Conversations about who should respond to mental health needs are changing. In early American history, many who suffered from severely stigmatized mental illness were treated as demonically possessed or as criminals. From the mid-19th to mid-20th centuries, large government psychiatric hospitals were a primary locus of care that advanced a medical model of care while seeking to segregate those with mental health challenges from the general community. A de-institutionalization movement began after the Civil Rights movement, as many formerly marginalized groups sought integration into common society. Deinstitutionalization coincided with a period of increasing specialization in American medicine, and an associated decline in the relative number of primary care practitioners. (Primary care practitioners are those trained widely to be both the initial point of contact for patients, and to develop long-term therapeutic relationships with them, facilitating care for their unique arrays of medical needs. Primary care providers include general practitioners, internists, family medicine physicians, pediatricians, and some categories of nurse practitioners.) Referral of patients with mental and behavioral health challenges to psychiatrists, psychologists, social workers, and counselors became the norm.

However, in recent decades American health policy has advocated improving and expanding primary care as a foundation of the health system. Accordingly, many mental health advocates now call for better integration of primary care with mental and behavioral health care. Such integration can occur bilaterally. Most commonly, it includes increased mental health assessment and treatment in primary care clinics, especially for the most common forms of depression, anxiety disorders, and substance abuse. While less common, it can also include more chronic disease treatment in mental health settings serving the seriously mentally ill--since there is evidence that significant chronic diseases such as diabetes and cardio-pulmonary disease disproportionately go undiagnosed in those who have been labeled as mentally ill, resulting in higher mortality. While integrative strategies are being deployed, critics voice concerns about whether associated provider training, systems structures, and insurance practice are currently adequate to support such integration.

An initial major government study conducted in 2000 found that approximately 25 percent of all primary care patients have diagnosable psychiatric disorders--most commonly, anxiety and depression--while primary care providers now deliver over half of the treatment for these conditions nationwide. However, still, only about 10% of patients with depression receive standard-of-care treatment from their primary care physician.1

Community advocates call for an integration of behavioral health support in the wider community. In particular, they focus on how non-health-professionals can support mental health in families, schools, workplaces, prisons, and faith communities. More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain.

Ethics for Emerging Technologies Master Library

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