Behavioral health primary care integration

There is strong evidence that integrating behavioral health into primary care practice improves mental health (Asarnow 2015, Cully 2017, ICER-Tice 2015, Cochrane-Bower 2011), especially depression symptoms (ICER-Tice 2015, CG-Mental health, Butler 2011, Gilbody 2006a). Integrating care also increases patients’ adherence to treatment (Kolko 2014, CG-Thota 2012), improves their quality of life (CG-Thota 2012), and increases patient satisfaction (ICER-Tice 2015, Kolko 2014) and engagement with health care providers (Wissow 2013).

Integrating depression screening and treatment into primary care has been shown to improve depression symptoms for adolescent, adult, and elderly patients (CG-Mental health, AHRQ-Butler 2008). Such care appears effective in various settings, including practices with limited resources and practices in rural and urban areas (CG-Mental health, Berger-Jenkins 2012, Serrano 2011). Integrated care improves youth mental health outcomes, including depression and substance use, more than usual care (Asarnow 2015). Integrated care in pediatric practices increases initiation and completion of treatment, improves behavior problems, and reduces hyperactivity and parental stress (Kolko 2014). Experts suggest that increasing incentives to integrate primary care and behavioral health care may improve children’s health (Asarnow 2015).

Collaborative care approaches that use case managers to organize and integrate behavioral and primary care improve response to treatment, increase remission and recovery from symptoms, and increase satisfaction with care among patients with depression in the short- and long-term (CG-Mental health, Gilbody 2006a). Coordination which includes regular and planned psychiatrist supervision of case managers has been shown to be more effective than efforts with unplanned supervision (Gilbody 2006a). Collaboration and communication between medical and behavioral health providers has also been shown to increase success and sustainability of integration efforts (Muse 2017).

Integrated care has been shown to reduce depression and anxiety for veterans with heart failure and chronic obstructive pulmonary disease (COPD), and can improve health-related quality of life for veterans with COPD in the short-term (Cully 2017). For patients suffering from chronic pain and substance abuse disorders in addition to depression, multiple interventions in primary care settings (e.g., motivational interviewing and cognitive behavioral therapy) may improve mental health and reduce drug and alcohol use more effectively than a single intervention (Haibach 2014).

Universal mental health screening during pediatric appointments can increase parent, youth, and primary care provider willingness to discuss mental health concerns. Framing screening as universal, confidential, and designed to improve communication may further support patient and family engagement (Wissow 2013). A Bronx-based study of a pediatric behavioral health integration program suggests programs that use pediatric psychologists and psychiatrists to integrate care can increase referral rates to pediatric mental health practitioners and increase primary care provider comfort managing school-age and adolescent attention deficit hyperactivity disorder-related behaviors (ADHD) more than clinics that use social workers to integrate behavioral health (German 2017). Experts suggest that psychologists who integrate behavioral health into pediatric primary care use principles of culturally adapted care to meet the needs of racial and ethnic minority youth (Arora 2017).

Tailoring behavioral health integration to address the needs of specific populations has the potential to encourage adoption in particular settings (e.g. schools, workplace, home-based care) (Ramanuj 2019). Behavioral health integration in specialties like gynecology can help patients cope with complex health challenges such as pain management (Witzeman 2024).

Economic studies indicate that integrating behavioral health and primary care to treat depression is associated with greater costs and better health outcomes than traditional care models. Overall, studies have shown integrated care to be cost effective in terms of quality adjusted life years (QALYs) saved (CG-Mental health). Integrated care may reduce costs and medical utilization in rural areas (Peterson 2017).

Behavioral health primary care integration has the potential to decrease disparities in mental health outcomes if they are culturally adapted and designed to reach groups that experience worse mental health outcomes. Experts suggest that culturally adapted care implemented by primary care psychologists may better meet the needs of racial and ethnic minority youth, but further research is needed to confirm these effects (Arora 2017). Some experts suggest that integrating behavioral health care into primary care may reduce stigma and cultural barriers faced by underserved racial and ethnic minority populations (OLoughlin 2019).

Mental health conditions and neurodiversity have long been stigmatized by society, seen as a source of shame for both the individuals who suffer from it and their families (Ahad 2023). Mental illness was typically viewed as a moral or spiritual failing (NLM-Psychiatric timeline); people with mental health conditions were regarded as a burden and ignored or minimized at best. Individuals with more severe issues were locked in asylums and kept from greater society, where treatments were often brutal, and almost always ineffective (PBS American Experience-Mental illness). The system could also be exploited, and those who stepped outside the bounds of society could be subjected to cruelty and incarceration in asylums, and later institutions (CSP-Mental illness).

While society’s understanding of and treatments for mental health have evolved over time, stigma around mental health conditions remains common in many communities (Ahad 2023). Stigma against mental health and substance use disorders, as well as distrust of the mental health care system, may prevent those who need help from seeking care, even if it is covered by their insurance (Heboyan 2021, Carlo 2020). Barriers in access to care for mental illness are a problem worldwide, and estimates for the U.S. suggest that less than half of individuals with mental illness receive treatment (Sugarman 2023). In western cultures, including the U.S., there are often assumptions about individuals with mental health conditions, such as the mistaken belief that they are unpredictable or dangerous, contributing to discrimination and social exclusion (Ahad 2023), and reducing options for work, education, housing, and social connections (APA-Stigma).

Integrated behavioral health care was introduced in the U.S. in the 1970s through two federally qualified health centers (FQHCs) that expanded their services to include behavioral health care (Manderscheid 2024). This area of care continues to advance as support and knowledge around behavioral health and its implications on physical health are better understood. The 2010 Affordable Care Act (ACA) emphasized integrated care, which has strengthened support for integrated care through policy solutions, education and training, and more (Manderscheid 2024). Currently, there are around 23,000 primary care practices that integrate behavioral health clinicians in the U.S. (RGC-State of integrated primary care).

• Do the health systems in your community integrate behavioral health into primary care settings? Do they include specific tailoring and culturally adapted care to reach specific populations within your community that lack access to behavioral health care?
• Are there partnerships that can lead to or strengthen behavioral health primary care integration efforts in your community?
• How can you reduce stigma around behavioral health topics? What cultural barriers are prominent in your community regarding behavioral health and mental health?

The Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral Health and Primary Care (AHRQ Academy) includes resources, research, and tools to support integrated care (AHRQ-Integrate). The Substance Abuse and Mental Health Services Administration (SAMHSA) includes numerous resources from federal agencies and national organizations on integrating behavioral health and primary care (SAMHSA-Children MH). The Primary Care Team LEAP is another example of an organization that offers guidance on how to integrate behavioral health into primary care through co-location or collaborative agreements (PCT-LEAP).

There are several models to integrate behavioral health into primary care practice. The AIMS Center at the University of Washington, for example, uses a Collaborative Care model based on five core principles: patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care (AIMS-Collaborative care).

AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care.

AIMS-Collaborative care - University of Washington. Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS).

PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF).

SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources.

SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrated models for behavioral health and primary care.

SNMHI-BHI - Safety Net Medical Home Initiative (SNMHI). Organized, evidence-based care: Behavioral health integration (BHI). Sponsored by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute.

WIPHL - Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL).

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Ahad 2023 - Ahad, A. A., Sanchez-Gonzalez, M., & Junquera, P. (2023). Understanding and addressing mental health stigma across cultures for improving psychiatric care: A narrative review. Cureus, 15(5), e39549

AHRQ-Butler 2008 - Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville: Agency of Healthcare Research and Quality (AHRQ); 2008.

AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care.

AIMS-Collaborative care - University of Washington. Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS).

APA-Stigma - American Psychiatric Association. (2024). Stigma, prejudice and discrimination against people with mental illness.

Arora 2017* - Arora PG, Godoy L, Hodgkinson S. Serving the underserved: Cultural considerations in behavioral health integration in pediatric primary care. Professional Psychology: Research and Practice. 2017;48(3):139-148.

Asarnow 2015 - Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics. 2015;169(10):929-937.

Berger-Jenkins 2012* - Berger-Jenkins E, McCord M, Gallagher T, Olfson M. Effect of routine mental health screening in a low-resource pediatric primary care population. Clinical Pediatrics. 2012;51(4):359-65.

Butler 2011* - Butler M, Kane RL, McAlpine D, et al. Does integrated care improve treatment for depression: A systematic review. The Journal of Ambulatory Care Management. 2011;34(2):11-25.

Carlo 2020* - Carlo, A. D., Barnett, B. S., & Frank, R. G. (2020). Behavioral health parity efforts in the U.S. JAMA, 324(5), 447.

CG-Mental health - The Guide to Community Preventive Services (The Community Guide). Mental health.

CG-Thota 2012* - Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: A Community Guide systematic review and meta-analysis. American Journal of Preventive Medicine. 2012;42(5):525-538.

Cochrane-Bower 2011* - Bower P, Knowles S, Coventry, PA, Rowland N. Counselling for mental health and psychosocial problems in primary care: Review. Cochrane Database of Systematic Reviews. 2011;(9):CD001025.

CSP-Mental illness - Concordia University St. Paul (CSP). (2020, July 13). A history of mental illness treatment: Obsolete practices.

Cully 2017 - Cully JA, Stanley MA, Petersen NJ, et al. Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: A pragmatic randomized clinical trial. Journal of General Internal Medicine. 2017;32(9):1014-1024.

German 2017 - Germán M, Rinke ML, Gurney BA, et al. Comparing two models of integrated behavioral health programs in pediatric primary care. Child and Adolescent Psychiatric Clinics of North America. 2017;26(4):815-828.

Gilbody 2006a* - Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine. 2006;166(21):2314-21.

Haibach 2014* - Haibach JP, Beehler GP, Dollar KM, Finnell DS. Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care. Medical Care. 2014;52(4):322-27.

Heboyan 2021* - Heboyan, V., Douglas, M. D., McGregor, B., & Benevides, T. W. (2021). Impact of mental health insurance legislation on mental health treatment in a longitudinal sample of adolescents. Medical Care, 59(10), 939–946.

ICER-Tice 2015 - Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. Institute for Clinical and Economic Review (ICER); 2015.

Kolko 2014 - Kolko DJ, Campo J, Kilbourne AM, et al. Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics. 2014;133(4):e981-e992.

Manderscheid 2024 - Manderscheid, R. W., & Ward, A. (2024). Looking toward the future of integrated care: History, developments, and opportunities. The Journal of Behavioral Health Services & Research, 51(4), 609–617.

MCW-Increasing integrated behavioral health - Medical College of Wisconsin (MCW). (2021). Increasing integrated behavioral health in primary care settings. Accessed December 10, 2025.

Muse 2017* - Muse AR, Lamson AL, Didericksen KW, Hodgson JL. A systematic review of evaluation research in integrated behavioral health care: Operational and financial characteristics. Families, Systems, & Health. 2017;35(2):136-154.

NLM-Psychiatric timeline - National Library of Medicine (NLM). Timeline of early psychiatric hospitals & asylums. Early American psychiatry: Diseases of the mind. National Institutes of Health.

OLoughlin 2019* - O’Loughlin, K., Donovan, E. K., Radcliff, Z., Ryan, M., & Rybarczyk, B. (2019). Using integrated behavioral healthcare to address behavioral health disparities in underserved populations. Translational Issues in Psychological Science, 5(4), 374–389.

PBS American Experience-Mental illness - American Experience. A brilliant madness timeline: Treatments for mental illness. PBS Wisconsin.

PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF).

Peterson 2017* - Peterson M, Turgesen J, Fisk L, McCarthy S. Integrated care in rural health: Seeking sustainability. Families, Systems, & Health. 2017;35(2):167-173.

Ramanuj 2019* - Ramanuj, P., Ferenchik, E., Docherty, M., Spaeth-Rublee, B., & Pincus, H. A. (2019). Evolving models of integrated behavioral health and primary care. Current Psychiatry Reports, 21(1), 4.

Raney 2017 - Raney L, Bergman D, Torous J, Hasselberg M. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Current Psychiatry Reports. 2017;19:86.

RGC-State of integrated primary care - Westfall, J. M., Jabbarpour, Y., Jetty, A., Kuwahara, R., Olaisen, H., Byun, H., Kamerow, D., Guerriero, M., McGehee, T., Carrozza, M., Topmiller, M., Grandmont, J., & Rankin, J. (2022). The state of integrated primary care and behavioral health in the United States 2022. Robert Graham Center.

SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources.

SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrated models for behavioral health and primary care.

Serrano 2011 - Serrano N, Monden K. The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ. 2011;110(3):113-119.

Sugarman 2023* - Sugarman DE, Busch AB. Telemental health for clinical assessment and treatment. BMJ. 2023;380:e072398.

Wissow 2013 - Wissow LS, Brown J, Fothergill KE, et al. Universal mental health screening in pediatric primary care: A systematic review. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(11):1134-1147.e23.

Witzeman 2024* - Witzeman, K. A., Lieberman, A., Beckman, E. J., Ross, K. V., & Coons, H. L. (2024). Integrated care for persons with persistent gynecologic conditions. Clinical Obstetrics & Gynecology, 67(1), 247–261.