Rural Models for Integrating Primary Care and Mental Health Services

  • Donna C. Bird
  • David Lambert
  • David Hartley
  • Peter G. Beeson
  • Andrew F. Coburn


This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Adams, R.D., & Benjamin, M.L. (1988). Innovative approaches to mental health services delivery in rural areas. Journal of Rural Community Psychology,9(2), 41–50.Google Scholar
  2. Andersen, S. M., & Harthorn, B. H. (1990). Changing the psychiatric knowledge of primary care physicians. General Hospital Psychiatry, 12, 177–190.Google Scholar
  3. Barrett, J.E. (1991). Practice-based mental health research in primary care: Directions for the 1990s. In H. Hibbard & P.A. Nutting, (Eds.),Primary care research: Theory and methods (pp. 315–322). Rockville, MD: Agency for Health Care Policy and Research.Google Scholar
  4. Beeson, P.G. (1990). Mental health services in rural America. State Health Reports, 58, 4–14.Google Scholar
  5. Borus, J.F., Janowitch, L.A., Kieffer, F., Morrill, R.G., Reich, L., Simone, E., & Towle, L. (1975). The coordination of mental health services at the neighborhood level. American Journal of Psychiatry, 132, 1177–1181.Google Scholar
  6. Borus, J.F. (1976). Neighborhood health centers as providers of primary mental health care. New England Journal of Medicine, 295, 140–145.Google Scholar
  7. Borus, J. F., Olendzki, M. C., Kessler, L., Burns, B. J., Brandt, U., Broverman, C. A., & Henderson, P. R. (1985). The “offset effect” of mental health treatment on ambulatory medical care utilization and charges. Archives of General Psychiatry, 42, 573–580.Google Scholar
  8. Boydston, J. C. (1983). Rural mental health: A partnership with physicians. Practice Digest, 6, 23–25.Google Scholar
  9. Broskowski, A. (1980). Evaluation of the primary health care project-community mental health center linkage initiative. Rockville, MD: Alcohol, Drug Abuse and Mental Health Administration.Google Scholar
  10. Broskowski, A. (1982). Linking mental health and health care systems. In H.C. Schulberg, & M. Killilea, (Eds.),The modern practice of community mental health (pp. 486–513). San Francisco: Jossey-Bass Publishers.Google Scholar
  11. Burns, B.J., Burke, J.D. Jr., & Ozarin, L.D. (1983). Linking health and mental health services in rural areas. International Journal of Mental Health,12(1–2), 130–143.Google Scholar
  12. Campbell, T.L. (1987). An opposing view. The Journal of Family Practice, 25, 184–187.Google Scholar
  13. Celenza, C.M., & Fenton, D.N. (1981). Integrating mental and medical health services: The Kennebec-Somerset Model. New Directions for Mental Health Services, 9, 39–49.Google Scholar
  14. Christianson, J., & Moscovice, I. (1993). Health care reform and rural health networks. Health Affairs,12(3), 38–75.Google Scholar
  15. Clayton, T. (1977). Issues in the delivery of rural mental health services. Hospital & Community Psychiatry, 28, 673–676.Google Scholar
  16. Coleman, J.V., & Patrick, D.L. (1976). Integrating mental health services in primary medical care. Medical Care, 14, 654–661.Google Scholar
  17. Defino, T. (1996 Mar/Apr). Healing body and mind. Healthplan, pp. 19–24.Google Scholar
  18. Depression Guidelines Panel. (1993).Depression in primary care: Volume 2. Treatment of major depression (AHCPR Publication Number 93-0551). Rockville, MD: Agency for Health Care Policy and Research.Google Scholar
  19. Essock, S.M., & Goldman, H.H. (1995). States' embrace of managed mental health care. Health Affairs,14(3), 34–44.Google Scholar
  20. Fehr, A., & Tyler, J.D. (1987). Public awareness of mental health services in rural communities. Journal of Rural Community Psychology,8(1), 36–40.Google Scholar
  21. Flax, J.W., Wagenfeld, M.O., Ivens, R.E., & Weiss, R.J. (1979). Mental health and rural america: An overview and annotated bibliography. Rockville, MD: National Institute of Mental Health.Google Scholar
  22. Geiger, H. J. (1984). Community health centers: Health care as an instrument of social change. In V.W. & R. Sidel (Eds.),Reforming medicine: Lessons of the last quarter century (pp. 11–32). New York: Pantheon Books.Google Scholar
  23. Goldman, H.H., Burns, B.J., & Burke, J.D. (1980). Integrating primary health care and mental health services: A preliminary report. Public Health Reports, 95, 535–539.Google Scholar
  24. Gonzalez, J.J., Magruder, K.M., & Keith, S.J. (1994). Mental disorders in primary care services: An update. Public Health Reports, 109, 251–258.Google Scholar
  25. Gonzalez, J.J., & Norquist, G. (1994). Mental health consultation-liaison interventions in primary care. In J. Miranda, A.A. Hohmann, C.C. Attkisson, & D.B. Larson, (Eds.),Mental disorders in primary care (pp. 347–373). San Francisco: Jossey-Bass Publishers.Google Scholar
  26. Goplerud, E. N. (1981). The tangled web of clinical and epidemiological evidence. In A. Broskowski, E. Marks., & S.H. Budman (Eds.),Linking health and mental health (pp. 59–76). Beverly Hills, CA: Sage Publications.Google Scholar
  27. Hankin, J., & Oktay, J. S. (1979). Mental disorder and primary medical care: An analytical review of the literature. Rockville, MD: US Department of Health, Education, and Welfare.Google Scholar
  28. Hohmann, A. A., Larson, D. B., Thompson, J. W., & Beardsley, R. S. (1991). Psychotropic medication prescription in U.S. ambulatory medical care. DICP, The Annals of Pharmacotherapy, 25, 85–89.Google Scholar
  29. Iglehart, J.K. (1996). Managed care and mental health. New England Journal of Medicine, 334, 131–135.Google Scholar
  30. Jones, K. R., & Vischi, T. R. (1979). Impact of alcohol, drug abuse and mental health treatment of medical care utilization. Medical Care,17(12), 1–82.Google Scholar
  31. Jones, L. R., Badger, L. W., Ficken, R. P., Leeper, J. D., & Anderson, R. L. (1987). Inside the hidden mental health network: Examining mental health care delivery of primary care physicians. General Hospital Psychiatry, 9, 287–293.Google Scholar
  32. Kamerow, D. B. (1987). Is screening for mental health problems worthwhile in family practice? Journal of Family Practice, 25, 181–184.Google Scholar
  33. Katon, W., Von Korff, M., Lin, E., Lipscomb, P., Russo, J., Wagner, E., & Polk, E. (1990) Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. General Hospital Psychiatry, 12, 355–362.Google Scholar
  34. Keller, P.A., Zimbelman, K.K., Murray, J.D., & Feil, R.N. (1980). Geographic distribution of psychologists in the northeastern United States. Journal of Rural Community Psychology,1(1), 18–24.Google Scholar
  35. Kessler, L. G., Cleary, P. D., & Burke, J. D., Jr. (1985). Psychiatric disorders in primary care. Archives of General Psychiatry, 42, 583–587.Google Scholar
  36. Koyanagi, C., & Manes, J. (1995). What did the health care reform debate mean for mental health policy? Health Affairs,14(3), 124–129.Google Scholar
  37. Knesper, D.I., Wheeler, J.R., & Pagnucco, D. J. (1984). Mental health services providers' distribution across counties in the United States. American Psychologist, 39, 1424–1434.Google Scholar
  38. Light, D. (1981). Becoming psychiatrists: The professional transformation of self. New York: W. W. Norton and Company.Google Scholar
  39. Magruder-Habib, K., Zung, W. W. K., & Feussner, J. R. (1990). Improving physicians' recognition and treatment of depression in general medical care. Medical Care, 28, 239–250.Google Scholar
  40. Mechanic, D. (1990). Treating mental illness: Generalist versus specialist. Health Affairs,9(4), 61–75.Google Scholar
  41. Mechanic, D. (1994). Integrating mental health into a general health care system. Hospital & Community Psychiatry, 45, 893–897.Google Scholar
  42. Morrill, R. G. (1972). A new mental health services model for the comprehensive neighborhood health center. American Journal of Public Health, 62, 1108–1111.Google Scholar
  43. Moscovice, I., Christianson, J.B., & Wellever, A. (1995). Measuring and evaluating the performance of vertically integrated rural health networks. The Journal of Rural Health,11(1), 9–21.Google Scholar
  44. Mumford, E., Schlesinger, H. J., Glass, G. V., Patrick, C., & Cuerdon, T. (1984). A new look at evidence about reduced cost of medical utilization following mental health treatment. American Journal of Psychiatry, 141, 1145–1158.Google Scholar
  45. Norquist, G. S., & Wells, K. B. (1991). How do HMOs reduce outpatient mental health care costs? American Journal of Psychiatry, 148, 96–101.Google Scholar
  46. Ozarin, L.D., Samuels, M.E., & Biedenkapp, J. (1978). Need for mental health services in federally funded rural primary health care systems. Public Health Reports, 93, 351–355.Google Scholar
  47. Parlour, R.R., Young, L.M., Jones, L.R., & Brady, T.J. (1985). Linkage of health and mental health services. In L.R. Jones, & R.R. Parlour, (Eds.),Psychiatric services for underserved rural populations (pp. 80–91). New York: Brunner/Mazel Publishers.Google Scholar
  48. Pincus, H.A., (1980). Linking general health and mental health systems of care: Conceptual models of implementation. American Journal of Psychiatry, 137, 315–320.Google Scholar
  49. Preston, J., Brown, F. W., & Hartley, B. (1992). Using telemedicine to improve health care in distant areas. Hospital & Community Psychiatry, 43, 25–32.Google Scholar
  50. Prindaville, G.M., Sidwell, L.H., & Milner, D.E. (1983). Integrating primary health care and mental health services—a successful rural linkage. Public Health Reports, 98, 67–72.Google Scholar
  51. Provan, K. G., & Milward, H. B. (1991). Institutional-level norms and organizational involvement in a service-implementation network. Journal of Public Administration Research and Theory, 1, 391–417.Google Scholar
  52. Prue, D.M., Keane, T.M., Cornell, J.E., & Foy, D.W. (1979). An analysis of distance variables that affect aftercare attendance. Community Mental Health Journal, 15, 149–154.Google Scholar
  53. Rosenberg, S. (1993). The role of states and communities in building viable rural health care delivery reform: An overview of the health care delivery situation in rural communities. In Implementing Health Care Reform in Rural America, Conference Proceedings, Des Moines, IA.Google Scholar
  54. Rosenthal, T. C., Shiffner, J. M., Lucas, C., & DeMaggio, M. (1991). Factors involved in successful psychotherapy referral in rural primary care. Family Medicine, 23, 527–530.Google Scholar
  55. Rost, K., Humphrey, J., & Kelleher, K. (1994). Physician management preferences and barriers to care for rural patients with depression. Archives of Family Medicine, 3, 409–414.Google Scholar
  56. Schlesinger, M. (1986). On the limits of expanding health care reform: Chronic care in prepaid settings. The Milbank Quarterly, 64, 189–215.Google Scholar
  57. Schulberg, H.C., McClelland, M., & Burns, B. J. (1987). Depression and physical illness: The prevalence, causation, and diagnosis of comorbidity. Clinical Psychology Review,7, 145–167.Google Scholar
  58. Sommers, I. (1989). Geographic location and mental health services utilization among the chronically mentally ill. Community Mental Health Journal,25, 132–144.Google Scholar
  59. Sturm, R., & Wells, K. B. (1995). How can care for depression become more cost-effective? Journal of the American Medical Association,273, 51–58.Google Scholar
  60. Sturm, R., Jackson, C. A., Meredith, L. S., Yip, W., Manning, W. G., Rogers, W. H., & Wells, K. B. (1995). Mental health care utilization in prepaid and fee-for-service plans among depressed patients in the medical outcomes study. Health Services Research,30, 319–340.Google Scholar
  61. Stuve, P., Beeson P.G., & Hartig, P. (1989). Trends in the rural community mental health work force: A case study. Hospital & Community Psychiatry, 40, 932–936.Google Scholar
  62. Travers, K.L., Ellis, R.B., & Dartt, L.A. (1995). Comparison of the rural health clinic and federally qualified health center programs. Rockville, MD: Office of Rural Health Policy.Google Scholar
  63. U.S. Congress, Office of Technology Assessment (1990). Health care in rural America. (OTA-H-434). Washington, DC: U.S. Government Printing Office.Google Scholar
  64. Van Hook, M., & Ford, M. (1993). Linking mental and primary health care in rural America. Paper presented at National Association of Rural Mental Health, Lincoln, NE.Google Scholar
  65. Wagenfeld, M.O., & Buffum, W.E. (1983). Problems in, and prospects for, rural mental health services in the United States. International Journal of Mental Health,12(1–2), 89–107.Google Scholar
  66. Wagenfeld, M.O., Murray, J.D., Mohatt, D.F., & DeBruyn, J.C. (1994). Mental health and rural America: 1980–1993. Washington, DC: Office of Rural Health Policy, Office of Rural Mental Health Research, and U.S. Public Health Service.Google Scholar
  67. Wells, K.B., Astrachan, B.M., Tischler, G.L., & Unützer, J. (1995). Issues and approaches in evaluating managed mental health care. The Milbank Quarterly,73(1), 57–75.Google Scholar
  68. Wertlieb, D., & Budman, S. (1982). The health-mental health linkage: Mandates and challenges for evaluation research. In G.J. Stahler, & W.R. Tash, (Eds.),Innovative approaches to mental health evaluation (pp. 59–96). New York: Academic Press.Google Scholar
  69. Zimmerman, M.A., & Wienckowski, L.A. (1991). Revisiting health and mental health linkages: A policy whose time has come ... again. Journal of Public Health Policy, 510–524.Google Scholar

Copyright information

© Human Sciences Press, Inc. 1998

Authors and Affiliations

  • Donna C. Bird
    • 1
  • David Lambert
    • 1
  • David Hartley
    • 2
  • Peter G. Beeson
    • 3
  • Andrew F. Coburn
    • 4
  1. 1.Maine Rural Health Research CenterUSA
  2. 2.Division of Rural HealthMaine Rural Health Research CenterUSA
  3. 3.Strategic and Financial Planning DivisionNebraska Department of Health and Human ServicesUSA
  4. 4.Edmund S. Muskie School of Public ServiceUSA

Personalised recommendations