (Schulberg et al., 1999). A special subgroup of meeting participants met to explore depression as a model for service integration.

There are many possible ways to organize and staff mental health services in primary care, for integration does not exclusively rely on a single setting or type of professional. Some programs described at the meeting use a psychiatric social worker to deliver mental health services and to “bridge” primary care and specialty mental health care, with patients seen in either setting. Other programs use multidisciplinary teams, including mental health care, to furnish care in the context of routine health visits and follow-up within the primary care setting. Regardless of the variation, a central feature of many programs is enhanced training of primary care providers in the detection of mental health problems.

Obstacles and Challenges

As is true for any new approach to health care, an array of obstacles stand in the way of attaining the promise

of integrated and collaborative care. The nature of the problem is compelling, and the opportunities plentiful. Our Nation’s health care system is a highly complex and diverse system serving the interests of consumers, professionals and providers, hospitals, insurers, employers, and government. The rationale for integration of care, according to meeting participants, needs to be made for each of these stakeholder groups and bolstered by empirical research on cost, efficacy, quality, and consumer satisfaction.

And beyond these traditional stakeholders are many vulnerable populations who are uninsured and thus left out of public or privately funded systems of care. The obstacles and challenges described by meeting participants are highlighted below.

Design

A major design challenge to the integration of mental health services and primary health care is the lack of motivation—on the part of consumers, providers, and payors.

l Consumers are hesitant to accept and follow through on mental health services.

l Primary care providers are overwhelmed by limited time to attend to each patient’s needs. Visits last on average 13 to 16 minutes, and patients have an average of six problems to address with their provider (Williams et al., 1999).

l Partnerships between primary care providers and mental health professionals have been stymied by different cultures of care, including styles of communication and duration of office visits.

l Payors have limited motivation to offer integrated programs owing to what they see as high start-up costs, lack of consumer demand, and limited evidence for cost neutrality or cost offsets (in terms of lower overall health care costs, lower disability costs, or improved worker productivity) (Malek, 1999).

l Other major design challenges include delegation of roles and responsibilities of primary care physicians and other professionals (e.g., mental health specialists, nurses, health educators) and the need for common integrated information technologies for medical records, scheduling, billing, and reporting.

Training and Practice Guidelines

There are few training programs and practice guidelines that emphasize the integration of mental health services and primary care.

l Primary care providers generally have little formal training in the diagnosis and treatment of mental disorders and even less in promoting mental health wellness and disease prevention.

l Primary care providers have sparse guidance about decision support, i.e., what disorders (alone or in combination) and at what level of severity can be treated effectively in primary care versus being referred to mental health specialty care.

l There are few incentives for educational institutions and professional organizations to step beyond existing training and practice programs to embrace integrated and collaborative approaches.

l If demand for services expands, integrated programs may be unable to keep apace because of an insufficient supply of well-trained mental health professionals in rural areas and many other parts of the country (Peterson et al., 1998).

Economics

There are many economic barriers to the creation and implementation of integrated care.

l The funding of mental health services is generally separate from the funding of general medical services.

l There is lack of parity, i.e., the level of funding of mental health services is more restrictive than and not on an equal footing with that for general health services. Further, over the past decade, spending for mental health services has decreased as a percentage of overall spending for health care (DHHS, 1999).

l An increasing number of health plans are moving to “carved-out” mental health services, i.e., separate systems of financing, delivering, and managing specialty mental health services. Carved-out mental health plans have little economic incentive to offer, or to participate in, integrated treatment because these plans cannot recoup cost offsets (reductions in overall health care utilization/costs as a result of treatment of mental disorders).

l There is little, if any, economic incentive for mental health and primary care providers to collaborate across disciplinary lines and develop a team approach to care.

Quality

There are few explicit programs for measuring quality of services that integrate mental health care and primary health care. One step forward has been the development of quality improvement programs for treating a single mental disorder—depression—in primary care (Wells et al., 2000).

l The development and continued monitoring of quality-improvement programs rests on a foundation of skills and knowledge concerning staffing and treatment of mental disorders in primary care, yet such knowledge has yet to be developed beyond that for depression.

l Greater attention to quality improvement is likely needed for vulnerable populations. For example, research has found that patients at greatest risk of having their mental health problems go undetected in primary care include African Americans, men, and younger patients (Borowsky et al., 2000).

Research

With the exception of depression, research is sparse on the development or evaluation of programs for the integration of mental health services and primary care.

l Research funds are generally limited to the conduct of research and thus cannot be used to sustain research programs found successful.

l Programs with strong efficacy based on research are difficult to translate into the “real world” of practice owing to heterogeneity and diversity of patient populations, comorbidity, and less monitoring of outcomes by providers (DHHS, 1999).

l Little research has been directed to integrating primary care and mental health services for people with severe mental illness.

l There has been a paucity of investigator-initiated research applications in this area.

Recommendations Toward Core Principles

Meeting participants agreed to the following principles—or fundamental elements required to facilitate the development and implementation of programs that integrate mental health services and primary health care. They provide a framework, not only for local programs, but also for a National initiative.

1. Emphasis on Consumers and Their Families. The needs of mental health consumers and their families should drive service delivery and systems of care. Cultural and ethnic diversity should be respected. The integration of mental health and primary care is meant to expand access to care and is not intended to preclude availability of mental health specialty care for those who need it.

2. Promoting Health and Overcoming Disparities. Promote health for all Americans and overcome disparities in the burden of illness and death experienced by African Americans, Hispanics, Native Americans, Alaska Natives, and Asians and Pacific Islanders.

3. Basic Characteristics. Research, training, and practice should incorporate consumer, family, and professional partnerships; cross-disciplinary professional collaborations; population-based health care; a holistic approach to health care; and respect for, and understanding the role of, spirituality and alternative medicine/traditional healing practices.

4. Financial Incentives for Team Approach. New types of financial incentives should be offered to encourage team approaches to care. The team includes consumers and families, primary care providers, mental health professionals, and nursing case managers. The team may also include care management, consultation, and specialty services.

5. Reimbursement. Reimbursement should be designed to support evidence-based care.

6. Collaboration/Colocation. Integrated service delivery should be guided by a commitment to collaboration or colocation of services.

7. Chronic Illness, Continuity of Care. Integrated service delivery should feature the treatment of chronic illness and continuity of care.

8. Standardized Quality and Outcome Measures. Quality and outcome measures should be standardized across systems and levels of care and include consumer/family participation. The collection of information should respect consumer and family privacy. The information should be transportable and longitudinal.

9. Building on Existing Models. The development of integrated programs should build on existing knowledge and/or models of care.

10. Research and Demonstrations. Research findings must be salient to key stakeholders, including diverse ethnic and cultural communities. Successful research and demonstration programs should be sustainable through multifaceted partnerships brokered by funding agencies.

11. Investment in Training. Training should build collaborative partnerships that are grounded in clinical and systemic decision making of the highest quality. Quality should reflect evidence-based knowledge that is disseminated in culturally sensitive ways to promote health and reduce stigma.

12. Information Technology. Information technology should be marshaled as a tool for communication, patient education, data collection, and access to care. This technology should support the infrastructure needed to deliver high-quality care while protecting patient and family confidentiality.

Recommendations Toward a National Action Strategy

The core principles provided the foundation on which participants were able to build consensus in developing actual strategies that would promote the bridging of primary care and mental health. These strategies were prioritized into the following action strategy recommendations. The recommendations reflect the merging of multistakeholder expert opinions from the fields of practice and research and were put forth as a guide to spawning a national action strategy to promote implementation of evidence-based quality care. Since the Carter Center meeting, this National Action Strategy has undergone further evolution.

1. Convene a group under the auspices of the DHHS to develop a framework for the integration

of mental health care and primary care, including a focus on comorbidities, diverse modalities, and diverse populations.

2. Incorporate a list of skills, knowledge, attitudes, and simple tools that reflects evidence-based “best practices” and treatment management, leading to improved outcomes.

3. Design education and training standards for the integration of mental health care and primary health care—with all stakeholders, including accreditation bodies—and promote implementation of those standards by schools of health and behavioral health.

4. Evaluate whether program and policy initiatives on integration lead to the elimination of racial and ethnic health disparities and promote equal access to high-quality health care.

5. Develop a plan for research and demonstration projects on integration that meet basic methodological requirements for generalizability with respect to service delivery models and health outcomes.

5.1 Articulate a vision for success for a consumer-driven integrated service delivery system that includes the following: awareness of the culture of primary care, patient education, professional training, follow-up care, and care management.

5.2 Bring together multiple private and public funding sources for projects and develop a plan for projects—sustainability, if the projects are found successful.

5.3 Convene accreditation and licensure and regulatory agencies to reduce barriers to implementation of research and demonstration projects (e.g., funding and/or regulatory waivers).

5.4 Lead to development of initiatives that foster the development of service and economic models with these basic features: (a) collaborative/integrated care among consumers, primary care providers, and mental health specialists to meet local needs; (b) evidence-based approach to care delivery based on scientific methods (e.g., randomized controlled trial, quasi-experimental design, case-control study, survey designs); and (c) mea

surement of outcomes, such as access, costs, functional status, quality of life, patient/family/provider satisfaction, health beliefs/stigma, relapse reduction, sentinel events, recovery, and the effects of consumer and provider incentives on health outcomes and process measures.

Annexure J, Katon W, Sullivan M, Miranda J. The effectiveness of treatments for depressed older adults in primary care. Paper presented at Exploring Opportunities to Advanced Mental Health Care for an Aging Population, sponsored by the John A. Hartford Foundation, Rockville, MD, 1997.

Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells, KB. Who is at risk of non-detection of mental health problems in primary care? J Gen Intern Med 2000;15(6):381–8.

Coyne JC, Fechner B, Ates S, Schwenk TL. Prevalence, nature and comorbidity of depressive disorders in primary care. Gen Hosp Psychiatry 1994;9(4):267–76.

Department of Health and Human Services (DHHS). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

Higgins ES. A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med 1994;3(10):908–17.

Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;14(4)237–47.

Malek SP. Financial, risk and structural issues related to the integration of behavioral health care in primary care settings under managed care. Research report published by Milliman & Robertson, Inc., 1999.

Millis JS. The Graduate Education of Physicians. Report of the Citizens’ Commission on Graduate Medical Education. Chicago: American Medical Association, 1966.

Murray CJL, Lopez AD (Eds.). The global burden of disease. Comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard School of Public Health, 1996.

Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, Hoven C, Farber L. Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 1997;154(12):1734–40.

Peterson B, West J, Tanielian T, Pincus H. Mental health practitioners and trainees. In RW Manderscheid, MJ Henderson (Eds.), Mental Health United States 1998 (pp. 14–246). Rockville, MD: U.S. Department of Health and Human Services, Center for Mental Health Services.

Reiger DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorder system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50(2):85–94.

Rost KM, Zhang M, Fortney J, et.al. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry 1998;20(1):12–20.

Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry 1999;60(Suppl 7):19–26.

Sherbourne CD, Jackson, CA, Meredith LS, Camp P., Wells KB. Prevalence of co-morbid anxiety disorders in primary care outpatients. Arch Fam Med 1996;5(1):27–34.

Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Annexure J, Miranda J, Carney MF, Rubenstein LV. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283(2):212–20.

Williams JW, Ross K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders: effects of physician specialty and practice structure. Arch of Fam Med 1999;8(1):58–67.

Participants

A Surgeon General’s Working Meeting on The Integration of Mental Health Services and Primary Health Care, Held on November 30 — December 1, 2000

Business / Health Care Systems

Kris Apgar

Director

Washington Business Group on Health

50 F Street, N.W.

Suite 600

Washington, DC 20001-1566

Ron I. Dozoretz, M.D.

Chairman and Chief Executive Officer

Value Options

8614 Westwood Center Drive, Suite 200

Vienna, VA 22182-2233

Saul Feldman, M.D., Ph.D.

Chairman & Chief Executive Officer

United Behavioral Health

425 Market Street, 27th Floor

San Francisco, CA, 94105-2426

Gary Gottlieb, M.D., M.B.A.

Chairman

Partners Psychiatry and Mental Health System

Professor of Psychiatry

Harvard Medical School

c/o Massachusetts General Hospital

Bulfinch Building, Suite 370E

55 Fruit Street

Boston, MA 02114-2696

Suzanne Paranjpe, Ph.D.

Senior Vice President

Greater Detroit Area Health Council

Health Information Action Group

333 West Fort Street, Suite 1500

Detroit, MI 48226-3156

Dennis E. Richling, M.D.

Union Pacific

1416 Dodge, Room 908

Omaha, NE 68179

Tara Wooldridge , L.C.S.W.

Manager

Employee Assistance Program

Delta Airlines

1050 Delta Boulevard

Atlanta, GA 30320-1989

Consumer / Patient / Family

Moe Armstrong, M.B.A., M.A.

P.O. Box 390812

Cambridge, MA 02139-0009

Don Daves

President

Board of Directors for NAMI Georgia

An Affiliate of the National Alliance for the Mentally Ill

3125 Presidential Parkway

Suite 335

Atlanta, GA 30340-3700

Carolyn Nava

Federation of Families for Children’s Mental Health

1101 King Street, Suite 420

Alexandria, VA 22314-2944

Delilah J. Ramirez

1150 Syracuse Street

Building # 8

Apartment # 141

Denver, CO 80220-3242

Experts

Elise Berryhill, Ph.D.

Muscogee (Creek) Nation Behavioral Health Services

100 West 7th Street

Okmulgee, OK 74447-5007

Virginia Trotter Betts, R.N., J.D., M.S.N., F.A.A.N.

Associate Director for Health Policy Initiative

University of Tennessee

Center for Health Services Research

66 North Pauline, Suite 463

Memphis, TN 38163

Homer L. Chin, M.D.

500 Northeast Multnomah Street

Suite 100

Portland, OR 97232-2022

Allen Dietrich, M.D.

Chair

MacArthur Foundation Initiative on Depression and Primary Care

Dartmouth Medical School

North College Street

Hanover, NH 03755

Lynn Elinson, Ph.D.

Deputy Director

National Program on Depression and Primary Care

University of Pittsburgh, School of Medicine

Western Psychiatric Institute and Clinic

3811 Ohara Street, Room 417

Pittsburgh, PA 15213-2597

Richard Frank, Ph.D.

Professor

Department of Health Care Policy

Harvard University

180 Longwood Avenue

Boston, MA 02115-5821

Greg Fricchione, M.D.

Director

The Carter Center Mental Health Program

Associate Professor of Psychiatry

Harvard Medical School

One Copenhill

453 Freedom Parkway

Atlanta, Georgia 30307-1496

Pablo Hernandez, M.D.

Administrator

Wyoming State Commission for Mental Health

Division of Behavioral Health

P.O. Box 177

Evanston, WY 82931

Dennis Hulet, A.A.A.

Principal and Healthcare Management Consultant

Milliman and Roberts

1301 5th Avenue

Suite 3800

Seattle, WA 98101-2646

Brent James, M.D., M.Stat.

Vice President for Medical Research

Intermountain Health Care

36 South State Street

Salt Lake City, Utah 84111-1486

Wayne Katon

Department of Psychiatry and Behavioral Sciences

Box 356560

University of Washington

1959 NE Pacific Street

Seattle, WA 98195-6560

Donald R. Lipsitt, M.D.

Clinical Professor of Psychiatry

Harvard Medical School

Medical Director

Institute for Behavioral Science in Health Care

15 Griggs Road

Brookline, MA 02446-4701

Anthony Radcliffe, M.D.

Director of Addiction Medicine

Kaiser Permanente Southern California

740 Buckingham Drive

Redlands, CA 92374-6421

Bruce Rollman, M.D., M.P.H.

Assistant Professor

Medicine, Psychiatry, and Health Services Administration

University of Pittsburgh, School of Medicine

Suite E820

2000 Lothrop Street

Pittsburgh, PA 15213-2582

Lisa V. Rubenstein, M.D., M.S.P.H.

Professor in Residence

University of California at Los Angeles and the Veterans’ Administration

Greater Los Angeles Health Care System

Director

Veterans’ Administration Health Services Research and Development Center of Excellence for the Study of Health Care Provider Behavior

Senior Natural Scientist

Rand

1700 Main Street

Santa Monica, CA 90401-3208

Dawn Swaby-Ellis, M.D.

Assistant Professor of Pediatrics

North DeKalb Health Center

3807 Clairmont Road

Chamblee, GA 30341-4911

Michael Von Korff, Sc.D.

Center for Health Studies

Group Health Cooperative

1730 Minor Avenue

Suite 1600

Seattle, WA 98101

“Real World” Programs

David N. Broadbent, M.D., M.P.H.

Rochester Primary Care NW

259 Monroe Avenue

Rochester, New York 10032-3632

Wayne Cannon, M.D.

Intermountain Health Care

36 South State Street

Salt Lake City, Utah 84111-1486

Henry Chung, M.D.

Medical Director

Depression /Anxiety Disease Management Team

Pfizer, Inc.

235 East 42nd Street

235/10/20

New York, NY 10017-5755

J. Sloan Manning, M.D.

Family Medicine

1127 Union Avenue

Memphis, TN 38104-6646

Linda Weinreb, M.D.

Director

Homeless Families Program

The Family Health Center

Department of Family Medicine and Community Health

University of Massachusetts Medical School

55 Lake Avenue North

Worcester, MA 01655

Facilitators

Brenda Reiss-Brennan, M.S., A.P.R.N., C.S.

President

Primary Care Family Therapy Clinics, Inc.

3570 West 9000 South

Suite 120

West Jordan, UT 84088-8874

Miriam Davis, Ph.D

Medical Writer and Consultant

13420 Montvale Drive

Silver Spring, MD 20904-1232

Steven Grossman

Senior Managing Director

Hill and Knowlton

600 New Hampshire Avenue, N.W.

Suite 601

Washington, DC 20037-2413

Core Group

Bernard Arons, M.D.

Director

Center for Mental Health Services

5600 Fishers Lane, Room 17–99

Rockville, MD 20857

Elaine Baldwin, M.Ed.

Director

Constituency Outreach and Education Programs

Office of Communications and Public Liaison

National Institute of Mental Health

National Institutes of Health

31 Center Drive, Room 4A52

Bethesda, MD 20892-2475

Eric Goplerud, Ph.D.

Associate Administrator for Managed Care

Substance Abuse and Mental Health Services Administration

Parklawn Building, Room 10–99

Rockville, MD 20857

Kate Gottfried, J.D., M.S.P.H

Senior Health Policy Advisor

Office of Public Health and Science

Office of Disease Prevention and Health Promotion

Department of Health and Human Services

200 Independence Avenue, S.E., Room 738G

Washington, DC 20201

Nicole Lurie, M.D., M.S.P.H.

(Then) Principal Deputy Assistant Secretary for Health

Department of Health and Human Services

200 Independence Avenue, S.E., Room 716G

Washington, DC 20201

Beverly Malone, Ph.D., R.N., F.A.A.N.

(Then) Deputy Assistant Secretary for Health

Department of Health and Human Services

200 Independence Avenue, S.E., Room 716G

Washington, DC 20201

Ron Manderscheid, Ph.D.

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

5600 Fishers Lane, Room 15C–04

Rockville, MD 20857

Harriet G. McCombs, Ph.D.

Health Resources and Services Administration

Bureau of Primary Health Care

4350 East-West Highway, 11th Floor

Bethesda, MD 20814

Charlotte Mullican, B.S.W., M.P.H.

Department of Health and Human Services

Agency for Healthcare Research and Quality

Building 6010, Room 300

Rockville, MD 20852

Rochelle Rollins, Ph.D.

Office of the Director

Bureau of Primary Health Care

Health Resources Services Administration, 11th Floor

4350 East-West Highway

Bethesda, MD 20814

Marc A. Safran, M.D., F.A.C.P.M.

Chief Medical Officer and Psychiatrist

Diabetes Program Branch

Chair

Mental Health Work Group

Centers for Disease Control and Prevention

4770 Buford Highway (Mail Stop K–10)

Atlanta, GA 30341

VADM David Satcher, M.D., Ph.D.

Surgeon General

(Then) Assistant Secretary for Health and Surgeon General

Department of Health and Human Services

200 Independence Avenue, S.E., Room 716G

Washington, DC 20201

Frank Sullivan, Ph.D.

Department of Health and Human Services

The Health Care Financing Administration

7500 Security Blvd

Mail Stop C4–25–15

Baltimore, MD 21244-1850

Foundations

Andrea Gerstenberger, Sc.D.

Senior Program Officer

California Health Care Foundation

476 Ninth Street

Oakland, CA 94607-4048

Peter Peccora

Casey Family Programs

1300 Dexter Avenue North, Suite 300

Seattle, WA 98109-3542

Constance M. Pechura, Ph.D.

Robert Wood Johnson Foundation

P.O. Box 2316

Route 1 and College Road East

Princeton, NJ 08543-2316

Observers

Irene Stith-Coleman, Ph.D.

Public Health Advisor

Department of Health and Human Services

200 Independence Avenue, S.E., Room 701H

Washington, DC 20201

Pat Cunningham, F.N.P.

Family Medicine

1127 Union Avenue

Memphis, TN 38104-6646

Karen Dale

Vice President / Product Development

Lifescape, LLC

8614 Westwood Center Drive

Suite 200

Vienna VA 22182-2233

Linda Gask, M.D.

MacColl Institute for HealthCare Innovation

1730 Minor Avenue, Suite 1290

Seattle, WA 98101-1448

John M. Hill

President

ValueOptions

3110 Fairview Park Drive

Falls Church, VA 22042

Shelley Jackson, J.D.

Senior Civil Rights Analyst

Department of Health and Human Services

Office of Civil Rights

200 Independence Avenue, S.W., Room 574E

Washington, DC 20201

Maria Llorente, M.D.

Associate Professor and Chief

Division of Geriatric Psychiatry, Department of Psychiatry and Behavioral Sciences

University of Miami School of Medicine and Miami Veterans’ Administration Medical Center

1201 N.W. 16th Street, #116A

Miami, FL 33125-1693

Sue Martone

Public Health Analyst

Health Resources and Services Administration

Department of Health & Human Services

5600 Fishers Lane

Rockville, MD 20857

Darlene Marion Meador, Ph.D.

Director

Program and Policy Development Section

Division of Mental Health, Mental Retardation and Substance Abuse

Georgia Department of Human Resources

2 Peachtree Street, N.W.

Suite 23–410

Atlanta, GA 30303-3171

David Mosen, Ph.D.

Outcomes Analyst/Research Associate

Institute for Health Care Delivery Research

Intermountain Health Care

36 South State Street, 16th Floor

Salt Lake City, UT 84111-1633

Joanne Nicholson, Ph.D.

Associate Professor

Department of Psychiatry, and

Associate Director

Center for Mental Health Services Research

Homeless Families Program

The Family Health Center

Department of Family Medicine and Community Health

University of Massachusetts Medical School

55 Lake Avenue North

Worcester, MA 01655-0242

CAPT Tina Russ, Ph.D.

Health Psychology Consultant

USAF

Office for Prevention and Health Services Assessment

AFMOA/SGZZ 2602 Doolittle Road, Building 804

Brooks Air Force Base, TX 78235-5249

Pat Salomon, M.D.

Director

Office of Early Childhood

Substance Abuse and Mental Health Services Administration

5600 Fishers Lane

Rockville, MD 20857

Bertha N. Williams, MS, RN