When Panic Looks Like a Heart Attack: What Cities Can Learn From Carla’s Case

Several years ago, I was part of a care team working with a middle-aged woman named Carla who frequently visited the emergency department for chest pain and shortness of breath. Despite extensive cardiac testing, no physical cause was ever found. It wasn’t until a behavioral health specialist joined one of our case reviews that the missing piece emerged. Through a series of structured interviews and collaborative review of her social history, the behavioral health provider identified untreated panic disorder as the likely driver of her symptoms. Had we continued to treat her solely through a physical health lens, Carla would have remained in a cycle of unnecessary testing, missed work, and deepening anxiety.

This case illustrates the power of interdisciplinary care teams in identifying diagnoses that can be overlooked when providers operate in silos. By bringing together primary care, behavioral health, and care coordination, we prevented continued fragmentation and provided Carla with a treatment plan that addressed both her mental and physical health. Within six months of integrated treatment, her emergency visits dropped to zero, and she reported a significant improvement in quality of life.

Structural Barriers to Integration

Despite the success of integrated approaches, systemic barriers continue to delay or obstruct coordination between physical and mental health providers. One of the primary challenges we face is the separation of billing systems and reimbursement structures. Mental health services are often billed under different codes and subject to different rules, which can discourage providers from offering integrated care, especially in fee-for-service environments. A 2021 report from the Commonwealth Fund found that only 15 percent of primary care practices in the U.S. had fully integrated behavioral health services, in part due to these financial hurdles¹.

Another challenge is the lack of shared electronic health records (EHRs) that support collaboration. Many behavioral health providers operate on stand-alone systems due to privacy regulations or organizational policy, making it difficult for primary care physicians to access timely mental health information. This disconnect can lead to duplicated services, medication contraindications, and missed opportunities for co-management. One solution we implemented in our clinic was the development of a shared care plan template within our EHR that allowed both physical and behavioral health providers to contribute in real time, with appropriate consent protocols in place. This significantly improved continuity and reduced administrative delays.

Overcoming Cultural and Professional Divides

Beyond structural issues, cultural barriers between disciplines often limit integration. Historically, mental health and physical health have been trained and treated separately, leading to different terminologies, treatment philosophies, and clinical workflows. These differences can create misunderstandings or resistance to collaboration. For example, I’ve observed primary care physicians hesitant to refer patients to behavioral health due to concerns about stigma or uncertainty around how mental health treatment aligns with their medical management plans.

To address this, we have instituted regular cross-disciplinary case conferences and co-training sessi