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PROLOGUESpecialization And Integration In Mental Health CareIn the astute judgment of a Health Affairs editorial adviser, fragmentation is the problem in mental health, but integration is not necessarily the solution. In the 1990s, integration was a vision that subsumed hospital, medical, and subacute care as well as financial management and insurance risk in a single health care organization. But things have not turned out that way in mental health or the general health sector, except on rare occasions. A riotously pluralistic provider universe and an equally disjointed array of financial arrangements in mental health have stopped this dream of reason in its tracks. But while big-bang notions about integration have failed to live up to expectations, problems resulting from uncoordinated services remain even more salient in mental than in general health care. Although this disorder has not proved vulnerable to frontal assault, it might be successfully attacked piecemeal with strategies to mend the system’s most egregious disconnects, one by one. The treatment of co-occurring mental health and substance abuse disorders is Exhibit A in the dialectic of specialized versus integrated care in the behavioral health arena. Both financing and treatment resources in these two fields are built on distinct foundations, despite the practical and clinical logic of tackling them in tandem, while recognizing that they are independent pathologies requiring differentiated approaches. In the first of three papers, Audrey Burnam and Katherine Watkins outline the problems created by separate arrangements for mental health and substance abuse treatment, and the limitations of many efforts to create linkages between these parallel worlds. More highly structured approaches to coordination are afoot in some states, these RAND authors report, and their paper reviews the prospects for bridging this troublesome divide. Even the most enthusiastic prophets of integration in the general health sector have often failed to give much emphasis to the need for a unified approach to mental and general health care. In the next paper, Marcela Horvitz-Lennon and colleagues focus on the prevalence of somatic disorders among the mentally ill and the barriers they face in obtaining treatment. Striking a note echoed in the Institute of Medicine’s 2006 report on mental health, these authors explore an array of options that might be available for creating linking mechanisms at the clinical level between separate systems of care, short of the more ambitious goal of structural or financial integration. In a third paper, Jane Knitzer and Janice Cooper make a similar point about the challenges of coordinating mental health services for children. Although integration of care at the system level might be a goal that lies out of reach for today’s children, many opportunities exist to link services and supports at the level of individual patients and families.
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