Why integrated care is needed now more than ever

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Vulnerable Populations

Amidst a global pandemic, some of our most vulnerable populations include individuals who were disadvantaged well before the pandemic arose. It is well documented that individuals with severe mental illness (SMI) die significantly earlier than the general population. In fact, the literature suggests that individuals with SMI die an average of 25 years earlier 1,2,3. Individuals with SMI include those who have schizophrenia, bipolar disorder, and severe major depression.

Another vulnerable population is individuals with substance use disorders, whose life expectancies are reduced by more than nine years compared to national averages 4. Mortality rates are even higher among individuals with co-occurring SMI and substance use disorders 5. Co-occurring mental illness and substance use disorders are termed ‘dual diagnosis.’

Mortality Gap

Individuals with dual diagnoses have an increased risk of mortality in comparison to the general population 6.   Individuals with substance use disorders and co-morbid psychiatric illnesses are at increased risk for relapse and are associated with poorer treatment prognosis and greater psychosocial impairment 4.

Many factors contribute to this mortality gap, and its effects are catastrophic, from lost quality of life to rising costs from untreated illness 7.  The National Alliance on Mental Health estimates that untreated mental illness costs the United States up to $300 billion every year due to losses in productivity 8.

One factor contributing to the mortality gap of individuals with dual diagnoses is poor management of co-morbid chronic medical conditions 6.  Other factors include a higher prevalence of physical comorbidities and lifestyle related to substance use among individuals with dual diagnoses 9. Fragmented healthcare services and lack of coordination among addiction services, behavioral health, and primary care treatment services further widen this health disparity gap.

Integration of Care

Care fragmentation has received more attention in recent years as integrated care has shown positive health outcomes 10. Integrated care is a model that involves the coordination of physical and mental health services in some capacity 11.

Specifically, integrated care involves the addition of behavioral health in primary care settings. For the general population, this form of integration is appropriate because it allows for primary care providers to screen for mental health conditions that would otherwise go unnoticed.

However, among individuals with SMI and addictive disorders, much interaction with healthcare providers is needed within the community mental health setting 12. It is in this environment that primary care services are best addressed. This type of model to address physical health within behavioral health settings is termed ‘reverse integrated care’ 13.


Care integration is an essential intervention to improve the general populations’ health, improve the patient’s care experience, and reduce per capita healthcare costs 11. Integration of care is particularly beneficial for individuals with dual diagnoses, and the literature shows improved patient outcomes as well as a reduction in utilization and costs of urgent care visits and hospitalizations10.

Substance Abuse and Mental Health Services Administration (SAMHSA) created a standard framework to demonstrate the levels of integrated healthcare, as the term ‘integration’ is used widely and not always consistently defined. SAMHSA built upon Doherty et al.’s (1996) seminal brief that first classified the various levels of integration. The underlying assumption was that as levels of collaboration or integration increased, the proficient handling of complex patients would increase as well 11.

Improved patient outcomes

One of the benefits of integrated care is more accessible services for patients and more frequent use of services. One study examined the relationship between the quality of care provided and mortality among individuals with dual diagnoses and found that more service utilization is associated with decreased mortality 5. This may be because more service utilization may lead to quicker identification of physical health problems or identification of mental health decompensation or signs of relapse. This suggests that interventions to increase service utilization, such as greater care integration, may lead to improved health outcomes and ultimately reduced mortality.  

Individuals struggling with both mental illness and addiction have always been a vulnerable population. COVID-19 has exacerbated difficulties for this population and highlighted the need for standardized integrated care. Integrated care is needed now more than ever. The mortality gap will continue to widen without implementing measures such as universal care integration.


1 Mangurian, C., Giwa, F., Shumway, M., Fuentes-Afflick, E., Pérez-Stable, E. J., Dilley, J. W., & Schillinger, D. (2013). Primary Care Providers’ Views on Metabolic Monitoring of Outpatients Taking Antipsychotic Medication. Psychiatric Services, 64(6), 597–599. https://doi.org/10.1176/appi.ps.002542012

2 Mangurian, C., Modlin, C., Williams, L., Essock, S., Riano, N. S., Shumway, M., Newcomer, J. W., Dilley, J. W., & Schillinger, D. (2018). A Doctor is in the House: Stakeholder Focus Groups About Expanded Scope of Practice of Community Psychiatrists. Community Mental Health Journal, 54(5), 507–513. https://doi.org/10.1007/s10597-017-0198-4

3 Olfson, M., Gerhard, T., Huang, C., Crystal, S., & Stroup, T. S. (2015). Premature Mortality Among Adults With Schizophrenia in the United States. JAMA Psychiatry, 72(12), 1172–1181. https://doi.org/10.1001/jamapsychiatry.2015.1737

4 Bogdanowicz, K. M., Stewart, R., Broadbent, M., Hatch, S. L., Hotopf, M., Strang, J., & Hayes, R. D. (2015). Double trouble: Psychiatric comorbidity and opioid addiction—All-cause and cause-specific mortality. Drug and Alcohol Dependence, 148, 85–92. https://doi.org/10.1016/j.drugalcdep.2014.12.025

5 Watkins, K. E., Paddock, S. M., Hudson, T. J., Ounpraseuth, S., Schrader, A. M., Hepner, K. A., & Sullivan, G. (2016). Association Between Quality Measures and Mortality in Individuals With Co-Occurring Mental Health and Substance Use Disorders. Journal of Substance Abuse Treatment, 69, 1–8. https://doi.org/10.1016/j.jsat.2016.06.001

6 Anastas, T., Waddell, E. N., Howk, S., Remiker, M., Horton-Dunbar, G., & Fagnan, L. J. (2019). Building Behavioral Health Homes: Clinician and Staff Perspectives on Creating Integrated Care Teams. The Journal of Behavioral Health Services & Research, 46(3), 475–486. https://doi.org/10.1007/s11414-018-9622-y

7 Kilbourne, A. M., Beck, K., Spaeth‐Rublee, B., Ramanuj, P., O’Brien, R. W., Tomoyasu, N., & Pincus, H. A. (2018). Measuring and improving the quality of mental health care: A global perspective. World Psychiatry, 17(1), 30–38. https://doi.org/10.1002/wps.20482

8 National Institute of Mental Health (2017). Annual Total Direct and Indirect Costs of Serious Mental Illness (2002). Retrieved from: https://www.nimh.nih.gov/health/statistics/cost/index.shtml.

9 Juel, A., Kristiansen, C. B., Madsen, N. J., Munk-Jørgensen, P., & Hjorth, P. (2017). Interventions to improve lifestyle and quality-of-life in patients with concurrent mental illness and substance use. Nordic Journal Of Psychiatry, 71(3), 197–204. https://doi.org/10.1080/08039488.2016.1251610

10 Assefa, M. T., Ford, J. H., 2nd, Osborne, E., McIlvaine, A., King, A., Campbell, K., Jo, B., & McGovern, M. P. (2019). Implementing integrated services in routine behavioral health care: Primary outcomes from a cluster randomized controlled trial. BMC Health Services Research, 19(1), 749–749. https://doi.org/10.1186/s12913-019-4624-x

11 Heath, B., Wise, R.P., and Reynolds. K. (2013). A review and proposed standard framework for levels of integrated healthcare. Washington, D.C. SAMHSA-HRSA, Center for Integrated Health Solutions.

12 Ward, M. C., & Druss, B. G. (2017). Reverse Integration Initiatives for Individuals With Serious Mental Illness. FOCUS, 15(3), 271–278. https://doi.org/10.1176/appi.focus.20170011

13 Maragakis, A., Siddharthan, R., RachBeisel, J., & Snipes, C. (2016). Creating a ‘reverse’ integrated primary and mental healthcare clinic for those with serious mental illness. Primary Health Care Research & Development, 17(5), 421–427. https://doi.org/10.1017/S1463423615000523

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