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Add Prevention to Our Field’s Mission and Anchor It in Primary Care
Behavioral health is becoming a critical focus in primary care. Interest is building on the medical side, independent of any steps taken within our field. Healthcare leaders are recognizing the prevalence and burden of behavioral issues. They understand the dangers of letting them progressively impact health. Behavioral health is increasingly seen as necessary for health promotion and disease prevention.
The behavioral healthcare field has traditionally functioned as a specialty service—clinicians and programs wait for clients to present themselves for care. A preventive focus would be proactive. It means keeping healthy people healthy and addressing problems early. Primary care has been the traditional setting for preventive work, with immunization being the prototype for primary prevention.
There are 2 general ways to approach prevention: targeting the whole population or targeting high-risk individuals within it. Behavioral clinicians have good risk-detection tools and are comfortable with this approach. Yet focusing on high-risk has drawbacks, so population-level strategies are also needed. Our field has much to offer in terms of prevention, and we should anchor our activities within primary care.
Some experts in our field have created valuable prevention programs. Yet aside from such individual contributions, our field has focused mainly on treatment. This includes efforts to integrate medical and behavioral care. The most common integration model, the collaborative care model, stresses risk screening and care coordination, not prevention. Innovative executives are needed to chart a new path.
Executives should be clear as they move our workforce into the primary care setting that we have 2 distinct but related goals there:
- We can improve access to care as therapists in primary care either give people the behavioral healthcare services they need or connect them with the right services.
- We can improve primary care’s overall health outcomes as we implement new prevention programs targeting the behavioral roots of illness.
The Prevention Paradox
Epidemiologists use the term “prevention paradox” to describe when most of the burden of a disease (i.e., its cost, mortality, and morbidity) comes from those at low or moderate risk, rather than the high-risk group. We tend to assume higher-risk people account for most of the disease burden, but high-risk cases may constitute a smaller percentage of the population. This paradox is common in our field.
Experts have discussed this recently in relation to suicidal behavior and the use of alcohol. They note most of a population’s burden comes from moderate alcohol use, not from heavy use or the impact of higher-risk individuals. There are simply many more people with moderate levels of consumption:
The prevention paradox therefore helps explain why more cases of disease or death could be prevented by targeting the broader population or indicated sub-populations, rather than specifically targeting only those with a high-risk profile.
This paradox has big implications as our field pursues prevention. Screening programs to identify high-risk individuals have a place, but executives also need to design solutions that are more population-based. Therapists in primary care can carry out some of these population solutions—low- and moderate-risk behaviors can be addressed with brief interventions rather than formal therapy.
While brief therapeutic conversations might serve to prevent problems, therapists have value beyond individualized interventions. They can help reshape the health culture of primary care in ways that benefit patients broadly. For example, this setting needs a culture in which clinicians listen empathically and refer patients to digital platforms to learn and contemplate personal issues.
Such a culture change is not just a conceptual shift. It emerges from a plethora of behaviorally focused services. Primary care needs ongoing well-being programs focused on diverse issues—e.g., stress, parenting, loneliness—with validated self-help tools—e.g., coping skills, mindfulness, sleep hygiene. This culture may be crafted by therapists, but primary care physicians (PCPs) must collaborate in sustaining it.
An Opportunity for Executives
Our field is becoming part of mainstream healthcare. Business consolidation has touched every segment of the healthcare industry, including behavioral care. With these changes, prevention will soon be added to our field’s agenda alongside treatment. However, most clinicians lack education about prevention and are consumed with treatment concerns. Behavioral executives must seize the opportunity to lead this expanded mission.
We are not starting from scratch. Large employers have been implementing interventions for wellness and wellbeing for decades. However, big employers with large concentrations of workers are a minority. Health promotion and disease prevention are better incorporated into primary care to reach more people. Behaviorally focused measures should be as common as vaccinations in primary care.
Behaviorally focused programs can impact both mind and body, and so they can improve total health. Moreover, we can impact population health, not just individual health. These goals await us in primary care, but a sense of ownership is required. We need to move beyond visitor status, beyond working as PCP consultants. We need to become co-owners of prevention as we move to the frontlines of healthcare.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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