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Objectives Mycobacterium bovis, a member of the Mycobacterium tuberculosis complex, can infect cats and has proven zoonotic risks for owners. Infected cats typically present with a history of outdoor lifestyle and hunting behaviour, and cutaneous granulomas are most commonly observed. The aim of this study is to describe an outbreak of tuberculous disease commencing with six young cats, living exclusively indoors in five different households across England, being presented to separate veterinarians across the UK with a variety of clinical signs. Methods Investigations into the pyogranulomatous lesions, lymphadenopathy and/or pulmonary disease of these cases consistently identified infection with M bovis. Infection was confirmed by PCR, where possible, or was indicated with a positive interferon-gamma release assay (IGRA), where material for PCR was unavailable. Incontact, cohabiting cats were screened by IGRA and follow-up testing was undertaken/advised where results were positive. A lifestyle investigation was undertaken to identify the source of infection. Results Six clinically sick cats and seven in-contact cats were identified with evidence of M bovis infection. Five clinical cases were either too sick to treat or deteriorated despite therapy, giving a mortality rate of 83%. Lifestyle investigations revealed the common factors between clusters to be that affected cats had mycobacterial infections speciated to M bovis, were exclusively indoor cats and were fed a commercially available raw food product produced by a single manufacturer. The Food Standards Agency, Animal & Plant Health Agency, Public Health England and the food manufacturer concerned have been notified/informed. Other possible sources of exposure for these cats to M bovis were explored and were excluded, including wildlife contact, access to raw milk, the presence of rodent populations inside the buildings in which the cats lived and exposure to known infectious humans. Conclusions and relevance Upon investigations, our results provide compelling, if circumstantial, evidence of an association between the commercial raw diet of these cats and their M bovis infections.

Telemental health has been promoted to address long-standing access barriers to rural mental health care, including low supply and long travel distances. Examples of rural telemental health programs are common; there is a less clear picture of how widely implemented these programs are, their organization, staffing, and services. There is also a need to understand the business case for these programs and assess whether and how they might realize their promise. To address these gaps, a national study was conducted of rural telemental health programs including an online survey of 53 programs and follow-up interviews with 23 programs. This article describes the current landscape and characteristics of these programs and then examines their business case. Can rural telemental health programs be sustained within current delivery systems and reimbursement structures? This question is explored in four areas: need and demand, infrastructure and workforce, funding and reimbursement, and organizational fit and alignment.

Discussions of the delivery of mental health care in rural areas tend to focus on system-level issues, including parity, historic barriers between physical and mental health systems, the growing role of managed care, the traditional separation of funding streams, and the shortage of qualified mental health providers willing to practice in rural areas. Although these public policy issues deserve attention, they are not particularly amenable to local solutions. In these system-level discussions, the needs of rural consumers and providers are often overlooked, and attention is diverted from the development of local-level solutions to the problems of rural mental health delivery systems.In this chapter, we suggest an alternative perspective, that of the public health model, to inform the discussion of delivering mental health services in rural areas. Within the context of the public health model, we take a broad view of mental health services that includes both a mental health orientation and a mental illness orientation. We describe the de facto rural mental health system, discuss the populations served by the existing systems and their service needs, identify access issues and barriers for these populations, and provide a series of tools with which stakeholders can begin to analyze their local delivery system. By doing so, stakeholders will develop a context for understanding how the various components of the system fit together. These tools will enable stakeholders to identify the multiple points of access within their community, to categorize those access points according to a logical framework, and to identify the clinical roles and functions of the various providers, agencies, and organizations that constitute their local mental health system. Within this context, we suggest opportunities to improve and integrate existing components of local mental health delivery systems in rural areas to better meet the needs of the people served by them. Elements of the Public Health ApproachPublic health focuses on the diagnosis, treatment, and etiology of disease; epidemiological surveillance of the health of the population at large; health pro-

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As of 2000, 21 states had implemented Medicaid managed behavioral health (MMBH) programs for a significant portion of their rural population. It is not clear how MMBH programs may work in rural areas since they are primarily designed to control mental health utilization. In rural areas the challenge is often to enhance service delivery, not to reduce it. MMBH programs may also affect important features of rural delivery systems, including access to care and coordination of primary care and specialty mental health providers. This article describes the implementation of MMBH programs in rural areas based on an inventory of states implementing MMBH programs in rural counties conducted between June 1999 and June 2000. The experience of MMBH programs in rural areas is also described based on case studies conducted in six states. All 21 states included the general Medicaid population (Temporary Assistance for Needy Families); 17 states included special Medicaid populations (adults with serious and persistent mental illness and children with serious emotional disturbances). Slightly less than half the states integrated (carved-in) behavioral health with physical health services in serving the general Medicaid population; only one state integrated these services for the special Medicaid population. Access to mental health care in rural areas had generally not been restricted. MMBH had little impact on the linkage between primary care and mental health. Local Managed Behavioral Health Organizations, formed by public sector entities and providers, played an increasingly important role in the evolution of MMBH.

he provision of mental healthcare in rural communities has been a vexing challenge for clinicians and patients for many years. There is a chronic shortage of specialty mental health providers, particularly psychiatrists and psychologists, which has shifted much of the burden of care to primary care. Primary care clinicians have historically lacked the training and time within their busy practices to feel comfortable providing mental healthcare, particularly since the shortage of specialty mental health clinicians deprives them of consultation and referral sources. People who live in rural areas must often overcome significant travel distances, stigma, and lack of insurance and other resources to access the scarce mental health services that do exist. 1 Despite this difficult picture, rural primary care and specialty mental health clinicians have persevered to provide some level of mental healthcare to people in rural areas. Over the last decade, improvements in clinical screening tools, treatment protocols and guidelines, and information technology have significantly enhanced the potential to increase access to and improve the quality of mental health services in rural communities, particularly to underserved populations. Recent policy initiatives hold much promise to provide the structural and financial support necessary to help rural communities realize these improvements.In this commentary, we first present a general discussion of the issues related to the delivery of mental health services in the United States with particular attention to how these issues complicate the delivery of services in rural areas. Next we describe the renewed call for integrating primary care and mental health in rural areas (hence "the once and future role of primary care" in our title) and related clinical and policy support to do so. We close by briefly describing the policy interventions and resources needed to further these integration efforts and to improve access to services for rural underserved populations. Our Fragmented Mental Health Delivery SystemThe mental health delivery system in the United States is characterized by a fragmentation of services, separation of funding streams and delivery systems, poor reimbursement, inadequate access to specialty mental health providers, and the mal-distribution of existing resources. These issues greatly complicate the delivery of services in rural areas.The United States mental health system is not a coordinated system of specialty mental health services but, rather, a fragmented collection of services and providers that has come to be known as the de facto mental health "system." 2,3 The term "system" is used to convey an understanding of where persons receive services, rather than to suggest a coherent whole that has developed according to a set of organizing principles. 4 Regier and colleagues identified four sectors where individuals may seek assistance for their mental health needs: (1) specialty mental health, (2) general medical/primary care, (3) human services, and (4) volun...