Provision of behavioral health services by primary care providers in rural areas: opportunity, responsibility, and politics

摘要

Many models of mental health service delivery to rural areas focus on service provision by primary care physicians. "Medicaid Managed Behavioral Health in Rural Areas," in this issue of The Journal of Rural Health, describes one such example. Thereare many reasons why this approach is intuitive and appears logical. Availability of psychiatrists and access to specialty care in rural areas is often limited. Even when available, residents may be reluctant to use formal mental health services becauseof stigma about mental illness and concern regarding anonymity. However, provision of mental health services by a primary care provider may not be the best or only solution. Models that propose provision of behavioral health care by primary care physicians without assessing their competence, confidence, and willingness to do so are shortsighted. The medical education of residents in primary care specialties must include formal instruction and clinical supervision in order to recognize and treat conditions most likely to be seen in a primary care practice (e.g., alcoholism, depression, anxiety, and dementia). Persons in rural areas who need specialized psychiatric services, such as those with serious mental illness (e.g., schizophrenia, bipolar disorder, or psychotic depression) are particularly vulnerable to a model that starts and stops with a primary care physician who does not have advanced training in psychiatry. Psychiatry residency programs have a responsibility to train psychiatrists with the skills and aptitude necessary for them to initiate and sustain effective consultative and supportive relationships with primary care providers who are likely to be the front-line providers of mental health services in rural areas.