Barriers and Enablers to IntegratingMental Health into Primary Care:A Policy Analysis

Anna Durbin, MPH, PhD candidateJanet Durbin, PhDJennifer M. Hensel, MD, MScRaisa Deber, PhD

Abstract

Integrating care for physical health and behavioural health (mental health and addictions) hasbeen a longstanding challenge, although research supports the clinical and cost effectiveness ofintegrated care for many clients. In one such model, primary care (PC) physicians work withspecialist physicians and non-physician providers (NPPs) to provide mental health and addictionscare in PC settings. This Ontario, Canada-focused policy analysis draws on research evidence toexamine potential barriers and enablers to this model of integrated care, focusing on mentalhealth. Funding challenges pertain to incentivizing PC physicians to select patients with mentalillness, include NPPs on the treatment team, and collaborate with specialist providers. Legal/regulatory challenges pertain to NPP scopes of practice for prescribing and counselling.Integrated care also requires revising the role of the physician and distribution of functionsamong the team. Policy support to integrate addictions treatment in PC may face similarchallenges but requires further exploration.

Address correspondence to Anna Durbin, MPH, PhD candidate, Institute of Health Policy, Management and Evaluation,University of Toronto, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada. Phone: +1-416-8241078; Email:Anna.durbin@gmail.com.

Jennifer M. Hensel, MD, MSc, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto,Ontario, Canada.

Raisa Deber, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario,Canada. Email: raisa.deber@utoronto.ca

Janet Durbin, PhD, Provincial System Support Program, Center for Addiction and Mental Health, Toronto, Ontario,Canada. Phone: +1-416-5358501; Email: Janet.Durbin@camh.ca

Jennifer M. Hensel, MD, MSc, Center for Addiction and Mental Health, Toronto, Ontario, Canada. Email:jennifer.hensel@mail.utoronto.ca

Journal of Behavioral Health Services & Research, 2013. 1–12. c) 2013 National Council for Community BehavioralHealthcare. DOI 10.1007/s11414-013-9359-6

Integrating Mental Health into Primary Care DURBIN et al.

Introduction

The integration of care for physical health and behavioural health (mental health and addictions) hasbeen a longstanding challenge. Although they are likely to have worse physical health problems thanthe general population, persons with mental illness—especially serious mental illness—are less likelyto use general, preventive and specialty healthcare services.1,2 Similarly, substance misuse disorders arenow viewed by clinical experts as chronic diseases, which are often associated with a variety of otherside effects and consequences (e.g. kidney disease, diabetes and major depression).3 One of the topicalsubcommittees created in the United States to support the work of the President’s New FreedomCommission on Mental Health4 in 2002 was charged with addressing the interface of mental healthwith general medicine.5 The Institute of Medicine report on Improving the Quality of Health Care forMental Health and Substance Use Conditions6 noted the need for health care delivery to understand andrespond to the interactions between mind/brain and body.

Primary care is seen as a focal point for integration, often being the first or only point of entry to thehealth care system for individuals with a host of mental and physical health problems.7 Integration ofmental health and addictions services into primary care is supported internationally 8–12 as a strategy toimprove access to person-centred mental health care, and a number of models have been proposed. Thefour quadrant clinical integration model13 is an example. Proposed by the National Council forCommunity Behavioral Healthcare, this model locates main responsibility for patient care within theprimary and speciality health care systems, considering the patient’s mental health and substance useneed and risk. In general, it suggests that persons with lowmental health and substance use complexity/risk be followed in the primary care systemwith specialty consultation accessed as needed (quadrant 1),while individuals with high mental health and substance use and physical health complexity be servedin the specialty mental health and substance use care system, with coordination with primary care. Tomanage patient mental health and substance use needs in the primary care setting, the model suggestsuse of standardized screening tools and inclusion of a behavioural health provider in the setting to assistwith assessment, treatment and care management.

An integrated approach to behavioural health at the level of primary care is commonly proposedto enhance the capacity of primary care providers to manage patient needs related to mental healthand substance use conditions and comorbid illnesses.5,14 Consistent with quadrant 1 care in theFour Quadrants model,13 the primary care physician (PCP) and psychiatrist or other mental healthprofessional are concurrently involved in the patient’s treatment but the PCP typically remains theongoing health-care provider.15 The PCP may deliver the mental health care supported byconsultation from the mental health specialist (indirect approach) or may arrange for the mentalhealth specialist to directly provide care, often at the primary care site (direct approach). Somemodels combine both approaches.16 Increasingly, other health professionals on the care team suchas social workers, nurses and occupational therapists are involved. This interdisciplinary teamshares information, makes joint decisions about care, and provides an expanded range of treatmentsand supports such as prevention and wellness education, proactive illness management andassistance to patients to access other services as needed.5,14 Canada, the United States, the UnitedKingdom, and Australia are among the locations that have adopted integrated and collaborativeprimary care approaches, while acknowledging that many issues still must be addressed beforethese models can be implemented on a large scale.8–12 This paper will focus exclusively on suchintegrated care approaches for mental health, hereafter referred to as integrated care (IC).5,14

Benefits of integrated care There are a number of benefits associated with IC. One is increasedpopulation access to mental health care. This is important because many individuals with mentalhealth needs do not receive mental health services.17 PCPs are the most commonly contactedproviders and often the only providers contacted for mental health care.17–19 In the United Statesand Canada, studies have found that PCPs are responsible for prescribing between 60 and 80 % of

The Journal of Behavioral Health Services & Research 2013

psychotropic medications.20,21 In IC, the same team treats physical and mental health problems,which is an important advantage since people with mental health issues often receive inadequatephysical health care.22 Studies across a range of health care systems demonstrated that IC modelscan achieve clinically meaningful improvements for depression outcomes and public healthbenefits in an array of populations, settings and organizations. Specific outcomes that have beenobserved are improved symptom outcomes in the short- and long-term, increased satisfaction withcare and greater quality of life.23–30 For patients, receiving services from PCPs can be lessstigmatizing, more coordinated, and more accessible than mental health specialist services.31,32

Cost effectiveness of IC has also been demonstrated. Dewa et al.33 reported that Ontarioemployees who received IC had fewer short-term disability days and returned to work faster. Forevery 100 individuals this translated into an estimated $50,000 in disability benefit savings (meanof $503 per individual). Similar results were reported by van Orden et al.24 who noted that IC wasassociated with significantly shorter referral delays, reduced time in treatment, fewer appointments,and lower treatment costs.

An additional benefit of IC is the ability to address both mental health and substance use needs.This is important due to the high rates of mental illness and comorbid substance use disorders.34

Screening, Brief Intervention and Referral to Treatment (SBIRT)35,36 is an example of a structuredintervention applicable in IC that addresses both conditions. SBIRT creates an opportunity toengage individuals in care for a problem for which they may not have necessarily sought help.Screening and brief intervention strategies are well-supported practices to increase recognition andtreatment of mental health and addictions problems in primary care but require willingness, time,and practice changes to implement.35

Identifying barriers and facilitators to implementing IC is critical, especially since primary carereform is underway in many jurisdictions internationally and offers opportunities to support IC.The present study examined the potential impact of primary care reform on implementation of ICfor mental health, using Canada’s largest province (population: about 13.5 million) Ontario, as anexample. The delivery of IC is important for both mental health and substance misusemanagement. However, the mental health and addictions treatment systems are still generallyseparate and are often addressed in separate policies and practice literatures. While this policyreview focuses on mental health, a final section addresses some key policy-relevant issues forintegrating addictions services into primary care.

Ontario uses a healthcare funding model described by the Organisation for Economic Co-operation and Development (OECD) as a public contracting model.37 Under this model, all legalresidents (‘insured persons’) must be covered by the provincially run health insurance system forall medically necessary care delivered by physicians or in hospitals in order to receive federalfunding under the terms of the Canada Health Act. This legislation is a floor, not a ceiling; otherservices may be covered by the provincial plan (and/or by private insurance), but this is notrequired. Delivery is largely private; in particular, physicians are private providers.38,39

Traditionally, primary care in Ontario had been delivered via solo physicians or small groups ofphysicians paid through fee for service (FFS) reimbursement. In recent years, Ontario hasintroduced several new primary care reimbursement models, which carry different incentivestructures.40,41 While the new models vary in PCP payment arrangements, all these models linkreimbursement at least in part to the number of patients rostered (or enrolled) in the primary carepractice. The main models include: enhanced (blended) FFS; blended capitation and team-basedblended capitation, which are called Family Health Teams. Salaried physician models are alsopresent in the system but constitute a very small portion of practices (4 %) and are not consideredfurther in this analysis.42 In enhanced FFS models, PCP reimbursement is mainly through FFSpayments. In blended capitation models, PCP reimbursement is mainly through a fixed paymentbased on the number of patients rostered into the practice (depending on the model, the precisepayments may vary by such factors as age and sex). Team-based blended capitation models allow

Integrating Mental Health into Primary Care DURBIN et al.

PCPs to apply for funding to include non-physician providers (NPPs), such as registered nurses,nurse practitioners, and social workers, in their practice. In the team-based blended capitationmodels only, PCPs may additionally apply to include NPPs (non-physician providers (NPPs), suchas registered nurses, nurse practitioners (NPs) and social workers, in their practice.43–45 Across allmodels, these main reimbursement strategies are blended with other approaches such as incentivepayments for delivery of specified services to rostered patients.

Aim With this range of primary care models, Ontario provides an appropriate setting to conduct apolicy analysis of barriers and enablers to IC. Our analysis focuses on funding arrangements andlegislation/regulation related to scope of practice—these have been identified as important systemwide factors that influence delivery of IC.15 For each of these policy areas, the mental healthliterature is summarized and then relevance to the Ontario context is examined. In a final sectionimplications of the findings and strategies for moving forward are presented.

Methods

Our search sought information relevant to funding, regulatory/legal barriers, and enablers toimplementation of IC. We conducted an environmental scan of scholarly literature—Ovid Medline,Embase and Social Work Abstracts and Google Scholar—using the following key words: mentalillness; mental health; collaborative mental health care; primary mental health care; shared care;integration; legislation; regulation; legal; funding; reimbursement; remuneration and capitation. Wealso used Google to search for relevant legislation, policy reports and position statements by theOntario government and by professional colleges and advocacy organizations that pertained toimplementation of IC in Ontario. Feedback from selected Ontario stakeholders helped to clarifyretrieved information and identify additional relevant sources.

Results

Regarding the impact of funding, the identified studies addressed patient selection, inclusion of NPPs,and reimbursement for collaboration. Regarding regulatory/legal issues, the reviewed literature addressedscope of practice for NPPs related tomedication prescription and counselling, and the role of the physician.

The impact of capitation funding models

Patient selection Under capitation, the PCP receives a fixed payment per enrolled patient fordelivery of required care. Thus in theory, capitation encourages care that keeps patients healthythrough prevention, early intervention, and collaboration with other providers. Comprehensive carecan be beneficial for individuals with more complex illness profiles that include mental andsubstance use disorders as well as physical illness.46,47 However, in capitation models, high-needspatients represent a larger financial risk to PCPs, unless there is adjusted compensation.48 Thus, ashas been shown in studies from the United States, patients with mental illness may be less likely tobe rostered by PCPs (cream-skimming) in capitation models, compared to FFS-based models.49–51

Although more sophisticated risk adjustment models may theoretically account for the costs ofserving different patient groups, including those with mental illness and addiction issues,52 theyhave traditionally been challenging to develop, and often did not sufficiently capture variability incosts.53 These methods, however, appear to be improving.54 Challenges still remain due to the widespectrum of severity of mental illness and substance use disorders, their varying courses over time,along with unpredictable fluctuations in cost.48,52 This unpredictability is accentuated because there

The Journal of Behavioral Health Services & Research 2013

are often high non-mental health medical costs among persons with chronic mental illness andsubstance use issues.54 Recent approaches to risk adjustment may mitigate challenges associatedwith this unpredictability. For example, some US states (e.g. Oregon, New York, and Missouri)have introduced tiered per member per month payment models to allow for greater payment onbehalf of patients who are expected to be high-users based on specific eligibility criteria, such ashaving two or more chronic diseases or serious mental illness.55 This approach has been viewedpositively by other states and is expected to be adopted in more widely across the USA.

Even if risk adjustment methods are better than they have been, it is questionable if primary careis the most appropriate setting to manage patients with severe mental illness, as indicated by theFour Quadrants model.13 However, if higher risk patients prefer to receive care in the primary caresetting and/or resist referral to specialists,32 that preference can be honoured, for example, bydeveloping protocols with specialist providers to manage care if needs escalate (e.g. when thepatient experiences an acute episode).

Inclusion of non-physician providers Reimbursement models can also influence who delivers carein the primary care setting and, in particular, which NPPs are included on the care team.Historically in the United States and Canada, health care systems have emphasized the medicalmodel and physician-delivered care.56,57

The lack of government funding for non-physician services can be a barrier for widespreadadoption of IC. For example, in Ontario in the 1970s, an effort to introduce NPs intoprimary care practices failed largely because the funding model at that time only paid forservices delivered by physicians or in hospitals. Unsurprisingly, PCPs did not find itfinancially attractive to pay for NPs without being able to collect payments from theprovincial health insurance plan.58 Sufficient funding is necessary to support recruitment ofthe right level and number of NPPs.59,60 Without sufficient funding, quality of care may becompromised due to shortages of appropriately trained staff and/or heavy caseloads whichcould be linked to, for example, employee burnout and high staff turnover.60,61

Application to Ontario context

Ontario’s reforms have resulted in more PCPs operating in blended capitation, which has thepotential to support IC. However, capitation payments to PCPs are only adjusted for patient ageand sex.44 Without these adjustments PCPs incur financial risk by caring for patients with moresevere mental illness—these patients are more likely than other patients to suffer deteriorations andless likely to comply with treatment recommendations and follow-up.62 In an effort to address thisinherent disincentive to treat these patients, financial incentives were introduced by the OntarioMinistry of Health and Long Term Care to encourage PCP enrollment of at least ten patients withbipolar disorder or schizophrenia. However, there are no policy incentives for PCPs to roster morethan ten patients with these conditions, to roster patients with this diagnosis with more severeillness or to roster patients with other mental illnesses.

Limited Ontario evidence on inclusion of patients with mental illness into each primary carepractice62 indicated that PCPs in capitation models appear to avoid selecting patients with moresevere mental illness into their practices. This is consistent with an older Ontario study43 that foundthat patients in the recently introduced capitation practices in Ontario had lower morbidity andcomorbidity indices than those in the enhanced FFS models. It was not clear if these patterns werepre-existing or developed after physicians joined capitation-based models, although ongoingresearch is addressing these issues.63 Similarly, a qualitative Ontario study identified lowremuneration as an obstacle to rostering homeless patients into an Ontario primary care practicebecause of their high rates of mental illness and addiction issues, and many related socialchallenges.64

Integrating Mental Health into Primary Care DURBIN et al.

Inclusion of non-physician providers Most funding models in Ontario do not cover outpatient servicesby NPPs, thereby requiring patients to pay out-of-pocket or be covered by private health insurance.However, by 2011, 186 team-based capitation practices in Ontario were serving approximately 20% ofthe Ontario population (2.6 million patients). In addition to involving over 2,000 physicians, thesepractices included over 1,500 NPPs whose services were insured for rostered patients.65 Teams arelimited, however, in the type of NPPs they can hire (i.e. eligible for designated funding by the Ministryof Health in Ontario). Currently funded professionals/positions include case worker/managers,counsellors, occupation therapists, health education/promoters, pharmacists, registered dieticians,NPs, registered nurses, registered practical nurses, psychologist/psychological associate and socialworkers/mental health workers.45 One current omission is peer workers. SAMSHA (the US federalSubstance Abuse and Mental Health Services Administration)66 has acknowledged an important rolefor peer workers in client recovery. While evidence is growing on the benefit of peer workers66 forclients (e.g. greater satisfaction with personal circumstances and less hospitalization) and for serviceproviders (e.g. more positive attitudes toward clients),67 these workers are not currently eligible forteam funding in Ontario, although PCPs may choose to pay for them from their practice funds.

The allowed salary ranges are set for each group of providers and may be insufficient to attractsome groups (e.g. psychologists) or recruit the required skill level. The decision on who to recruitdepends on how many mental health patients are rostered into the practice and the cost of recruitingqualified mental health professionals. In team-based capitation models, non-physician mentalhealth professionals often need to work independently and possess a high level of expertise,especially if the local area lacks specialist mental health services.64 With fixed budgets, there maybe incentives to recruit lower-paid, less-skilled staff, such as mental health workers, rather thanhighly trained mental health professionals, such as psychologists.

Appropriate compensation for PCP time spent in collaboration with mental health specialistphysicians is important to encourage collaboration.48 Although medically necessary mental healthspecialists physician services are covered by the Ontario funding model, reimbursement for suchnon-direct patient care activities may not be. Some team-based models do include funds for specificactivities, such as staff education and ‘sessional fees’ for patient consultation, but the amount ofsuch funding varies and may not be adequate. However, the amount of sessional funding availablevaries and may not adequately cover the needs of the team-based model.

Regulatory and legal factors—mental health evidence

Scope of practice for non-physicians related to medication prescription Prescribing and managingpsychotropic medications is a potential area for shared practice and is governed by legislation. Inevery jurisdiction, physicians have prescribing rights for all medications. However, fewerjurisdictions provide these privileges to NPPs, such as NPs, pharmacists, physician assistants,and psychologists. Despite opposition from some bodies in organized medicine,68 the extension, ofscope of practice to include prescribing privileges has been gaining support. While opinions vary,prescribing by NPPs has been identified as an opportunity for inter-professional team work inhealth care delivery in general. In addition to reducing PCP workload, NPPs typically have moretime to guide, support, and monitor patients.69

Extending prescribing privileges for psychotropic medication has received support in the UnitedKingdom and United States. Jones and colleagues70,71 found that nurses’ mental health prescribingyielded positive responses from physicians, nurses, and patients. Mental health nurses wereperceived as highly patient centred—i.e. accessible and including patients in their medicationdecisions. They were also perceived to be working within their level of competency andconforming to evidence-based prescribing practices. However, adequate training and supervisionwas identified as critical, as well as a redesign of primary care to incorporate their role.

The Journal of Behavioral Health Services & Research 2013

Over the last two decades there has also been increasing support and pursuit of prescribingprivileges for psychologists in the United States. Prescriptive authority has been awarded in twostates (New Mexico and Louisiana), one territory (Guam), two military branches, and some federalagencies.20 Legislation is currently being sought in many other jurisdictions. Since prescribingpsychologists are often required to have a collaborating PCP, in many cases integrated models areused. In a 2-year study of psychologists embedded within a primary care clinic, other providers feltthat psychologist prescribing was safe, helpful, convenient and improved patient care.20 As withthe case of nurses, however, opponents of prescribing psychologists often cite training and safetyconcerns as critical barriers.72

Scope of practice for non-physicians related to counselling Extending the role and scope of whocan deliver counselling is another area that may benefit from shared scopes of practice in IC.Specifically, non-physician mental health professionals can expand primary care practice capacityby providing detailed assessments and some psychotherapies.14,15 In contrast to prescribing, thereare not legal/regulatory barriers here, since this is rarely a controlled act and most scopes ofpractice allow this. There are many potential providers of counselling and psychotherapy servicesincluding nurses, social workers, and psychologists.73 Having a range of providers also allowspatients to have the opportunity to select a provider with whom they have the best therapeuticrelationship. This step toward individually tailored and “person-centred” medical care has manyadvantages. For example, a study on urban, low-income women with severe mental disordersfound that those who trusted their mental health provider tended to be more engaged with theoverall healthcare system and were more trusting of other medical providers to whom they werereferred.74 Additionally, because of receiving mental health care, many of these women had a senseof having something to live for, and consequently wanting to get medical healthcare services to beable to take care of themselves.

The role of the physician IC represents a major practice change from the traditional single or sharedphysician practices that are centred on the physician–patient interaction. As such, it may encounterresistance from PCPs, especially those who lack the experience and knowledge to collaborateeffectively with NPPs.14,15,23 However, physician approval of IC may improve as PCPs gainexperience in team-based environments. For example, PCPs may believe they offer a better qualityof care when supported by a mental health specialist, since treating mental health problems can bechallenging in a 12 to 15 min office visit even for well-trained and motivated PCPs. In addition,physicians often feel unsupported in the role.5,75 One study reported that PCPs had greatersatisfaction when working with psychologists, and felt that mental health problems were diagnosedmore quickly and patient care improved, as did the physicians’ knowledge of psychologicalmanagement and treatment.76

Inter-professional education may also help to increase trust and understanding of otherprofessions’ roles and assist in communication for individuals in IC models. Unutzer5 recommendsthat training programs include placements in general medical settings where physicians areexposed to more common mental disorders and have opportunities to learn effective consultationand collaboration with other health colleagues.Although PCPs may become more favourable towards IC, issues related to liability must beaddressed before physicians and their medical associations lend their official support to IC.77

Application to an Ontario context

Shared roles to extend practice capacity for mental health care delivery is particularly importantwhen there is large population dispersion across diverse geographic areas 17 and lower availabilityof mental health care providers, including psychiatrists, in rural areas; such is the case in Ontario.78

Integrating Mental Health into Primary Care DURBIN et al.

Scope of practice related to mental health medication prescription privileges Ontario recentlyamended the Ontario Regulated Health Professions Act (RHPA) which defines controlled acts andgoverns activities of a range of health professionals, including but not limited to physicians, nursepractitioners and psychologists. Recent amendments expanded professional scope of practice, thusbroadening the roles and responsibilities that non-medical professionals can assume in delivery ofprimary care.

While NPs and pharmacists have some prescribing privileges in Ontario, there are limitations ondrugs that can be prescribed by these professionals. For example, while NPs are independentprescribers and can prescribe the same drug formulary as physicians, they cannot prescribecontrolled substances (e.g. opiates, benzodiazepines).79,80 In Ontario psychologists do not haveprescribing privileges. While there is interest within the Ontario Psychological Association topursue such authority,81 substantial opposition remains. It is not clear if and when prescriptiveprivileges will be awarded. Following amendments to the RHPA, pharmacists are allowed to bothcontinue and modify most prescriptions, and initiate prescriptions for smoking cessationmedicines.82 In addition to prescribing, trained non-physicians can contribute to medicationmanagement by educating patients about medication goals and side effects, and clarifying issuesthat may otherwise require attention from a PCP.64 Psychologists, in particular, can contributebecause they are trained diagnosticians and behaviour health specialists.

Scope of practice related to mental health counselling The range of professionals who can delivercounselling is broader, which gives team-based capitation models flexibility.64 Social workers(MSWs), mental health workers (BAs/BSWs), and psychologists are among the professionals who aretrained to provide mental health counselling in team-based capitation models in Ontario. In spite ofthese similarities, they are distinguished by compensation—social workers/mental health workersmake approximately one half the annual salary of psychologists. The discrepancy in salary and thelimited availability of psychologists—especially in rural areas—likely explain why there are manymore social workers/mental health workers than psychologists in team-based models in Ontario.

Thus, while the potential to share or delegate some roles exist, IC providers need to agree on roles andscope of practice, especially since practitioners have different degrees of responsibility and authority.11,83

The role of the physician Obtaining support from physicians is critical to successfulimplementation of IC.64 Some PCPs have reported being dissatisfied with the quality ofmental health care they are able to provide and finding it increasingly challenging to meetthe needs of patients with chronic and complex medical conditions.84,85 In Ontario, the bodyrepresenting all physicians (Ontario Medical Association) has been supportive of IC whilestill insistent that the role of physicians as providers of mental health care not be diminishedin IC settings.86

The Canadian Medical Protective Association (CMPA), the organization that provides liabilityprotection to physicians across Canada, argues that while fear of increased medico-legal liability isoften cited as a barrier to health professionals working collaboratively, there is no need forextensive changes to the medical liability system. They accentuate the importance of bothphysicians and NPPs who work collaboratively having professional liability protection and/orinsurance coverage. The CMPA concludes that none of these issues are so substantial that theyshould impede IC.87 In Ontario, physicians have to get their own liability protection throughthe CMPA. NPPs and clerical staff are covered through professional and vicarious liabilityplans that are purchased through the Family Health Team. Mulvale and Bourgeault15 haveargued that there is a need for development of a clearer legal framework on responsibility forpatient care and liability issues since multiple providers are involved in IC. The extent thatlegal responsibility for team performance lies primarily with the responsible physician maylimit delegation and collaboration.

The Journal of Behavioral Health Services & Research 2013

Integrating addiction services into primary care

IC is also a recommended strategy to increase capacity and management of substance usedisorders within primary care.88,89 Yet similar to mental health, there are barriers toimplementation. This section briefly outlines some policy relevant challenges.

Screening, assessment and brief intervention is a recommended approach to management ofsubstance use in PC (e.g. SBIRT).35 However, there are concerns related to the feasibility ofimplementation of screening and assessment tools, in part regarding who administers the tool,quality of tools and time.90,91 As well, patients should be able to receive treatment shortly after theidentification of an active issue through screening;92 however, identifying relevant services andmaking referrals can be difficult and time consuming.91 PCPs may also be concerned aboutpotential negative responses from their patients to the screening, especially due to variation in whatsubstance use patterns are considered inappropriate,90 and consequently fear disrupting thetreatment alliance.

Compared to mental health, primary care practices may face more challenges in recruiting andretaining staff with required expertise. For example, special prescribing licenses and training areoften required for delivery of specialized services (e.g. methadone administration) in Canada andthe USA.93 In addition, addiction specialists can be difficult to recruit since many providers havelimited training in the diagnosis, management and science of addiction.90,94,95 Education inmedical schools and continuing education about substance misuse has been described asinadequate, inconsistently applied and a low priority.96 Physicians have cited a lack of confidencein their capabilities to provide these services.94 Another possible deterrent for some providers isthat many addictions (e.g. opioid dependence) are best managed by a combination ofpharmacological strategies and psychotherapeutic interventions.97 which can require increasedcommunication, paperwork and time.98 Finally, IC for people with both mental illness andsubstance misuse may be particularly challenging since those with concurrent disorders are morelikely to miss medical appointments, experience relapse and be readmitted to hospital.99,100

Implications for Behavioural Health

IC is a strategy to improve management of patients with mental health and substance use problems inprimary care settings. In this Ontario-focused policy analysis, several key challenges to implementationof IC for mental health were identified. Related to funding, these pertained to incentivizing PCPs totreat patients with mental illness and substance use problems, and involving NPPs in delivery of care.Scope of practice related to psychiatric medication prescribing and counselling was also identified as afactor that affects how responsibilities are shared in collaborative models and quality of care. Theremaybe some resistance from physicians, especially from those who are used to more traditional methods ofcare delivery. This resistance may be diminished by providing more exposure to collaborative models,more education and by highlighting the benefits to PCPs, such as more satisfaction with the quality ofmental health care they are able to deliver and improved patient outcomes. However, issues related toprovider insurance/liability and support from the representative physician organizations in Ontario mayneed to be addressed. Similarly, there are many challenges in the integration of addictions treatment intoprimary care including resource accessibility, provider recruitment and team co-ordination, althoughthis paper did not examine these issues in depth. This remains an area for further exploration.

While this analysis focused on primary care reforms in Ontario, the issues addressed in thispaper have relevance for delivery of IC in other jurisdictions. In the United States, fundingapproaches for health service delivery programs vary; however, the need for reimbursement thatsupports widespread uptake of IC remains. Similar to Ontario, a US review of mental healthcare atthe interface with general medicine5 noted the challenge of reimbursement for patient educationactivities and proactive outreach monitoring, and suggested that support for these functions be built

Integrating Mental Health into Primary Care DURBIN et al.

into provider contracts in capitation-based arrangements and billing codes in fee-for-servicearrangements. More generally, since major legislative changes (Patient Protection and AffordableCare Act) will take effect in the United States in 2014 or earlier, risk adjustment in plans andreinsurance, especially for high needs patients such as those with mental health conditions, will getmore attention.54,101

Monitoring and evaluation In this dynamic primary care reform environment, there is a need forongoing monitoring of the nature and impact of change, especially regarding uptake of capitationmodels.44,60,102–104 In Ontario, the Auditor General has raised concerns about new primary care modelsand made a number of recommendations to the Ministry of Health and Long Term Care, includingongoing review of new models. In the context of evidence-based quality improvement, performancestandards that specifically address the key features of collaborative care are needed.87

Next steps

In this policy analysis, a variety of enablers were noted, but many barriers still must beaddressed to allow IC to expand and popularize in Ontario and internationally.105 Furtherexamination is still required to determine how to provide optimal care for patients depending onthe level of their behavioural and physical needs, including when, where and by whom. In addition,many policy issues discussed in this paper are not exclusively relevant to the provision ofbehavioural health care in primary care settings; for example, funding and legislation that supportinvolvement from a broader array of professionals in primary care treatment may improve the careof patients with other chronic diseases.

Acknowledgments

An earlier version of this paper won the Best Doctoral Submission for Canadian Association forHealth Services and Policy Research (CAHSPR), 2011

Conflict of Interest There were no financial or other relationships that might lead to a conflict, orperceived conflict, of interest.

References

1. Carney CP, Allen J, Doebbeling BN. Receipt of clinical preventive medical services among psychiatric patients. Psychiatric Services2002; 53(8):1028–1030.

2. Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental disorders and use of cardiovascular procedures aftermyocardial infarction. Journal of the American Journal Association 2000; 283(4):506–511.

3. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, andoutcomes evaluation. JAMA 2000; 284(13):1689–1695.

4. New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. 2003; DHHS pubSMA-03-03882. Available at: http://store.samhsa.gov/product/Achieving-the-Promise-Transforming-Mental-Health-Care-in-America-Ex-ecutive-Summary/SMA03-3831

5. Unutzer J, Schoenbaum M, Druss BG, Katon WJ. Transforming mental health care at the interface with general medicine: report for thePresident’s commission. Psychiatric Services 2006; 57(1):37–47.

6. Committee on crossing the Quality chasm: Adaptation to mental health and addictive disorders. Improving the quality of health care formental and substance-use conditions: Quality chasm series. 2006.

7. Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated service system. Psychiatric Services 2000;51(7):890–892.

8. World Health Organization (WHO), World Organization of Family Doctors (Wonca). Integrating mental health into primary care. Aglobal perspective. 2008.

The Journal of Behavioral Health Services & Research 2013

9. The Carter Center. The President’s new freedom commission on mental health: Transforming the vision. 2003. Available at: http://www.cartercenter.org/documents/1701.pdf

10. Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system.Journal of Clinical Psychology in Medical Settings 2008; 15(1):73–78.

11. Gask L. Overt and covert barriers to the integration of primary and specialist mental health care. Social Science &Medicine 2005; 61(8):1785–1794.12. Richards DA, Lankshear AJ, Fletcher J, et al. Developing a U.K. protocol for collaborative care: a qualitative study. General Hospital

Psychiatry 2006; 28(4):296–305.13. Mauer BJ. Behavioral Health/Primary Care Integration. The four quadrant model and evidence-based practices. 2006. Available at: http://

www.thenationalcouncil.org/galleries/business-practice%20files/4%20Quadrant.pdf.14. Kates N, Mazowita G, Lemire F, et al. The evolution of collaborative mental health care in Canada: A shared vision for the future. The

Canadian Journal of Psychiatry 2011; 56(5).15. Mulvale G, Bourgeault IL. Finding the right mix: How do contextual factors affect collaborative mental health care? Canadian Public

Policy 2007; 33(supplement 1):S49–S64.16. Pawlenko N. Collaborative Mental Health Care in Primary Health Care Across Canada: A Policy Review. 2005. Available at: http://

www.ccmhi.ca/en/products/documents/06_PolicyReview_EN.pdf17. Vasiliadis HM, Lesage A, Adair C, Wang PS, Kessler RC. Do Canada and the United States differ in prevalence of depression and

utilization of services? Psychiatric Services 2007; 58(1):63–71.18. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use of mental health services in Ontario: epidemiologic findings. Canadian

Journal of Psychiatry 1996; 41(9):572–577.19. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service

system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry1993;50(2):85–94.

20. Shearer DS, Harmon SC, Seavey BM, Tiu AY. The primary care prescribing psychologist model: medical provider ratings of the safety, impactand utility of prescribing psychology in a primary care setting. Journal of Clinical Psychology in Medical Settings 2012; 19(4):420–429.

21. Lavoie KL, Fleet RP. Should psychologists be granted prescription privileges? A review of the prescription privilege debate forpsychiatrists. Canadian Journal of Psychiatry2002; 47(5):443–449.

22. Druss BG, von Esenwein SA. Improving general medical care for persons with mental and addictive disorders: systematic review.General Hospital Psychiatry 2006; 28(2):145–153.

23. Craven MA, Bland R. Better practices in collaborative mental health care: an analysis of the evidence base. Canadian Journal ofPsychiatry 2006; 51(6 Suppl 1):7S–72S.

24. van Orden M, Hoffman T, Haffmans J, Spinhoven P, Hoencamp E. Collaborative mental health care versus care as usual in a primary caresetting: a randomized controlled trial. Psychiatric Services 2009; 60(1):74–79.

25. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomizedcontrolled trial. JAMA 2002; 288(22):2836–2845.

26. Vera M, Perez-Pedrogo C, Huertas SE, et al. Collaborative care for depressed patients with chronic medical conditions: a randomized trialin Puerto Rico. Psychiatric Services 2010; 61(2):144–150.

27. Chew-Graham CA, Lovell K, Roberts C, et al. A randomised controlled trial to test the feasibility of a collaborative care model for themanagement of depression in older people. British Journal of General Practice 2007; 57(538):364–370.

28. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review oflonger-term outcomes. Archives of Internal Medicine 2006; 166(21):2314–2321.

29. Pyne JM, Fortney JC, Tripathi SP, Maciejewski ML, Edlund MJ, Williams DK. Cost-effectiveness analysis of a rural telemedicinecollaborative care intervention for depression. Archives of General Psychiatry 2010; 67(8):812–821.

30. Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guidesystematic review and meta-analysis. American Journal of Preventive Medicine 2012; 42(5):525–538.

31. Meadows GN, Harvey CA, Joubert L, Barton D, Bedi G. Best practices: the consultation-liaison in primary-care psychiatry program: astructured approach to long-term collaboration. Psychiatric Services 2007; 58(8):1036–1038.

32. Mickus M, Colenda CC, Hogan AJ. Knowledge of mental health benefits and preferences for type of mental health providers among thegeneral public. Psychiatric Services 2000; 51(2):199–202.

33. Dewa CS, Hoch JS, CarmenG, Guscott R, Anderson C. Cost, effectiveness, and cost-effectiveness of a collaborative mental health care programfor people receiving short-term disability benefits for psychiatric disorders. Canadian Journal of Psychiatry 2009; 54(6):379–388.

34. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from theEpidemiologic Catchment Area (ECA) Study. JAMA 1990; 264(19):2511–2518.

35. Substance Abuse and Mental Health Services Administration (SAMHSA). National registry of Evidence‐based programs and practices.Intervention summary: Project ASSERT. Rockville, MD: SAMHSA. 2011. Available at: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=222#std5132013.

36. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT):Toward a public health approach to the management of substance abuse. Substance Abuse 2007; 28(3):7–30.

37. Tuohy CH. Accidental Logics: The dynamics of change in the health care arena in the United States, Britain and Canada. New York:Oxford University Press, 1999.

38. Marchildon GP. Health systems in transition. Canada: Health system review. 2013. Second edition. Toronto: University of Toronto Press,2013.

39. Deber R. Delivering health care services: Public, not-for-profit, or private? In: Marchildon GP, McIntosh T, Forest PG (Eds.) The fiscalsustainability of health care in Canada: Romanow papers, Volume 1. Toronto, ON: University of Toronto Press, 2004, pp. 233–296.

40. Deber R, Hollander MJ, Jacobs P. Models of funding and reimbursement in health care: A conceptual framework. Canadian PublicAdministration 2008; 51(3):381.

Integrating Mental Health into Primary Care DURBIN et al.

41. Léger P. Physician payment mechanisms: Overview and options for Canada. Commissioned research. 2011; CHSRF Series on Cost Drivers andHealth System Efficiency: Paper 3. Available at: http://www.cfhi-fcass.ca/publicationsandresources/researchreports/commissionedresearch/11-03-15/f24f57b9-aa81-4ab2-a539-d85746d36789.aspx

42. Ontario’s Community Health Centres. Addressing the great health divide. A solution for the provincial government and Local HealthIntegration Networks. Available at: http://www.questchc.ca/NewVersion/documents/AddressingOntariosGreatHealthDivide.pdf

43. Glazier RH, Klein-Geltink J, Kopp A, Sibley LM. Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation. Canadian Medical Association Journal 2009; 180(11):E72–81.

44. Glazier RH, Redelmeier DA. Building the patient-centered medical home in Ontario. JAMA 2010; 303(21):2186–2187.45. Ministry of Health and Long Term Care. Guide to interdisciplinary provider compensation. Version 3.2. 2010. Available at: http://

www.health.gov.on.ca/en/pro/programs/fht/docs/fht_inter_provider.pdf, 2013.46. Samele C, Patel M, Boydell J, Leese M, Wessely S, Murray R. Physical illness and lifestyle risk factors in people with their first

presentation of psychosis. Social Psychiatry and Psychiatric Epidemiology 2007; 42(2):117–124.47. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. British Journal of Psychiatry 2011;

199(6):441–442.48. Dewa CS, Hoch JS, Goering P. Using financial incentives to promote shared mental health care. Canadian Journal of Psychiatry 2001;

46(6):488–495.49. Grazier KL, Eselius LL, Hu TW, Shore KK, G'Sell WA. Effects of a mental health carve-out on use, costs, and payers: a four-year study.

Journal of Behavioral Health Services & Research (JBHS&R) 1999; 26(4):381–389.50. Leff HS, Wieman DA, McFarland BH, et al. Assessment of Medicaid managed behavioral health care for persons with serious mental

illness. Psychiatric Services2005; 56(10):1245–1253.51. Gosden T, Forland F, Kristiansen IS, et al. Impact of payment method on behaviour of primary care physicians: a systematic review.

Journal of Health Services Research & Policy 2001; 6(1):44–55.52. Ettner SL, Denmead G, Dilonardo J, Cao H, Belanger AJ. The impact of managed care on the substance abuse treatment patterns and

outcomes of Medicaid beneficiaries: Maryland's Health Choice program. Journal of Behavioral Health Services & Research (JBHS&R)2003; 30(1):41–62.

53. Ettner SL, Frank RG, McGuire TG, Hermann RC. Risk adjustment alternatives in paying for behavioral health care under Medicaid.Health Services Research 2001; 36(4):793–811.

54. Barry CL, Weiner JP, Lemke K, Busch SH. Risk adjustment in health insurance exchanges for individuals with mental illness. AmericanJournal of Psychiatry 2012; 169(7):704–709.

55. Kaiser Commission on Medicaid and the uninsured. Medicaid health homes for beneficiaries with chronic conditions. Executivesummary. 2012. Available at: http://www.kff.org/medicaid/upload/8340.pdf.

56. Deber RB, Gamble B, Mah CL. Canada: variations on a common theme. Italian Journal of Public Health 2010;7(4): 336–343.57. Sharfstein SS, Stoline AM. Reform issues for insuring mental health care. Health Affairs (Millwood) 1992; 11(3):84–97.58. Kaasalainen S, Martin-Misener R, Kilpatrick K, et al. A historical overview of the development of advanced practice nursing roles in

Canada. Nursing Leadership (Tor Ont) 2010; 23 Spec No 2010:35–60.59. Poole DL, Colby IC. Do public neighborhood centers have the capacity to be instruments of change in human services? Social Work

2002; 47(2):142–152.60. Megivern DM, McMillen JC, Proctor EK, Striley CL, Cabassa LJ, Munson MR. Quality of care: expanding the social work dialogue.

Social Work 2007; 52(2):115–124.61. Donnelly M. Making the difference: Quality strategy in the public sector. Managing Service Quality 1999; 9(1):47–52.62. Steele L, Durbin A, Sibley LM, Glazier R. Inclusion of persons with mental illness in patient-centred medical homes: cross-sectional

findings from Ontario, Canada. Open Medicine 2013; 7(1).63. Glazier RH, Zagorski BM, Rayner J. Comparison of primary care models in Ontario by Demographics, Case Mix and Emergency

Department Use, 2008/09 to 2009/10. 2012. Available at: http://www.ices.on.ca/file/ICES_Primary%20Care%20Models%20English.pdf64. Mulvale G, Danner U, Pasic D. Advancing community-based collaborative mental health care through interdisciplinary family health

teams in Ontario. Canadian Journal of Community Mental Health 2008; 27(2):55–73.65. Association of Family Health Teams of Ontario. Board of directors. Report to the membership. 2011. Available at: http://www.afhto.ca/

wp-content/uploads/2012-AFHTO-Annual-Report.pdf66. SAMHSA. Components of Recovery. Transforming mental health care in America, federal action agenda: First steps. 2004. Available

at: http://www.samhsa.gov/pubs/mhc/MHC_recovery.htm. Accessed 2013.67. Simpson EL, House AO. Involving users in the delivery and evaluation of mental health services: systematic review. BMJ 2002;

325(7375):1265.68. Edwards N, Rowan M, Marck P, Grinspun D. Understanding whole systems change in health care: the case of nurse practitioners in

Canada. Policy, Politics & Nursing Practice 2011; 12(1):4–17.69. O’Connor SA. Should prescribing authority be shared with non physicians? Canadian Family Physician 2009; 55(12):176.70. Jones M, Bennett J, Lucas B, Miller D, Gray R. Mental health nurse supplementary prescribing: experiences of mental health nurses,

psychiatrists and patients. Journal of Advanced Nursing 2007; 59(5):488–496.71. Jones A. Exploring independent nurse prescribing for mental health settings. Journal of Psychiatric and Mental Health Nursing 2008;

15:109.72. Lavoie KL, Barone S. Prescription privileges for psychologists: a comprehensive review and critical analysis of current issues and

controversies. CNS Drugs 2006; 20(1):51–66.73. Dewa C, Rogers J, Kates N, Goering P. Community care for individuals moderately affected by mental health problems (MMI): best

practices. London (ON): Thames Valley District Health Council, Huron Perth Grey Bruce District Health Council, Essex, Kent andLambton District Health Council; 2000.

74. Borba CP, DePadilla L, McCarty FA, von Esenwein SA, Druss BG, Sterk CE. A qualitative study examining the perceived barriers andfacilitators to medical healthcare services among women with a serious mental illness. Women’s Health Issues 2012; 22(2):e217–24.

The Journal of Behavioral Health Services & Research 2013

75. Morgan C, Charalambides M, Hutchinson G, Murray RM. Migration, ethnicity, and psychosis: toward a sociodevelopmental model.Schizophrenia Bulletin 2010; 36(4):655–664.

76. Chomienne M-, Grenier J, Gaboury I, Hogg W, Ritchie P, Farmanova-Haynes E. Family doctors and psychologists working together:Doctors' and patients' perspectives. Journal of Evaluation in Clinical Practice 2011; 17(2):282–287.

77. McLean TR. Crossing the quality chasm: Autonomous Physician Extenders Will Necessitate a Shift to Enterprise Liability coverage forhealth care delivery. Health Matrix 2002; 12:239–295.

78. Kurdyak P: When more does not help. A study of psychiatrist supply and practice patterns in Ontario. Ontario Psychiatric OutreachProgram Retreat, Toronto, September, 2011. Available at: http://www.opop.ca/CMFiles/Publications/Annual%20Retreats/2011/Psychiatrist%20Supply_15_9_11.pdf

79. College of Nurses of Ontario. FAQ: Bill 179. 2012. Available at: http://www.cno.org/what-is-cno/regulation-and-legislation/legislation-governing-nursing/faq-bill-179/2013.

80. College of Nurses of Ontario. Practice Standard: Nurse Practitioner (41038 2011–78). 2011. Available at: http://www.cno.org/Global/docs/prac/41038_StrdRnec.pdf. 2013.

81. Nelson C. The Re-positioning of Psychology in Ontario—Advocacy and the Ontario. Journal of Clinical Psychology Practice 2010; 1:12.82. Law MR, Ma T, Fisher J, Sketris IS. Independent pharmacist prescribing in Canada. Canadian Pharmacists Journal 2012; 145(1):17–23.e1.83. Whitehead C. The doctor dilemma in interprofessional education and care: how and why will physicians collaborate? Medical Education

2007; 41(10):1010–1016.84. The College of Family Physicians of Canada. Canada’s largest physician survey warns of chronic illness impact on the Health Care

System. 2011. Available at: http://www.cfpc.ca/SNM_2010_Communique/85. Clatney L, Macdonald H, Shah SM. Mental health care in the primary care setting: family physicians' perspectives. Canadian Family

Physician 2008; 54(6):884–889.86. Ontario Medical Association. OMA Submission Regarding Ministry of Health and Long Term Care Discussion Paper: “Every Door is the

Right Door” . 2009. Available at : ht tp:/ /www.aghps.com/doc/OMA%20submission%20on%20Every%20Door%20is%20the%20right%20Door%20Sept%202009.PDF

87. Petsch J, Tepper J. The next challenges for primary care in Ontario. 2012. Available at: http://healthydebate.ca/2012/10/topic/community-long-term-care/the-next-challenges-for-primary-care-in-ontario.

88. Strang J, Babor T, Caulkins J, Fischer B, Foxcroft D, Humphreys K. Drug policy and the public good: evidence for effectiveinterventions. Lancet 2012; 379(9810):71–83.

89. Giesbrecht N, Wettlaufer A, April N, et al. Strategies to reduce alcohol-related strategies to reduce alcohol-related harms andcosts in Canada: arms and costs in Canada: A comparison of provincial policies. Toronto: Centre for Addiction and MentalHealth. 2013. Available at: http://www.camh.ca/en/research/news_and_publications/reports_and_books/Documents/Strategies%20to%20Reduce%20Alcohol%20Related%20Harms%20and%20Costs%202013.pdf2013.

90. Nilsen P, Kaner E, Babor TF. Brief intervention, three decades on. Nordic Studies on Alcohol and Drugs 2008; 25:453–467.91. Smythe C, Powell B, Murphy L, Pulford R. Results of the survey of mental health addictions agencies in Ontario for concurrent disorders

screening & assessment tool. Centre for Addiction and Mental Health. 2013. Available at: http://www.ofcmhap.on.ca/content/results-survey-mental-health-addictions-agencies-ontario-concurrent-disorders-screening-asse2003.

92. Pilowsky DJ, Wu LT. Screening for alcohol and drug use disorders among adults in primary care: a review. Journal of Substance abuseand Rehabilitation 2012; 3(1):25–34.

93. College of Family Physicians and Surgeons of Ontario. Methadone maintenance treatment program standards and clinical guidelines(Fourth edition). 2011. Available at: http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1984, 2013.

94. Yoast RA, Wilford BB, Hayashi SW. Encouraging physicians to screen for and intervene in substance use disorders: obstacles andstrategies for change. Journal of Addictive Diseases 2008; 27(3):77–97.

95. Ernst D, Miller WR, Rollnick S. Treating substance abuse in primary care: a demonstration project. International Journal of IntegratedCare 2007; 7:e36.

96. Scott M, Parthasarathy S, Kohn C, Hinman A, Sterling S,Weisner C. Adolescents with substance diagnoses in an HMO: factors associated withmedical provider referrals to substance abuse and mental health treatment. Mental Health Services Research 2004; 6(1):47–60.

97. Amato L, Minozzi S, Vecchi S, Davoli M, Perucci CA. An Overview of Cochrnae systematic reviews of pharmacological andpsychosocial treatment of opioid dependence. Background paper for the meeting “1st Consultation on Technical Guidelines for Treatmentof Opioid Dependence”. 2005. Available at: http://www.who.int/substance_abuse/activities/overview_of_cochrane_systematic_reviews.pdf

98. Brauser D. Many Docs Still Don't Understand Opioid Dependence. 2013. Medscape. Available at: http://www.medscape.com/viewarticle/806303?src=rss, 2013.

99. Swofford CD, Kasckow JW, Scheller-Gilkey G, Inderbitzin LB. Substance use: a powerful predictor of relapse in schizophrenia.Schizophrenia Research 1996; 20(1–2):145–151.

100. Linszen DH, Dingemans PM, Lenior ME. Cannabis abuse and the course of recent-onset schizophrenic disorders. Archives of GeneralPsychiatry 1994; 51(4):273–279.

101. NAMI State Advocacy. The Affordable Care Act. 2011. Available at: http://www.nami.org/Content/NavigationMenu/State_Advocacy/About_the_Issue/Affordable_Care_Act_Fact_Sheet_2011.pdf.

102. Mayne J. Building An Evaluative Culture: The key to effective evaluation and results management. The Canadian Journal of ProgramEvaluation; 24(2).

103. Drummond D. Commission on the reform of Ontario's public services. Public services for Ontarians: A Path to Sustainability andExcellence. 2012; ISBN 978-1-4435-8898-0. Available at: http://www.fin.gov.on.ca/en/reformcommission/chapters/report.pdf

104. Pauly MV, Kissick WL, Roper LE. Lessons from the first twenty years of Medicare: research implications for public and private sectorpolicy. University of Pennsylvania Press, 1988.

105. Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. 2010. Available at: http://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html.

Integrating Mental Health into Primary Care DURBIN et al.