• Behavioral health service integration
• Collaborative care
• Consultation-liaison psychiatry
• Integrated behavioral health services
• Proactive CL psychiatry
• Proactive consultation-liaison psychiatry

• Behavioral health integration
• Financial sustainability
• Implementation
• Qualitative evaluation
• Technology barriers

• Behavioral health
• Integrated care
• Integration framework
• Primary care
• Technical assistance

Primary care has been dubbed the “de facto” mental health system of the United States since the 1970s. Since then, various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs. Despite increases in collaborative care implementation and reimbursement, prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb. Meanwhile, primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether, citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available, high false-positive results, and small treatment effects. In this perspective, a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care. In addition, we propose systemic changes to improve the dissemination of mental health treatment in primary care.

• Mental health
• Collaborative care
• Primary care
• Depression
• Integrated care
• Anxiety

• Behavioral health consultation
• Integrated primary care
• Pediatrics
• Primary care behavioral health (PCBH) model

• Primary care
• Public policy issues

• Behavioral health
• Children
• Financing
• Policy
• Youth

• Behavioral health
• integrated care
• palliative care
• psychiatric comorbidity
• serious illness care
• staff development
• workforce

• K12 DA000357 NIDA NIH HHS

• Depression
• Depressive Disorder
• Humans
• Mass Screening
• Primary Health Care

• Community interventions (MeSH)
• Community networks (MeSH)
• Community-based interventions (MeSH)
• Health disparities
• Mental health (MeSH)
• Mental health equity
• Mental health intervention (MeSH)
• Multi-sector interventions
• Social determinants of health
• Social problems (MeSH)

• Community Medicine
• Health Promotion
• Humans
• Mental Health
• Psychotic Disorders/prevention & control
• Psychotic Disorders/therapy
• Schools
• Social Environment

• K12 DA000357 NIDA NIH HHS
• R01 MD007721 NIMHD NIH HHS

• Co-occurring conditions
• Collaborative care
• Integrated care
• Mental health services
• Primary care

In a large statewide initiative, New York State implemented collaborative care (CC) from 2012 to 2014 in 32 primary care settings where residents were trained and supported its sustainability through payment reforms implemented in 2015. Twenty-six clinics entered the sustainability phase and six opted out, providing an opportunity to examine factors predicting continued CC participation and fidelity.

We used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics. To characterize barriers and facilitators, we conducted 31 semi-structured interviews with psychiatrists, clinic administrators, primary care physicians, and depression care managers (24 at sustaining, 7 at opt-out clinics).

At the end of the implementation phase, clinics opting to continue the program had significantly higher care manager full-time equivalents (FTEs) and achieved greater clinical improvement rates (46% vs. 7.5%, p = 0.004) than opt-out clinics. At 1 and 2 years into sustainability, the 26 sustaining clinics had steady rates of depression screening, staffing FTEs and treatment titration rates, significantly higher contacts/patient and improvement rates and fewer enrolled patients/FTE.

During the sustainability phase, opt-out sites reported lower patient caseloads/FTE, psychiatry and care manager FTEs, and physician/psychiatrist CC involvement compared to sustaining clinics. Key barriers to sustainability noted by respondents included time/resources/personnel (71% of respondents from sustaining clinics vs. 86% from opt-out), patient engagement (67% vs. 43%), and staff/provider engagement (50% vs. 43%). Fewer respondents mentioned early implementation barriers such as leadership support, training, finance, and screening/referral logistics. Facilitators included engaging patients (e.g., warm handoffs) (79% vs. 86%) and staff/providers (71% vs. 100%), and hiring personnel (75% vs. 57%), particularly paraprofessionals for administrative tasks (67% vs. 0%).

Clinics that saw early clinical improvement and who invested in staffing FTEs were more likely to elect to enter the sustainability phase. Structural rules (e.g., payment reform) both encouraged participation in the sustainability phase and boosted long-term outcomes. While limited to settings with academic affiliations, these results demonstrate that patient and provider engagement and care manager resources are critical factors to ensuring sustainability.

The online version of this article (10.1186/s13012-018-0818-6) contains supplementary material, which is available to authorized users.

• Depression
• Primary health care
• Sustainability