Integrating Mental Health and Primary Care: From Dipping a Toe to Taking a Plunge

David C. Rettew, MD


May 22, 2023

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.[1]

David C. Rettew, MD

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.[2] The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

  • Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.

  • Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.[3]

  • Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.[4]

  • Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.[5,6] The AAP itself has released a number of toolkits and training materials related to mental health care that are available.[7]

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.[8] Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.[9] This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

This article originally appeared on, part of the Medscape Professional Network.

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