President's Column

In these early years of the 21st century we are witnessing dramatic improvements in health-care science and technology. However, the overall picture for health care is not good. Health-care costs continue to escalate faster than other segments of the economy, and the number of uninsured recently passed 45 million Americans. The Institute of Medicine recently concluded that the "health-care delivery system is incapable of meeting the present, let alone the future needs of the American public."

These problems are clearly so serious that they should compel a complete re-examination of the U.S. health-care system. One core assumption that requires rethinking is the idea of the separation of mind from body--the notion pervading our concepts of health and illness that there are some illnesses that are physical and others that are mental, a notion that informs the current practice in health-care reimbursement of subcapitating mental health benefits. As we all know, mind and body are not separate, but rather they are inseparable. By assuming that mind and body are separate, and, further, assuming that the only role that the mind plays in health and illness is in mental health and illness, we have maintained a health-care system that is unable to deal with the many varied roles that mind and behavior play in so-called physical illness. This system, further, does not even deal with mental health and illness, per se, effectively.

System flaws

Descarte's 17th-century metaphysical philosophy, which separates mind from body, has an enormous negative impact on our health-care system. Because of it, our health-care system does not systematically attend to the many psychological risk factors for both morbidity and mortality, and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. Further, our health-care system does not fully utilize appropriate tools to tackle the current chronic-disease epidemic, such as the numerous disease-management programs aimed at treatment adherence and lifestyle improvement developed and validated by psychologists. Nor does it utilize fully the many well-documented psychological interventions for acute illness and management of stressful medical procedures. In addition, the psychological impact of having a medical illness is not well addressed by the health-care system, nor is the fact that many people suffering from a physical illness have comorbid psychological illness, nor is prescription drug abuse. Finally, the lion's share of mental health problems are treated, ineffectively, by primary-care providers.

Mind-body dualism, is, in a word, bankrupt. We need to transform our biomedical health-care system to one based on the biopsychosocial model, which will emphasize collaboration between medical and behavioral health-care providers, and the integration of psychology into the very heart of heath care. In order to reform the U.S. health-care system along these lines we must appeal directly to the public and to decision-makers, not alone, but in collaboration with other like-minded physician, provider, consumer and policy groups. We need to articulate the public's dissatisfaction with the biomedical health-care system that results in their care provider not having time to listen to all of their concerns or offering ineffective care. We need to put forth a vision of integrated care, a care system that offers health care for the whole person. This is one of my initiatives as president of APA.

Making a statement

The initiative is chaired by Dr. Margaret Heldring, who has established a number of work groups in such areas as science, economics, education and training, culture and disparities, clinical examples/best practices, policy and outreach, women's health and rural health (see page 14 for a list of work groups and their members). These groups are reviewing the literature in their respective domains to provide a solid foundation for our policy statement on integrated collaborative care--health care for the whole person--for which we are seeking partners among a broad range of physician, provider, consumer and policy groups (see page 14 for the current list of partners).

In the meantime, the Health Care for the Whole Person Task Force has crafted a draft statement of vision about integrated health care. Approved in principle by APA's Board of Directors and Council of Representatives at their February meetings, the statement provides the rationale for an integrated model of public health and health care. Reports from the Institute of Medicine, the National Institutes of Health, and the President Bush's New Freedom Commission on Mental Health provide the frame for the Health Care for the Whole Person initiative, as each report urges closer ties between mental and physical health and recommends a collaborative, multidisciplinary approach to health care. As health-care and public health groups sign on as partners, they are invited to make comments to the statement of vision.