U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Building Bridges

Mental Health Consumers and 

Primary Health Care Representatives 

in Dialogue

Mental Health Consumers and 

Primary Health Care Representatives 

in Dialogue

Building Bridges

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Acknowledgments

Numerous people contributed to the development of this 

publication (see the “Participant List”). The publication was 

prepared for the Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S. Department of Health and 

Human Services (HHS), under contract number 280-01-8054. 

Carole Schauer and Paolo del Vecchio served as the Government 

Project Officers. 

Disclaimer

The views, opinions, and content of this publication are those of 

the dialogue participants and do not necessarily reflect the views, 

opinions, or policies of the Center for Mental Health Services 

(CMHS), SAMHSA, or HHS. 

Public Domain Notice 

All material appearing in this document is in the public domain 

and may be reproduced without permission from SAMHSA. 

Citation of the source is appreciated. This publication may not 

be reproduced or distributed for a fee without specific written 

authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication can be accessed electronically on the Internet 

at www.samhsa.gov. For additional free copies of this publication, 

call SAMHSA’s National Mental Health Information Center at

1-800-789-2647.

Recommended Citation

Building Bridges: Mental Health Consumers and Primary Care 

Representatives in Dialogue. HHS Pub. No. 4040. Rockville, MD: 

Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration, 2005.

Originating Office

Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration, 1 Choke Cherry Road, Rockville, 

MD 20857

HHS Publication No. (SMA) 06-4040

Printed 2006

iii
iv

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue
v

Foreword

Mental health is essential to overall health, and Americans are 

becoming increasingly aware of the connection. The United States, 

however, has traditionally had a “system” of care in which mental 

health has been set apart, separate from primary or general health 

care. Now that it is understood that mental and general health are 

inextricably linked, the two disciplines must be brought together. 

It is essential to facilitate access for persons with mental health 

problems to high-quality, affordable, coordinated mental and 

general health care that is provided in a way that makes sense in 

their lives. 

Many changes must take place to accomplish this integration 

at the Federal, State, and local levels, as discussed in Achieving 

the Promise: Transforming Mental Health Care in America, the 

final report of the President’s New Freedom Commission on 

Mental Health (2003a) and Transforming Mental Health Care 

in America—The Federal Action Agenda: First Steps (2005). The 

Substance Abuse and Mental Health Services Administration 

(SAMHSA) and its Center for Mental Health Services (CMHS) 

are working to transform the way that services are provided for 

people who experience mental health problems nationwide. 

The Commission’s transformation goals are presented in the 

box below. Goal 1 highlights Americans’ lack of awareness that 

mental illnesses can be treated and that recovery is possible. The 

Commission stated the imperative to “address mental health with 

the same urgency as physical health.”

New Freedom Commission on Mental Health:

Transformation of the U.S. Mental Health System 

Goal 1. Americans understand that mental health is essential to 

 overall health.

Goal 2. Mental health care is consumer and family driven.

Goal 3. Disparities in mental health services are eliminated.

Goal 4. Early mental health screening, assessment, and referral 

 to services are common practice.

Goal 5. Excellent mental health care is delivered and research 

 is accelerated.

Goal 6. Technology is used to access mental health care and 

 information. 

Source: New Freedom Commission on Mental Health. (2003). 

Achieving the Promise: Transforming Mental Health Care in 

America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, 

MD. www.mentalhealthcommission.gov 
vi

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

CMHS’s traditional focus has been on providing mental health 

services. But in discussions of integrating primary health care 

with mental health, prevention of mental illnesses and promotion 

of mental health must also be considered. The more that mental 

health promotion, mental illness prevention, and substance abuse 

prevention become part of the prevention agenda for public 

health, the better the stage can be set for developing the financing 

mechanisms and policies that will make transformation possible.

A series of CMHS dialogue meetings has examined approaches 

that impact personal and, ultimately, systems transformation. 

Participants in the dialogues share their own relevant experiences 

that promoted or hindered recovery. Both personal and systems 

transformation depend on relationships and connections between 

people, and dialogues help to identify barriers and to forge 

relationships that lead to recommendations and actions that foster 

recovery for consumers of mental health services.

In March 2005, CMHS sponsored a dialogue between invited 

consumers of mental health services and representatives of 

various sectors of the primary health system. In an effort 

to develop improved mutual understanding, respect, and 

partnerships, the two dozen participants

• Identified issues involving mental health consumers and their 

experiences with primary care providers, including those that 

both hinder and help recovery; and 

• Developed recommendations regarding attitudinal shifts and 

systems transformation that can lead to improved mental and 

general health care responses to people with mental illnesses 

by primary care and mental health providers. 

The participants’ findings and recommendations are summarized 

in this publication to be helpful when engaging in activities that 

promote mental health systems transformation.
vii

Contents

Overview .........................................................................................1

Dialogue Themes and Findings .....................................................5

 In Their Own Words ................................................................5

Issues of Personhood and Relationships ..............................10

 Person-Level Factors That Promote Recovery ..................10

 Person-Level Factors That Hinder Recovery ....................11

Issues Related to Systems and Contexts ...............................12

 System-Level Factors That Promote Recovery .................12

 System-Level Factors That Hinder Recovery ...................15

Recommendations for Action .......................................................21

 Communication and Engagement of Mental Health and 

Primary Care Providers in Integrating Care ..........................21

Stakeholder Education ..........................................................23

Stakeholder Accountability ...................................................24

Research ................................................................................25

Finance ..................................................................................26

Planned Actions in the Community ......................................27

Selected References and Resources ............................................31

 References and Related Publications ...................................31

Federal and Other Resources ...............................................34

Participant List .............................................................................41
viii

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue
1

Overview

Our country must make a commitment: Americans with mental 

illness deserve our understanding, and they deserve excellent care. 

They deserve a health system that treats their illness with the same 

urgency as a physical illness.

—President George W. Bush (2002)

Although mental health and general health are clearly 

connected, a chasm exists between the mental health care and 

general health care systems in both practice and financing. The 

intersection of mental health and primary health, under discussion 

since the mid-1990s, recently has garnered increased attention and 

concern at the national and State levels. It has become apparent 

that consumers of mental health services experience unnecessary 

suffering, functional impairment, mortality, economic losses, 

and health care costs as a result of ineffective care due to the 

fragmentation of the Nation’s multiple health care systems. The 

President’s New Freedom Commission on Mental Health found 

that mental illnesses are shockingly common and affect almost 

every American family (New Freedom Commission, 2003a).

The effects of the dichotomy in care are evident in both general 

medical settings and mental health settings. For example, half 

of the care for common mental disorders is delivered in general 

medical settings (New Freedom Commission, 2003a), and 35 

percent of persons with serious mental disorders have at least 

one medical disorder that is not diagnosed (Bazelon Center, 

2004). The reports of the President’s New Freedom Commission 

on Mental Health (2003a) and its Subcommittee on Mental Health 

Interface with General Medicine (New Freedom Commission, 

2003b) describe the extent and seriousness of the problem: 

• Mental health problems are common in primary care. 

• Mental health problems commonly occur with other general 

medical conditions. Studies have shown that adults with 

common general medical disorders, such as coronary heart 

disease, have high rates of depression and anxiety. Depression 

also impairs self-care and adherence to treatments for chronic 

medical illnesses.

• Mental health problems often go undiagnosed and untreated 

or undertreated in primary care. Studies show that effective 

treatments for most common mental disorders are rarely 

used effectively in primary care. Older adults, children and 

adolescents, individuals from ethnic minority groups, and 
2

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

patients uninsured or of low income seen in the public sector 

are particularly unlikely to receive care for mental health 

problems.

• Individual, provider, and system factors contribute to poor 

quality care on the primary care–mental health interface:

• Persons may fail to recognize or correctly identify their 

symptoms of mental illness, and even when they do, 

they may be reluctant to seek care because of stigma and 

discrimination. 

• Primary care providers may lack the necessary time, training, 

or resources to provide appropriate treatment for mental 

health problems. 

• Last, mental health benefits typically are more restricted and 

more heavily managed than other medical benefits. Lack of 

parity for insurance coverage between mental health and 

general medical care represents an ongoing system-level 

barrier to obtaining needed mental health services in the 

United States.

• General medical disorders are common, but often they are 

treated poorly in specialty mental health care settings. The 

problems underlying the gaps in medical care of individuals 

with serious mental illnesses parallel the problems that occur 

in the treatment of depression and anxiety disorders in general 

medical settings. 

• Mental health financing poses challenges. Insurance plans 

that place greater restrictions on treating mental illnesses 

than on other illnesses prevent some individuals from getting 

the care that would dramatically improve their lives. Mental 

health benefits traditionally have been more limited than other 

medical benefits in both private and public health insurance 

programs. 

For each of its six goals, the Commission offered 

recommendations to transform systems that provide—or 

should provide—support for mental health recovery. In 

Recommendation 1.2, the Commission stated the imperative 

to “address mental health with the same urgency as physical 

health.” Essentially, general health providers must develop the 

capacity to recognize and either treat or refer individuals who 

need more specialized care. Mental health providers must develop 

the capacity to recognize when consumers of their services need 

attention for their general medical problems and to refer them for 

appropriate care. 
3

Recommendation 1.2: Address mental health with the 

same urgency as physical health.

Recognize the Connection Between Mental Health and 

Physical Health

Health care and other human service systems should treat 

adults with serious mental illnesses and children with serious 

emotional disturbances with the same dignity, urgency, and 

quality of care that is given to people with any other form of 

illness. Doing so can contribute greatly to reducing stigma while 

encouraging people in need to seek help. . . . Good mental 

health improves the quality of life for people with serious 

physical illnesses and may contribute to longer life in general. 

(New Freedom Commission, 2003a)

In Recommendation 4.4, the Commission called for screening 

“for mental disorders in primary health care, across the lifespan, 

and connecting to treatment and supports.”

Recommendation 4.4: Screen for mental disorders in 

primary health care, across the lifespan, and connect to 

treatment and supports.

Expand Screening and Collaborative Care in Primary 

Care Settings

Collaborative care models should be widely implemented 

in primary health care settings and reimbursed by public and 

private insurers. Numerous studies have documented the 

effectiveness of collaborative care models. Expanded screening 

and collaborative care . . . could save lives. . . .

The federal government could better coordinate the funding 

and the clinical care provided by publicly funded community 

health clinics to consumers with multiple conditions, including 

physical, mental, and co-occurring substance abuse disorders. 

(New Freedom Commission, 2003a)

 In recent years, numerous meetings, reports, and papers 

have addressed the issue of the integration of mental health 

and primary health care, and a number of ongoing initiatives 

are working to effect the integration (see “Selected References 

and Resources”). Despite these initiatives, little face-to-face 

discussion has taken place between mental health consumers and 

representatives of the primary care system on what is needed on 

the interface between primary and mental health care to promote 

recovery. 
4

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

In March 2005, hosted by CMHS, a group of mental health 

consumers met with primary care providers, researchers, and 

policymakers in dialogue. The meeting provided a forum in 

which to develop trust and to build mutual understanding and 

respect, a first step toward creating effective alliances that support 

recovery for consumers who come into contact with primary care 

systems. The participants shared the understanding that recovery 

from mental illnesses is now a possibility—even an expectation. 

Persons with mental health diagnoses now can expect to achieve 

satisfying, hopeful, purposeful, and contributing lives—despite 

any limitations their disorders may cause. The efforts of a 

burgeoning cadre of consumer advocates and peer supporters 

across the country have been critically important in fostering hope 

and the means and methods for consumers to set and achieve 

their goals for a meaningful life in the community. 

Among other topics, dialogue participants discussed

• Access to, and the availability, affordability, and quality of, 

medical and mental health services;

• Interaction of general health and mental health;

• Role, practice, and purview of primary care in mental health 

care and of mental health care in primary health care;

• Cultural and other disparities;

• Medications and side effects;

• Financing;

• Cross-training in primary care and mental health care; and

• Recovery orientation of care.

The participants discussed their experiences, identified factors 

that promote and hinder recovery of persons in general and 

mental health care systems, described instances in which medical 

conditions were not adequately diagnosed and treated in mental 

health care settings, as well as instances in which mental health 

problems were not adequately diagnosed and treated in general 

health care settings. Participants synthesized their discussions 

and developed recommendations to address attitudinal and 

bureaucratic barriers and to create opportunities for promoting 

recovery. 
5

Dialogue Themes and Findings

“I am a whole person, and all my parts come together.”

—Family member, consumer, policymaker 

In Their Own Words

Participants introduced themselves and shared relevant personal 

and professional experiences related to the intersection of mental 

health and general health. 

. . . My primary care doctor would never ask me about mental 

health issues, how I was doing on an emotional basis. He would 

consider physical illnesses only from a biological perspective, and 

how I was doing and feeling never came up in all those years. 

—Consumer, policymaker

. . . We’re talking about two dimensions: to equip and empower 

primary care physicians to recognize and treat mental health 

problems, and to ensure that consumers who receive mental 

health care receive high-quality general medical care.

—Mental health provider, advocate, educator 

. . . Primary care must see mental health as part of its charge 

and responsibility, and vice versa. The ultimate goal is for 

primary care and mental health care to work together.

Developing a coordinated plan is the context for all work.

—Mental health administrator

 At the heart of many of their comments was the toxic effect 

of stigma and discrimination . . .

. . . I am overweight, Black, and a trauma survivor. I have to 

do a lot of working with people to get them to notice my 

physical complaints. I keep trying to get my rights. 

—Consumer/advocate

. . . I felt stigma and shame for many years, 

which kept me from seeking services. 

—Consumer, policymaker

. . . The African American community needs a lot of education 

on identifying when there’s a problem, and then getting help. 

Often we’re told, “Just pray a lot.” “Just be strong.” It’s looked 

upon as a character flaw if we have any mental problems.

 —Advocate
6

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

And of many mental health providers’ lack of knowledge about 

current mental health approaches. . . .

I heard about recovery in 1998, but at one point 

a psychiatrist told me my illness was “like a record. 

Every year the needle goes around and makes deeper and

deeper scratches, until someday there are only scratches

—no music.” Immediately I changed providers.

—Consumer, service provider 

Some participants recounted instances in which general medical 

conditions were not adequately treated in mental health 

settings. . . .

. . . Of a hundred consumers we surveyed about their general 

health care, twenty-six had diabetes, but only three people had

had any diabetes-care education and only one had had a blood 

test. The group had an aggregate of 130 visits to the emergency 

room. But with grant funds, we held a wellness education 

meeting and then hired nurses to work in community mental 

health centers to incorporate physical wellness into recovery. 

Preliminary data show a 10 percent cost savings from avoidance 

of emergency room visits.

 —State policymaker

Others described instances in which inappropriate attention to 

mental health issues in primary care settings was given. . . .

. . . When I’m depressed, I do have real physical symptoms. I 

had to be aggressive to get my doctor to follow through on my 

complaints about severe fatigue that felt different from regular 

depression. At first he said it was “just depression,” but after 

a series of tests, it turned out I had anemia. Learning that 

I had anemia made me feel good, since it demonstrated 

that I wasn’t totally crazy. 

 —Consumer/advocate

. . . Most people in my State with mental illnesses find 

getting day-to-day health care very difficult. When they do 

access it, all physical symptoms filter through our psychiatric 

diagnoses, and it’s sometimes difficult to get physicians to 

listen to the real issues. Psychiatric symptoms often are 

physically based, but the problems I experience related 

to my thyroid have nothing to do with depression. 

—Consumer/advocate
7

Some participants observed that mental health consumers often 

do not receive the dental care they require. . . .

. . . Forty percent of consumers had uncared-for dental needs 

when I became county medical director. After one consumer 

received dental care, her panic attacks decreased by 95 percent. 

—Primary care provider, educator, researcher

Some described how support from other consumers made a 

difference in their health and their lives. . . . 

. . . I became involved a long time ago with the consumer 

movement, because I found more hope, strength, 

and courage with consumers than I had anywhere else. 

—Consumer/advocate

Others offered their perspectives on the particular vulnerability 

of persons who are members of minority groups and other special 

populations. . . . 

. . . Providers often overlook depression as an accompaniment

to general medical problems, and when they 

occur in minority populations, there is even less 

recognition of how symptoms might present. . . .

 We need to educate providers about co-occurring disorders. 

—Family member, primary care provider, educator

And others asserted that healing relationships with providers 

make all the difference. . . .

. . . Everything is built on relationships and communication.

—Consumer advocate/peer specialist

. . . Because of today’s rapid-paced health care system, providers 

have lost the ability to wonder about who is this person, to try to 

figure out how best to help. Better ways exist to address mental 

health issues than the way our claims system forces us to. 

—Primary care provider, educator, researcher

 Some described their perspectives on research. . . . 

. . . I am concerned that research on evidence-based 

practices is not recovery focused. 

—Consumer/advocate

. . . Improvement of patient safety in mental health is critical. 

To improve quality it is important to “follow the deaths.” States, 
8

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

or even law enforcement, can aggregate information across 

populations for analysis. 

—Mental health provider, researcher

In the words of a consumer/advocate...

I don’t remember a time before mental illness. My parents 

were told that I would never succeed in society and to put me 

in an institution. They didn’t, but throughout the years, I have 

had many misdiagnoses and a lot of medications that didn’t 

help me. Just in the past fifteen years have I been able to reach 

toward recovery. 

I became involved a long time ago with the consumer 

movement, because I found more hope, strength, and courage 

with consumers than I have anywhere else. Most of all, it was 

the acceptance; I didn’t have to explain who I was. Talking with 

professionals is not the same as seeing consumers living lives of 

joy—and, yes, of troubles. 

In the early 1990s, I worked to establish a statewide consumer 

organization. In that one year, three consumers had died in one 

state hospital in Virginia. They were young people, all of them 

with medical conditions, and they died within three months 

of each other. On the eve of the first statewide consumer 

conference, we held a memorial service. We allowed time for 

consumers to call out the names of other consumers—friends—

who had died in the past year. Forty-five minutes later, we 

ended the service. We had heard so very many names. It was 

so stunning. 

I was appointed as the first publicly self-identified consumer 

to serve on the state board of mental health. I discovered that 

when people like us die in hospitals, critical incident reports 

must be completed and a root cause analysis conducted. But 

those of us in the community just disappear. 

I’ve become aware of how young we are when we consumers 

die, typically from causes that are eminently preventable. 

Poverty explains part of the problem, but we are a medically 

fragile population. We have many autoimmune diseases with 

inflammatory processes that produce extraordinary fragility. 

We also can place some blame on a medical care system that 

we have hard time accessing and on doctors who don’t know 

how to talk to us, don’t trust what we say, and don’t adequately 

report our symptoms. When doctors treat us, they need to be 

more probing and to try to do things differently so that people 

can live.
9

In the words of a primary care provider...

I am a pediatrician and a family member of a person with a 

mental illness. If I had to take just one message to mental health 

providers, it would be that the family is the patient—not just 

the patient. I have felt excluded and frustrated. Even though 

my spouse and I are guardians and caregivers, we have gone 

months without an opportunity to speak with the psychiatrist....

Pediatricians want to do something about mental health, 

because we can’t take adequate care of our kids. We have no 

relationship with mental health providers in the community, and 

we can’t get reimbursed. 

Nevertheless, we have accomplished some wonderful things 

in my State. We have been able to secure reimbursement for 

twenty-six unmanaged mental health visits annually, including 

six visits without a diagnosis, for a primary care physician. The 

American Academy of Pediatrics is very interested in our work. 

I teach pediatric residents advocacy and I teach behavioral 

health. In our community, the greatest unmet need is behavioral 

health services, and as a faculty, we are modeling personal 

change in response to that need. We are enriching the 

curriculum and sending residents into agencies that care for 

families and on home visits to children with chronic illnesses. 

We also have become involved with schools, which are de facto 

mental health providers, and we are developing community 

protocols for exchanging confidential information. 

The most recent state mental health plan was created 

without pediatricians at the table. General pediatricians are 

small business owners. We need to meet a payroll, and we’re 

accountable for a certain level of productivity. In any hour, 

should we see six kids with sore throats or just one child with 

a complex mental health issue? What we do is to see the child 

with mental health problems last in the day, on our own time, 

because, under the existing insurance rules, we cannot obtain 

adequate reimbursement. 

As pediatricians, we need screening tools for mental health, 

and we need to establish relationships with mental health 

providers. If I have a child with an orthopedic problem, I can 

make referrals and get feedback. But if I refer a child to a 

mental health provider, I rarely hear anything back—and if it’s 

a referral to the public mental health sector, it’s a black hole. 

Patients must follow up on referrals on their own; if I call to 

follow up, I can’t get through. 
10

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Issues of Personhood and Relationships

Participants identified a series of person-level factors that 

promote and that hinder recovery. These factors are listed below. 

Person-Level Factors That Promote Recovery

Participants identified the overarching value of all stakeholders 

understanding the concepts of recovery and wellness, including 

the acknowledgment that recovery is possible; the importance of 

prevention programs; and the roles that spirituality, joy, and hope 

can play. Other person-level factors that promote recovery include

• Primary care providers who incorporate wellness into care, 

work at a continuously healing relationship, and respect 

persons with psychiatric diagnoses. Respect can take 

the form of active listening, taking complaints seriously, 

attention to followup, truthfulness, self-disclosure, creativity 

in communicating with consumers, time management in 

delivery of care, acknowledgment of their own limitations, and 

advocacy on behalf of consumers. 

• Primary care and specialty mental health providers who 

communicate with each other to coordinate care on general 

medical and psychiatric issues.

• Providers who encourage active consumer (and family) 

involvement and dialogue in decisionmaking on care.

. . . We need to focus more on methods of engagement 

rather than on compliance or noncompliance.

—Consumer/advocate

• Providers who offer hope—and who sustain that hope when 

patients cannot.

• Providers who are familiar with, and attend to, the needs, 

data, and evidence for special populations, including children 

(at various developmental stages); gay, lesbian, bisexual, and 

transgender individuals; women and men; racial and ethnic 

minorities; immigrants and refugees; persons in the criminal 

justice system; trauma victims and survivors; and older persons.

. . . We know that children, older adults, and people in 

rural areas are very much underserved in terms 

of their mental health needs. 

—Family member, primary care provider, educator
11

• Primary care providers who monitor the physical side effects of 

medications.

An “electric” feeling I described, which the primary 

care doctor thought originally was part of my psychosis, 

turned out to be a reaction to a medication. 

—Consumer/advocate

• Providers who incorporate wellness into care.

• Consumer awareness of how to navigate the health care 

system. Local resource guides can help increase access to 

information about services.

• Consumers who engage in self-advocacy and have knowledge 

of their own needs and their State-specific consumer rights. 

Self-advocacy incorporates, for example, advance directives; 

peer advocacy and the use of durable powers of attorney; and 

adequately empowered, well-funded consumer ombudsmen. 

• Creation and use of advance directives and proxies for health 

care to accommodate situations when consumers cannot selfadvocate. 

Person-Level Factors That Hinder Recovery

Dialogue participants also identified a number of factors that 

hinder recovery. They considered the broad area of stigma and 

discrimination to be an overarching negative factor. Other factors 

included

• Primary care and mental health providers who lack interest, or 

knowledge, in working with the medical problems of persons 

with mental illnesses; 

• Providers who do not follow through and who are bound by 

arbitrary time constraints;

• Providers or consumers, or both, who take an “us versus 

them” perspective and who experience conflict over who is “in 

charge” rather than developing a partnership;

• Providers who ignore or are unaware of wellness and 

prevention perspectives; and

• Consumers who fear medical treatment, perhaps as a 

consequence of trauma, and do not seek help for general 

medical complaints.
12

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

. . . We can place blame on a medical care system,

which we have a hard time accessing, for doctors who 

don’t know how to talk to us, don’t trust what we say, 

and don’t adequately report our symptoms. 

—Consumer/advocate 

Issues Related to Systems and Contexts

Participants identified a number of system-level factors that they 

know promote or hinder recovery. System refers to a broad range 

of jurisdictions—Federal, State, and local departments of mental 

and general health, and communities in general.

System-Level Factors That Promote Recovery

Dialogue participants identified a series of system-level factors 

that promote recovery at the intersection of general medical and 

mental health care. They recognized as an overarching theme 

the importance of integration and coordination of mental health 

and primary care services, so that everyone’s multiple needs are 

met, individuals are tracked who are served by both systems, 

and no one falls through the cracks. Other system-level factors 

that promote recovery were discussed, primarily in the categories 

of service provision, community connections, advocacy, and 

research. 

. . . We have provided primary care at our clinic for thirty years. 

We have incorporated pharmacy, dental, pediatrics, OB-GYN, 

and recently mental health services. We treat the family. Our 

patient population is uninsured, underinsured, uneducated, 

and unaware of rights and resources. We takea holistic

approach. It takes away the stigma when no one else 

knows why they’re coming through our doors. 

—Mental health administrator

Service provision

• Flexibility in handling individuals’ health needs at the point of 

entry to the service system, using such models as co-located 

general medical and mental health care, primary care providers 

who work in mental health settings, and mental health 

providers who work in primary care settings.

. . . Every door should be the right door to obtain treatment. 

The greatest system challenge is to create a health care system 

to meet everyone’s needs, like an amoeba that shapes around 
13

anyone who walks through the door. And we need 

research that creates evidence to show that not doing 

so has a deleterious impact on the community. 

—Policymaker

• Primary and mental health providers who have acquired 

cultural competency skills related to mental illnesses (e.g., 

understanding the relationship of consumers’ cultures to 

their attitudes toward mental and general health care; the 

impacts of personal trauma and historical abuses; and ethnopharmacology, which is the study of differences in response 

to drugs based on varied ethnicity, such as drug metabolism, 

dosing, and side-effects).

• Mental health service providers trained to assess consumers’ 

primary care needs and who refer them appropriately for care.

• Primary care providers trained to assess and treat or refer 

persons with mental disorders. 

• Incentives for providers to implement proposed and existing 

mandates regarding integration of general medical and mental 

health care.

. . . Incentives, such as proper reimbursement or 

continuing education units, may help to produce 

outcomes such as choice or good practices. 

—Consumer-operated service provider/advocate

• Consumer ombudsman programs that serve primary care 

settings.

• Data tracking that provides evidence to support funding for 

quality improvements.

. . . We need to find out why people are dying. Death rates of 

people with serious mental illness are very high. Obesity puts people 

at risk, but some care issues in the medical and surgical sectors 

are unaddressed. A pilot study of community psychiatric patients 

in the 1990s found many cases of oversedation with antipsychotics, 

discharge without adequate instructions, and no communication 

between physicians, between services, or with the family.

—Primary care provider, researcher
14

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Community Connections

• Inclusion of mental health assessment and services in school 

health programs and establishment of school-based clinics.

• Primary care representatives who are involved in consumer and 

community advocacy initiatives.

• Resource guides that identify community resources for primary 

care and mental health, to foster referrals by providers to 

appropriate services. 

• Communities that offer supports for consumers.

• Advocacy mechanisms to engage support for consumers from 

the community.

Advocacy

• Education of policymakers, health care providers, and other 

stakeholder groups on the need for integration of primary and 

mental health care and on the need to understand that health 

problems such as obesity, hypertension, and smoking should 

not be viewed as inevitable byproducts of having mental 

illnesses and taking psychotropic medications.

• Identification of State leadership in mental health to target for 

education.

• Grassroots efforts to promote integration of primary and mental 

health care among providers and other stakeholders.

. . . The American Academy of Pediatrics has made mental 

health a priority issue and has established a mental health 

task force to help primary care physicians provide 

behavioral health services in primary care settings.

—Family member, primary care service provider, educator

Research

• Development and funding of a research agenda, including 

research on the health needs of special populations and 

the benefit of coordinating care between mental health and 

primary care providers.

• Efforts to promote translation of research into practice.

• Significant involvement of consumers in research initiatives.
15

. . . The National Institutes of Health has embraced 

community-based participatory action research as an 

evidence-based practice. When the community is involved in 

research, the findings are more likely to come into play later on. 

—Consumer/advocate

• Community-based participatory action research (as adopted by 

the National Institutes of Health) that fosters relevancy of the 

research to the community.

• International research as a resource for perspectives and 

approaches to mental health care.

. . . The real, serious questions that affect our 

lives are not touched by researchers. 

—Consumer/advocate

System-Level Factors That Hinder Recovery

Overarching systemic factors that hinder recovery include

• Lack of access to mental health care or primary care, or both;

• Higher rates of co-occurring general medical disorders in 

people with mental health disorders;

• Stigma and discrimination;

• Lack of a public health approach and systems that are 

sufficiently flexible to address all health needs;

• Lack of integrated and coordinated care between primary care 

and mental health providers; and

• Absence of a “no wrong door” policy that accommodates 

consumers wherever they seek care. 

 In addition, participants identified a long list of system-related 

factors that impede recovery, including issues related to service 

provision, community connections, research, public policy, and 

consumer issues, plus a number of other concerns.

. . . Many mental health consumers never see a mental health 

professional and are more likely to receive assistance for 

mental health needs in the primary care system. People with 

serious mental illness experience disparities in terms of the 

prevalence of such general health problems as heart disease 

and diabetes. More of them die sooner from these conditions, 

and some medications may predispose them to chronic 

conditions. People of color are predisposed to chronic disease. 

We need to be aware of this double or triple whammy. 

—Mental health provider, advocate, educator
16

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

. . . Different settings of care put consumers at risk. The question 

of who is “in charge” of a consumer’s care after discharge from the 

hospital remains unclear. A primary care provider who is watching 

blood levels needs to work with the prescribing psychiatrist. 

—Consumer/advocate

. . . Lack of access sometimes drives people to go to jail 

deliberately to get effective and coordinated health care. Then the 

Justice Department pays for health care, not Medicaid or Medicare. 

—Consumer/advocate, service provider

Service provision

• Persons with mental health problems who lack access to 

specialty providers.

• Lack of electronic medical records and appropriate 

confidentiality and other safeguards to help track persons 

between care systems. 

• Within managed care, insufficient time for providers to deal 

with complex problems, particularly those of persons who do 

not always communicate clearly.

• Medical education that does not teach the practical skills 

necessary to cross the mental health and primary care divide.

Family medicine offers a limited training perspective on 

how to be a family care–oriented mental health provider. 

—Primary care provider

• Lack of awareness or focus, or both, on the specific needs 

of men and of women, and the needs of persons with cooccurring mental health and general medical disorders.

• Lack of awareness or focus, or both, on basic nutritional 

knowledge and other health promotion issues.

. . . Understanding wellness and preventive care does not 

happen in the public mental health system. When I do recovery 

training sessions for provider staff and I bring up the concept of 

helping people with smoking cessation and active lifestyles, 

the staff usually tell me they have too many other issues to 

worry about or it would be too stressful—as if obesity 

and heart disease among their clients were not stressful. 

—Consumer/advocate, service provider
17

• Lack of cultural competence among providers. Relatively few 

providers recognize or understand the legacy of historical 

trauma or the unique needs and attitudes of minorities toward 

mental health and mental illness.

• Lack of trauma-informed services, or training in how to provide 

the services, offered by most mental health and primary care 

providers. Physical examinations can result in retraumatization 

of consumers who have experienced trauma (including 

seclusion and restraint). 

. . . Some kinds of trauma events affect our ability to 

receive certain kinds of primary care, such as dental or 

gynecological. Practitioners need to be educated about the 

realities of trauma and how to deal with it when it 

turns up in their patient population. 

—Consumer/advocate

• Reduction in inpatient hospital beds, which puts the availability 

of acute psychiatric care at risk. 

• Lack of a partnership relationship between consumers and their 

mental health service providers.

. . . The mental health system is the only system 

where coercion is part of the culture.

—State policymaker

. . . What turned things around for me was a psychiatrist 

whose greatest interest was asking questions and listening and 

researching some more, and asking and listening. The crux is the 

relationship and the understanding that you both have valuable 

information that can be shared back and forth. 

—Consumer/advocate

• Inadequate patient safety concerns at the interface of primary 

care and mental health care.

• Primary care physicians, including pediatricians, and 

psychiatrists accorded lower status by practitioners in other 

specialties, a form of stigma and discrimination. 

. . . Often family care physicians, psychiatrists, and pediatricians 

are the lowest paid in terms of “pecking order.” Incentives are 

lacking, so the pool of providers burns out and turns over. 

—Primary care provider
18

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Community Connections

• Schools that do not recognize or refer for treatment students 

with unmet primary care or mental health needs, or both.

. . . Schools can play an important role in recognition, 

advocacy, and treatment of mental disorders.

—Family member, primary care provider, educator

• Inadequate connections between schools and parents. 

• Absence of appropriate advocates for students with special 

health (including mental health) needs.

• Lack of funding for school-based clinics.

• Lack of partnerships, informed by consumer voices, at the 

policy level among hospitals, the community mental health 

system, academic centers, and governments.

• Lack of support to identify and eliminate disparities among 

racial, ethnic, and other minorities, including the GLBT 

community.

. . . Many consumers have turned to the faith community before 

coming to mental health specialty centers for care. It makes sense 

to develop relationships with the faith community. Providers can 

learn from faith leaders about their conceptions of mental illnesses 

or mental health and offer them support to help their congregants. 

—Mental health provider, advocate, educator

Research

• Lack of research on the medical care of mental health 

consumers in terms of quality of service delivery and safety.

• Insufficient research on ethno-pharmacology, which is the 

study of differences in response to medicines based on one’s 

ethnicity.

• Limited role of consumers in research and in training sessions 

for consumer and provider partnership grants. 

• Children omitted from the research agenda. 

• Consumers distrustful of, and not engaged in, research.

Research is needed on issues that members of minorities have, 

including gay, lesbian, bisexual, and transgender (GLBT) people. 

They have higher rates of smoking, women have higher rates 

of diabetes, and men have higher rates of sexually transmitted 
19

diseases and AIDS. And we don’t have a comprehensive 

picture of the mental health needs of the gay community.

—Consumer/advocate

Public Policy

• Inadequate reimbursement for care given by mental health 

service providers.

• Inequitable, inadequate reimbursement for coordination of care 

between mental health and primary care systems.

. . . Therapists don’t talk with primary care doctors. I have 

not figured out where I need to go and where I need to look 

to further my recovery. It’s a hard system to figure out. 

—Consumer, policymaker

. . . Coordination of care is not currently reimbursed, despite the 

Institute of Medicine’s identification of this barrier. 

—Primary care provider, researcher

• Billing and coding rules that do not provide for mental health 

care in primary care services.

• Discriminatory laws and regulations that impede equal 

insurance coverage over the lifespan for mental and general 

medical disorders, that establish barriers to treating cooccurring mental health and substance abuse problems, and 

that prohibit qualification of persons with mental illnesses for 

organ transplants.

. . . Over the years, the mental health and substance abuse 

communities have been at odds. When people come in 

with both needs, no one takes responsibility for both issues. 

—Mental health provider, advocate, educator

• Gaps in Medicaid coverage and coordination and lack of 

awareness about mental health services covered by Medicaid.

• Uneven access to care due to geography and other 

demographic factors. 

• Insufficient attention to co-occurring mental health and primary 

care needs in solicitations for applications for grants.
20

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Consumer Issues

• Definitions impact policy; some consumers assert that the 

terms “self-determination” and “psychiatric disability” appear 

incompatible. 

• Peer-to-peer stigma regarding who is a consumer.
21

Recommendations for Action

Plato said, “The greatest mistake in the treatment of 

diseases is that there are physicians for the body and physicians

for the soul, although the two cannot be separated.” This was 

a call for connection, for integrating mental health 

into overall health and well-being.

 —Former U.S. Surgeon General David Satcher (2004)

Dialogue participants proposed a series of recommendations 

for action by relevant stakeholders, such as Federal and State 

agencies, policymakers, providers of mental health and primary 

care, advocates and educators. Major categories include 

communication and engagement on the integration of medical 

and mental health care, stakeholder education, stakeholder 

accountability, research considerations, and financing issues. 

1. Communication and Engagement of Mental Health 

and Primary Care Providers in Integrating Care 

 Overarching principles include development of training 

modules on inclusion and access and consumer 

involvement in working with providers.

Policy

1.1. SAMHSA should collaborate with the Health 

Resources and Services Administration (HRSA) and 

the Centers for Medicare and Medicaid Services 

(CMS) to devise financing policies to foster 

integrated care.

1.2. Develop materials to clarify, for all health care 

providers, the confidentiality provisions associated 

with the Health Insurance Portability and 

Accountability Act (HIPAA).

1.3. Create standardized protocols for the exchange of 

information between primary care and behavioral 

health care providers, including school-based 

providers.

1.4. Review and identify a point person in each State 

to promote recommendations in the report by the 

National Association of State Mental Health Program 

Directors (NASMHPD) on integrating behavioral 

health and primary care services (see Parks & 

Pollack, 2005). 
22

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

1.5. Incorporate integration efforts with Welfare to Work 

and Ticket to Work programs.

1.6. Concentrate efforts on issues relevant to underserved 

populations.

Program development

1.7. Develop a Wellness Recovery Action Plan (WRAP) 

program for primary care, self-care, and selfmanagement support.

1.8. Promote placement of nurse practitioners in 

community mental health settings for routine primary 

care.

1.9. Develop quality improvement programs for 

providers, including incentives to improve care.

1.10. Develop a quick screening tool for primary care 

providers to determine patients’ preferences for level 

of their participation in determining care.

1.11. Develop a role for peer support specialists in 

primary care.

Consumer-related activities

1.12. Develop a national consumer association. 

1.13. Provide communications training for consumers to 

work with providers.

1.14. Conduct similar dialogue meetings among 

stakeholders at the local and State levels to highlight 

consumer involvement in integrated care.

1.15. Offer incentives for training of providers by 

consumers.

1.16. Develop a Web site to promote primary care and 

behavioral health integration.

1.17. Train emergency room staff in behavioral health 

issues.

1.18. Develop an anthology of stories of what works, from 

both consumers and providers, to help identify good 

models of integration and coordination of primary 

and mental health care.
23

1.19. Develop a speakers bureau on the integration of 

mental health and primary care to address stigma 

issues related to access of quality care and mental 

illness.

2. Stakeholder Education 

 Stakeholders include policymakers, primary care providers, 

mental health care providers, consumers, families, 

community representatives, and others.

Provider issues

2.1. Create opportunities to meet provider needs for 

training (e.g., on consumer involvement in care, 

cultural competence, and motivational interviewing).

2.2. Conduct an initiative to improve care options for 

members of minority groups (e.g., the American 

Psychiatric Association’s minority outreach initiative 

targets primary care providers and faith-based 

organizations).

2.3. Collaborate with Morehouse School of Medicine’s 

National Primary Care Center on integrated care.

2.4. Establish a 1-year certification program in mental 

health for primary care providers. 

2.5. Educate dentists about working with clients who 

have mental health problems.

2.6. Create incentives for information acquisition 

regarding the integration and coordination of 

primary and behavioral health care. 

2.7. Train front-office staff of primary care providers to 

interact with persons with mental health problems. 

2.8. Offer technology or Internet training on the benefits 

and implementation of integrated mental health and 

primary care services.

2.9. Replicate this dialogue model within mental health 

and primary care settings.

2.10. Train mental health providers in the importance of 

addressing general health needs and of coordinating 

care between general medical and mental health 

providers.
24

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Consumer involvement

2.11. Educate providers and staff to realize that consumer 

involvement has positive outcomes.

2.12. Educate stakeholders on the effectiveness of 

consumer-operated services. 

2.13. Educate consumers about how to improve 

interactions with primary care providers.

2.14. Educate first responders (e.g., police, fire, and 

ambulance) on appropriate responses in situations 

that involve mental health consumers.

2.15. Educate consumers about their rights.

2.16. Educate consumers to advocate for themselves 

and peers. 

Resource development 

2.17. With the Department of Veterans Affairs and other 

relevant organizations, develop curricula on trauma 

and its consequences for health.

2.18. Target education of, and partnerships between, 

employers and purchasers of health care regarding 

innovative programs to integrate primary and mental 

health care in the workplace.

2.19. Survey primary care provider guilds’ approach to 

training and publish and disseminate a report on 

successful integration models.

2.20. Develop resources to educate stakeholders on cost 

savings related to prevention programs and increased 

access to care.

2.21. Develop materials and integrate recovery into 

curricula for training providers.

3. Stakeholder Accountability 

We need accountability for research, reimbursement, and 

engagement. We need mechanisms to hold everyone, including 

funders, consumers, and providers, accountable. 

—Consumer/advocate, service provider
25

3.1. Plan for and track quality improvement, including 

development of a consumer evaluation form and a 

single set of standards and measures for providers. 

Planning and implementation must be collaborative 

and must incorporate both significant input from 

consumers and involvement of accreditation 

organizations.

3.2. Publish report cards for satisfaction and 

dissatisfaction at all levels and for all stakeholders. 

Consumers should interview consumers, to 

reduce threat of loss of care by providers, and 

questionnaires should be developed that are 

appropriate for consumers who cannot read.

3.3. Hold managed care organizations accountable, and 

survey providers on their experiences.

3.4. Focus on compliance with the Americans with 

Disabilities Act in terms of access to care. 

3.5. Develop tools for training and tracking outcomes, 

and provide incentives for providers to track 

outcomes.

4. Research 

A top priority is the translation, dissemination, and 

implementation of what we know to work. 

—Primary care provider, educator, researcher

4.1. Focus research on recovery-oriented practices to add 

to the evidence base of programs that work. 

4.2. Create a guide that describes the latest research in 

mental health and primary care. 

4.3. Review the literature on international research.

4.4. Support community-based, participatory action 

research; use consumer-run research as part of larger 

grants; require consumer direction of research and 

accountability to the community.

4.5. Provide funding to evaluate consumer-operated 

programs (e.g., small incentive grants).

4.6. Provide funding to expand the evidence base for 

best models of coordination between primary care 

and specialty mental health providers.
26

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

4.7. Provide technical assistance to consumer researchers.

4.8. Conduct research on the effectiveness of “alternative” 

therapies, such as physical exercise or yoga.

4.9. Conduct research on pharmaceuticals’ side effects 

related to such concerns as sleep, nutrition, and a 

holistic approach.

5. Finance

Creating better access to health care lowers costs. After decreasing 

barriers to outpatient mental health services in 1992, North 

Carolina’s State Employee Health Plan experienced a 70 percent 

reduction in mental health hospital days and a steady reduction in 

average per member/per month costs for the next six years.

—Family member, primary care service provider, educator

Funding

5.1. Ensure that systems have the resources to provide 

high-quality general medical and mental health care.

5.2. Address the high cost of medications. 

5.3. Raise pay scales for psychiatrists.

5.4. Eliminate mental health carve-outs from managed 

care plans to reduce fragmentation (need a single 

point of entry). 

5.5. Develop a report that demonstrates the costeffectiveness of increased access to mental health 

and primary care, pooling data from separately 

funded programs.

5.6. Increase funding for pilot programs for 

self-directed care.

Reimbursement

5.7. Provide reimbursement in all States for all mental 

health providers, including certified peer specialists 

and other consumer-providers, and providers of 

respite and home care. 

5.8. Provide reimbursement on a continuum of care 

provided by community mental health centers.

5.9. Provide reimbursement for collaboration between 

professionals, that is, reimbursement for physician-
27

to-physician, mental health professional-to-physician, 

and physician-to-mental health professional 

consultation.

5.10. Increase Medicaid buy-in programs and disseminate 

information nationwide. 

5.11. Eliminate the lifetime cap on reimbursement for 

Medicare inpatient care.

5.12. Conduct a financial review and reform such 

procedures as billing, coding, and reimbursement to 

ensure delivery of appropriate mental health services 

in primary care settings. 

Community collaboration 

5.13. Develop partnerships between general medical 

and mental health community-based service 

organizations.

5.14. Collaborate with unions on workplace initiatives.

5.15. Create a toolkit to help stakeholders educate 

legislators and other policymakers.

Incentives

5.16. Offer incentives for training to primary care 

providers in how to care for people with mental 

illnesses.

5.17. Establish work incentives for consumers, providing 

such supports as personal care assistants.

5.18. Establish incentives that promote self-directed care, 

consumer control and choice of services, and a 

wider variety of services. 

6. Planned Actions in the Community

 To close the dialogue meeting, participants identified a 

number of activities they planned to undertake in their 

communities. They recognized that this effort requires 

maximizing creative thinking about where the best points 
28

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

of intersection and intervention are to implement systems 

transformation. Planned community actions included

• Increased interaction with the broader disability community, 

including mental health, developmental disability, and other 

systems with similar issues;

• Increased engagement at the State level with CMS to 

broaden the availability of Medicaid coverage;

• Replication of dialogues on the local and State levels among 

mental health consumers and representatives of the mental 

health and primary care sectors as a consciousness-raising 

effort; and

• Organization of community events where primary care 

providers and mental health providers can meet to establish 

connections.

. . . Primary care must see mental health as part of its charge 

and responsibility, and vice versa. The ultimate goal is for 

primary care and mental health care to work together. 

Developing a coordinated plan is the context for all work.

—State policymaker 
29

Innovative Mental Health Treatments and Services

The New Freedom Commission’s Subcommittee on Mental 

Health Interface with General Medicine (2003b) observed that 

although highly effective treatments are available for mental 

disorders, a number of patient, provider, and system-level 

barriers impede the effective delivery of these treatments. The 

subcommittee identified a number of ingredients necessary to 

improve care for common mental disorders at the interface of 

general medicine and mental health. Many of these ingredients 

are congruent with those identified by participants in the 

dialogue: 

1. Educated consumers, primary care providers, and mental 

health providers.

2. Efficient and effective methods to screen for, diagnose, and 

monitor common mental disorders in primary care. 

3. Information systems that can support proactive tracking 

of both quality and outcomes of care by primary care and 

specialty mental health providers in order to prevent patients 

from “falling through the cracks.”

4. Well-established performance criteria for quality of mental 

health care at the interface of general medicine and mental 

health. 

5. Evidence-based, collaborative, and stepped care treatment 

protocols that match treatment intensity to clinical outcomes.

6. Trained mental health staff (psychiatrists, psychologists, 

clinical social workers, or other mental health workers) who 

can support primary care providers with education, proactive 

followup, case management, psychotherapy, and consultation 

for patients who do not respond to firstline treatments in 

primary care.

7. Effective mechanisms to refer patients who do not improve 

with treatment in primary care to specialty mental health 

care and to coordinate treatments between primary care and 

specialty mental health care. 

8. Financing mechanisms for evidence-based models of care for 

common mental disorders in primary care. These mechanisms 

include payment for case management for common mental 

disorders in primary care according to evidence-based 

protocols, consultation to primary care providers and 

supervision of mental health case managers by qualified 

mental health specialists, psychotherapy at copayment rates 

equal to those for the treatment of general medical disorders, 

and prescription medications for common mental disorders.
30

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue
31

Selected References 

and Resources*

References and Related Publications

American Association of Community Psychiatrists. (2002). Position 

paper on interface and integration with primary care providers. 

www.comm.psych.pitt.edu/finds/primarycare.htm

Bazelon Center for Mental Health Law. (2004). Get it together: How 

to integrate physical and mental health care for people with 

serious mental disorders. Executive summary. Washington, DC: 

Bazelon Center for Mental Health Law.

Belar, C. D., & Deardorff, W. W. (1995). Clinical health psychology 

in medical settings: A practitioner’s guidebook (Rev. ed.). 

Washington, DC: American Psychological Association.

Blount, A. (Ed.). (1998). Integrated primary care: The future of 

medical and mental health collaboration. New York: Norton 

Professional Books. 

Bush, G. W. (2004, April 29). Speech, Albuquerque, New Mexico, 

quoted in New Freedom Commission on Mental Health, 

Achieving the promise: Transforming mental health care in 

America. Final report. (2003). DHHS Pub. No. SMA-03-3832, 

p. 19. Rockville, MD: U.S. Department of Health and Human 

Services.

Cummings, N. A., O’Donohue, W. A., Hayes, S. C., & Follette, V. 

(2001). Integrated behavioral healthcare: Positioning mental 

health practice with medical/surgical practice. San Diego, CA: 

Academic Press.

Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. (Eds.). 

(2003). Primary care psychology. Washington, DC: American 

Psychological Association.

Gatchel, R. J., & Oordt, M. S. (2003). Clinical health psychology 

and primary care: Practical advice and clinical guidance 

for successful collaboration. Washington, DC: American 

Psychological Association.

Institute of Medicine. (2006). Improving the Quality of Health Care 

for Mental and Substance-Use Conditions. Washington, DC: 

National Academies Press. www.nap.edu/books/0309100445/

html

 * This list is provided as a resource. It is not exhaustive, and it 

does not imply endorsement by SAMHSA.
32

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Murray, C. J. L., & Lopez, A. D. (Eds.). (1996). The global burden of 

disease: A 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 on 

behalf of the World Health Organization and the World Bank.

 National Association of State Mental Health Program Directors 

(NASMHPD). (2005, January). Integrating behavioral health and 

primary care services: Opportunities and challenges for state 

mental health authorities. www.nasmhpd.org/general_files/

publications/med_directors_pubs/Final%20Technical%20Report

%20on%20Primary%20Care%20-%20Behavioral%20Health%20In

tegration.final.pdf

National Council for Community Behavioral Healthcare. (2003). 

Background paper: Behavioral health/primary care integration 

models, competencies, and infrastructure. www.nccbh.org (Use 

search function.)

National Depressive and Manic-Depressive Association. (2000). 

A call to action to the primary care community and people 

with depression. www.dbsalliance.org/PDF/BeyondDiagnosis.

pdf. (The group is now known as the Depression and Bipolar 

Support Alliance.)

National Mental Health Association. Can’t make the grade: NMHA 

state mental health assessment project. www.nmha.org/

cantmakethegrade/index.cfm 

New Freedom Commission on Mental Health. (2003a). Achieving 

the promise: Transforming mental health care in America. Final 

report. DHHS Pub. No. SMA-03-3832. Rockville, MD. www.

mentalhealthcommission.gov

New Freedom Commission on Mental Health. (2003b). 

An outline for the draft report of the Subcommittee on 

Mental Health Interface with General Medicine. http://

mentalhealthcommission.gov/subcommittee/Sub_Chairs.htm

Northern Manhattan Community Voices Collaborative. (n.d.). 

Mental health: The neglected epidemic. Convening and 

promoting a dialogue among consumers, providers and 

policymakers. www.communityvoices.org/non_publication_

pdfs/NM-MentalHealthPaper.pdf

Parks, J., & Pollack, D. (Eds.). (2005). Integrating behavioral health 

and primary care services: Opportunities and challenges for 

state mental health authorities. Executive summary, technical 

report. Alexandria, VA: National Association of State Mental 

Health Program Directors. 
33

www.nasmhpd.org/general_files/publications/med_directors_

pubs/Final%20Technical%20Report%20on%20Primary%20Care%

20-%20Behavioral%20Health%20Integration.final.pdf

Patterson, J., Peek, C. J., Heinrich, R. L., Bischoff, R. J., & Scherger, 

J. (2001). Mental health professionals in medical settings: A 

primer. New York: W.W. Norton.

Pincus, H. A. (2003). The future of behavioral health and primary 

care: Drowning in the mainstream or left on the bank? 

Psychosomatics 44, 1–11.

Satcher, D. (2004). The connection between mental health and 

general health. The President’s New Freedom Commission on 

Mental Health: Transforming the vision. Atlanta, GA: The Carter 

Center.

Seaburn, D. B., Lorenz, A. D., Gunn, W. B., Jr., Gawinski, B. A., 

& Mauksch, L. B. (1996). Models of collaboration: A guide 

for mental health professionals working with health care 

practitioners. New York: Basic Books.

Smith, S. R. (2004, October 6). Remarks to the HRSA-SAMHSA 

Primary and Behavioral Health Care Summit, Arlington, VA. 

http://newsroom.hrsa.gov/speeches/2004speeches/smith-oct26-

health-care-summit.htm

Substance Abuse and Mental Health Services Administration, 

U.S. Department of Health and Human Services. (2005). 

Transforming Mental Health Care in America. Federal Action 

Agenda: First Steps. DHHS Pub. No. SMA-05-4060. Rockville, 

MD: Author.

U.S. Department of Health and Human Services. (2001). National 

strategy for suicide prevention: Goals and objectives for action. 

Rockville, MD: U.S. Public Health Service.

U.S. Public Health Service, Office of the Surgeon General. (1999). 

Mental health: A report of the surgeon general. Rockville, MD: 

Author.

World Federation for Mental Health. (2004). The relationship 

between physical and mental health: Co-occurring disorders. 

www.wfmh.org/wmhday/2004.htm

World Health Organization. (2001). Mental health: New 

understanding, new hope. World Health Report 2001. Geneva: 

Author.
34

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

World Health Organization. (2002). WHO guide to mental 

and neurological health in primary care. London: WHO 

Collaborating Centre for Research and Training for Mental 

Health. www.mentalneurologicalprimarycare.org

Federal and Other Resources

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

The Center for Mental Health Services (CMHS) leads the national 

system that delivers mental health services in order to provide 

the treatment and support services needed by adults with 

mental disorders and children with serious emotional problems. 

SAMHSA’s three centers, CMHS, the Center for Substance Abuse 

Prevention, and the Center for Substance Abuse Treatment, along 

with other Federal agencies, have inaugurated a new collaboration 

to span the silos of general medical and mental health care.

 Address: 1 Choke Cherry Road, Rockville, MD 20857

 Web site: www.mentalhealth.samhsa.gov

 Enews Alert: www.mentalhealth.samhsa.gov/onsumersurvivor 

 (see signup at bottom of screen)

 Funding opportunities: www.samhsa.gov 

 (click on Hot Topics, “New Grant Funding Opportunities”)

 Resource Center to Address Discrimination and Stigma: 

 www.adscenter.org

 Elimination of Barriers Initiative: 

 www.allmentalhealth.samhsa.gov;

 in Spanish: 

 www.nuestrasalud.samhsa.gov

Centers for Disease Control and Prevention: Coordinated 

School Health Program

The Centers for Disease Control and Prevention’s coordinated 

school health program model consists of eight interactive 

components. These components are health education, physical 

education, health services, nutrition services, counseling and 

psychological services, healthy school environment, health 

promotion for staff, and family/community involvement. 

 Web site: www.cdc.gov/HealthyYouth/CSHP/index.htm
35

Health Resources and Services Administration, Bureau of 

Primary Health Care 

The Health Resources and Services Administration (HRSA) 

ensures that underserved and vulnerable people get the health 

care they need through a nationwide network of community and 

migrant health centers and health care for the homeless programs. 

Materials are available on primary health care, access, insurance, 

and other topics from the HRSA Information Center. HRSA’s 

Primary Care Integration Initiative aims to eliminate disparities of 

underserved individuals and families with primary mental health 

and substance abuse disorders. By 2006, HRSA expects to expand 

dramatically the number of people nationwide served by new and 

existing community health centers that provide mental health and 

substance abuse treatment in addition to primary medical care 

(Parks & Pollack, 2005). 

 Web site: www.hrsa.gov

 HRSA Information Center: www.ask.hrsa.gov/Primary.cfm

National Institute of Mental Health 

The National Institute of Mental Health’s (NIMH’s) Primary 

Care Research Program conducts studies on the delivery and 

effectiveness of mental health services within the general health 

care sector; recognition, diagnosis, management, and treatment 

of mental and emotional problems by primary care providers; 

coordination of general medical care with, and referrals to, 

mental health specialists; provision of psychiatric emergency 

services, consultation and liaison psychiatry, and other psychiatry, 

psychology, and social work services within the general medical 

care sector; and studies that improve understanding of how 

best to improve care for people with mental disorders and cooccurring general medical conditions.

 NIMH Primary Care Research Program (82-SEPC)

 Contact: Carmen Moten, Ph.D., Chief, 

 Primary Care Research Program 

 Address: 6001 Executive Boulevard, Room 7146/MSC 9631, 

 Rockville, MD 20852

 Telephone: 301-443-3725

 E-mail: cmoten@mail.nih.gov

***
36

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) has 

compiled a policy statement on mental health and a position 

paper on mental health care services by family physicians.

 Address: P.O. Box 11210, Shawnee Mission, KS 66207-1210

 Telephone: 1-800-274-2237; 913-906-6000

 Web site: www.aafp.org

 Policy statement on mental health: www.aafp.org/x6925.xml

 “Mental Health Care Services by Family Physicians (Position 

 Paper)”: www.aafp.org/x6928.xml

American Academy of Pediatrics

The American Academy of Pediatrics (AAP) offers information 

on children’s behavioral health and professional education and 

resources. The group has established a task force to help primary 

care physicians provide behavioral health services in primary care 

settings.

 Address: 141 Northwest Point Boulevard, 

 Elk Grove Village, IL 60007-1098

 Web site: www.aap.org

American Association of Community Psychiatrists 

The American Association of Community Psychiatrists has 

recommended that mental health and substance abuse treatment 

providers at the local level incorporate a systematic program 

to coordinate or integrate with primary care providers and 

organizations in their communities, with the goal to improve 

bidirectional communication, share essential information, and 

adopt appropriate confidentiality and consent protocols (Parks & 

Pollack, 2005, 5).

 Address: University of Pittsburgh, 3811 O’Hara Street, 

 Pittsburgh, PA 15213

 Web site: www.comm.psych.pitt.edu

 “Position Paper on Interface and Integration with Primary 

 Care Providers” (October 2002): www.comm.psych.pitt.edu/

 finds/primarycare.htm
37

American Psychiatric Association

Integration of mental and general health is a priority of the 

American Psychiatric Association (APA), which is developing 

an initiative to address the issues. An ongoing APA program is 

Bridging the Gaps between Dental Health and Mental Health.

 Address: 1000 Wilson Boulevard, Arlington, VA 22209

 Telephone: 1-888-357-7924 

 Web site: www.psych.org

American Public Health Association

The American Public Health Association (APHA) promotes the 

scientific and professional foundation of public health practice 

and policy, advocates the conditions for a healthy global society, 

emphasizes prevention, and enhances the ability of members to 

promote and protect environmental and community health.

 Address: 800 I Street, N.W., Washington, DC 20001

 Telephone: 202-777-APHA (202-777-2742)

 Web site: www.apha.org

Community Voices: HealthCare for the Underserved

Managed by the National Center for Primary Care at the 

Morehouse School of Medicine, Community Voices sites are 

making a significant contribution to understanding the health 

care challenges facing communities, advancing recommendations 

for change, and implementing solutions. Community Voices 

is designed to strengthen community support services and to 

help ensure the survival of safety net providers. Communities 

are piloting various approaches and strategies and bridging 

health care delivery to underserved populations with new policy 

solutions.

 Web site: www.communityvoices.org

 The Northern Manhattan Community Voices Collaborative’s 

 “Mental Health: The Neglected Epidemic: Convening and 

 Promoting a Dialogue Among Consumers, Providers and 

 Policy Makers”: www.communityvoices.org/non_publication_

 pdfs/NM-MentalHealthPaper.pdf
38

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Health Guide USA: Primary Care Association

This Web site offers users access to a wide variety of online health 

care-related resources, including primary care associations. 

 Web site: http://healthguideusa.org

National Association of Community Health Centers

The National Association of Community Health Center’s 

(NACHC’s) Web site reflects its commitment to help those 

involved with America’s community, migrant, and homeless health 

centers, including Federal and State policymakers, primary care 

associations, health centers, clinicians, and patients. 

 Address: 7200 Wisconsin Avenue, Suite 210, 

 Bethesda, MD 20814

 Telephone: 301-347-0400

 Web site: www.nachc.com

National Association of State Mental Health 

Program Directors

A nonprofit organization dedicated to serving the needs of the 

nation’s public mental health system through policy development, 

information dissemination, and technical assistance, the National 

Association of State Mental Health Program Directors (NASHMPD) 

published in 2005 a technical report on the integration of 

behavioral health and primary care services. 

 Address: 66 Canal Center Plaza, Suite 302, 

 Alexandria VA 22314

 Telephone: 703-739-9333

 Web site: www.nasmhpd.org

“Integrating Behavioral Health and Primary Care Services: 

Opportunities and Challenges for State Mental Health 

Authorities”: www.nasmhpd.org/general_files/publications/

med_directors_pubs/Final%20Technical%20Report%20on%20

Primary%20Care%20-%20Behavioral%20Health%20Integration.

final.pdf

National Council for Community Behavioral Healthcare

The National Council for Community Behavioral Healthcare 

(NCCBH) is a trade association that represents the providers of 

mental health, substance abuse, and developmental disability 
39

services. In May 2003, the council published a background paper 

on behavioral health and primary care integration. 

 Address: 12300 Twinbrook Parkway, Suite 320, 

 Rockville, MD 20852

 Telephone: 301-984-6200; fax: 301-881-7159

 Web site: www.nccbh.org

“Background Paper: Behavioral Health/Primary Care 

Integration Models, Competencies, and Infrastructure”: www.

nccbh.org/HTML/LEARN/PCI/PrimaryCareDiscPaper.pdf

National Mental Health Association

The National Mental Health Association’s (NMHA’s) Primary 

Care Initiative reaches out to providers to improve the manner 

in which depression and anxiety are detected and treated in 

primary care settings, particularly to make certain that individuals 

who have been encouraged to seek treatment for depression 

and anxiety disorders can be assured that their provider is aware 

of the prevalence, symptoms, and treatment of these illnesses. 

NMHA has developed educational programs and materials for 

practitioners and patients, as well as fact sheets about depression 

and anxiety disorders in primary care settings, and distributes free 

educational materials, brochures, and screening tools; provides 

access to support groups and referral networks; and provides 

technical assistance and consultation as needed to primary care 

practitioners and health care partners interested in participating in 

this initiative.

 Address: 2001 North Beauregard Street, 12th Floor, 

 Alexandria, VA 22311

 Telephone: 1-800-969-NMHA (1-800-969-6642)

 Web site: www.nmha.org

ParentsMedGuide.org

The American Psychiatric Association and the American Academy 

of Child and Adolescent Psychiatry have posted guides on this 

Web site to help patients, families, and physicians make informed 

decisions about obtaining and administering the most appropriate 

care for a child with depression. The guides have been endorsed 

by many national medical, family, and patient advocacy 

organizations.

 Web site: www.parentsmedguide.org
40

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue
41

Participant List

Planning Committee

Jon Delman

Director

Consumer Quality Initiatives

Dorchester, MA

Douglas DaVoe

Executive Director

Ohio Advocates for Mental Health

Columbus, OH

Harold Alan Pincus, M.D.

Professor and Executive Vice Chairman

Department of Psychiatry

University of Pittsburgh School of Medicine

Pittsburgh, PA

Anelle Primm, M.D.

Director, Office of Minority and National Affairs

American Psychiatric Association

Arlington, VA 

Dialogue Participants

Mary Ann Beall

Consumer/advocate

Falls Church, VA

Mary Blake

Director of Training/Communications

Consumer Action Network

Washington, DC 

William Brent

Chief Financial Officer

Teche Action Community Health Center

Franklin, LA

Mario Cruz, M.D.

Department of Psychiatry

University of Pittsburgh Medical Center

Pittsburgh, PA
42

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Dialogue Participants (cont.)

Gail Daumit, M.D., M.H.S.

Assistant Professor of Medicine

Johns Hopkins University School of Medicine

Baltimore, MD

Gloria Dickerson

Consumer/advocate

M-Power, Inc.

Boston, MA

Mark Fields

Peer Specialist

Mental Health Consumer Advocates 

 Oasis Advocacy and Social Center

Providence, RI

Jane M. Foy, M.D.

Associate Professor 

Wake Forest University Health Sciences, 

 Department of Pediatrics

Winston-Salem, NC

Laurel Labadie

Executive Director

Wings Enrichment Center

Marysville, OH 

Paula Lafferty

Director

Hearts and Ears

Baltimore, MD 

Liz Reardon, M.P.H.

Managed Care Director

Office of Vermont Health Access

Waterbury, VT

Amy Smith

Program Director

Community Connections Drop-In/Empowerment Center

Aurora, CO
43

Asha Subramanian, M.D.

Assistant Director of Community Health, 

 Department of Family Medicine

Georgetown University School of Medicine

Washington, DC 

Misha Subwick

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Rockville, MD

Federal Representatives: SAMHSA/

 Center for Mental Health Services

Paolo del Vecchio, M.S.W.

Associate Director for Consumer Affairs

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Rockville, MD

Elizabeth Lopez, Ph.D.

Public Health Analyst

Office of Policy, Planning, and Budget 

Substance Abuse and Mental Health Services Administration

Rockville, MD

Chris Marshall

Consumer Affairs Specialist

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Rockville, MD

Carole Schauer, R.N., M.S.

Senior Consumer Affairs Specialist

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Rockville, MD

Carlton Speight

Consumer Affairs Specialist

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Rockville, MD
44

Mental Health Consumers and Primary 

Health Care Representatives in Dialogue

Facilitator

Sheila Thorne

President and CEO

Multicultural Healthcare Marketing Group, LLC

Teaneck, NJ

Writer

Irene Saunders Goldstein

Arlington, VA

SMA 06-4040

2006