Integrating Behavioral and Social Sciences in the Medical School Curriculum: Opportunities and Challenges for Psychology

The Institute of Medicine has reviewed and made recommendations concerning current teaching approaches, content, and barriers to the incorporation of behavioral/social sciences in medical school curricula (Cuff & Vanselow, 2004). This paper discusses those recommendations, the history of medical education reform, the barriers to and evolution of behavioral/social sciences’ inclusion, and the implications for psychology’s future role in academic medicine. Psychological concepts and technology permeate medical practice, but little progress has been made in integrating psychological and biological sciences. Looking to its basic science domains (e.g. cognition, learning, development, neuroscience), psychology can take scientific leadership in illuminating the mechanisms by which behavioral/social processes interact with biological functions in health, thereby providing the empirical basis for a truly integrated bio-behavioral curriculum. This article is based upon a symposium, “IOM Report on Enhancing Behavioral & Social Science in Medical Education: Impact and Opportunities for Psychology,” presented at the Annual meeting of the American Psychological Association, Washington, D.C., August 21, 2005. Suzanne Bennett Johnson, Chair; Elena Reyes, John E. Carr, and Anthony Errichetti, participants; Eugene K. Emory, Discussant.     

The Difficulty of Making Psychology Research and Clinical Practice Relevant to Medicine: Experiences and Observations

Psychology and medicine research and practice have demonstrated substantial and unique bodies of knowledge designed to both improve patient care and respond to contemporary health care needs for use of evidence and cost consciousness. At their full potential they represent a significant paradigm shift in healthcare. Despite impressive successes, it is clear that we are just on the cusp of such a change. These findings have had limited impact and penetration into medical practice, particularly outside of academic medicine and large, organized systems of health care, and there are multiple examples of such limitations in various arenas of health care. There also appear to be common themes to such examples which provide us opportunities to consider how psychologists might move things ahead. They also suggest how our unique position in academic medicine can both limit our impact and provide ways of creating continued shifts in the healthcare paradigm. This paper is based in part on the author’s presentation at the Association of Psychologists in Academic Health Centers 3rd National Conference in Minneapolis, Minnesota, May 2007.     

Performance of Mental Health Counselors in Integrated Primary and Behavioral Health Care

Integrated primary and behavioral health care (IPBH) is becoming a preferred mode of service delivery in the United States. Integrated care includes the participation of medical and mental health professionals, such as mental health counselors. The clinical outcomes of these professionals need to be studied to determine their effectiveness in such settings. We examined the performance of 10 mental health counselors on the clinical outcome of 1,747 clients treated in an IPBH center. Analyses using growth curve modeling and pre‐post test design revealed that mental health counselors were effective overall, but they differed in client dropout rates and efficiency in reducing clients' initial symptoms. We used the analyses to rank order counselors based on their effectiveness. Counselors who were the most effective varied in their efficiency but demonstrated the lowest client dropout rates. Implications for future research and counseling practice were discussed.     

Examining the Effectiveness of Integrated Behavioral and Primary Health Care Treatment

Using a quasi‐experimental, pre–post test design of 196 persons diagnosed with serious mental illness, the authors compared the effectiveness of an integrated behavioral and primary health care (IBPH) treatment approach vs. a treatment‐as‐usual approach over a 12‐month period. A profile analysis of 5 mean difference scores, each representing a separate component of client holistic functioning, indicated that individuals receiving IBPH experienced a 24‐times greater improvement in overall functioning. Recommendations for treatment and client care are provided.     

The Medical Offset Effect: Patterns in Outpatient Services Reduction for High Utilizers of Health Care

Psychosocial intervention has been found to be related to subsequent reductions in health care use. Studies generally measure this “offset effect” by combining medical use categories into one outcome variable, such as outpatient doctor visits. However, using a general outcome variable may obscure more specific patterns of reduction. In an effort to identify potential “targets” for mental health intervention, outpatient care for health screening, illness visits, laboratory/X-ray, and urgent care were considered. Health care use reductions were most prominent for high utilizers and were found across a number of different types of outpatient care. With high utilizers, those who participated in MFT showed significant reductions of 68% for health screening visits, 38% for illness visits, 56% for laboratory/X-ray visits, and 78% for urgent care visits.     

Health-Related Quality of Life in a National Sample of Caregivers: Findings from the Behavioral Risk Factor Surveillance System

Purpose Recent national public health agendas, such as Healthy People 2010, call for improved public health surveillance and health promotion programs for people with disabilities and their caregivers. The goal of this study was to understand the public health impact of caregiving on health-related quality of life (HRQoL) using population-level data. Design & Methods A cross-sectional study design was used. 184,450 adults surveyed during the 2000 national Behavioral Risk Factor Surveillance System survey formed the sample. Binary logistic regression models ascertained differences between caregivers and non-caregivers in reporting reduced (“fair” or “poor”) health. Ordinary least squares regression (OLS) and multinomial logistic regression models examined the influence of caregiving status on HRQoL, measured as categories of healthy days reported in the last 30 days and the number of days reported as physical and mental health not good in the last 30 days. Results Sixteen percent (16%) of the survey respondents were caregivers. There was an interaction effect between caregiving status and age of the caregiver. In the fully adjusted models, caregivers <55 years old had a 35% increased risk of having fair or poor health (odds ratio [OR] = 1.35, 95% confidence interval [CI] 1.28, 1.43) as compared to non-caregivers in that age group, while caregivers 55 years and older had a 3% decreased risk in having fair or poor health (OR = 0.97, 95% confidence interval [CI] 0.92, 1.03) compared to non-caregivers of the same age. In the adjusted models that examined the association of caregiving and healthy days, younger caregivers similarly showed larger deficits in both mental and physical HRQoL compared to older caregivers. For example combining mental and physical days, caregivers <55 had 1.44 fewer healthy days (β = −1.44, standard error (SE) = 0.07), while caregivers 55+ had 0.55 fewer days *β = −0.55, standard error (SE) = 0.13 (compared to non-caregivers in their respective age groups). Implications With increasing population age and the projected increase in caregivers, it is important that we understand the social and public health burden of caregiving and begin to identify interventions to sustain the HRQoL of caregivers. We found that caregivers have a slight to modest decline in HRQoL compared to non-caregivers, and that caregiving affects the HRQoL of younger adults more than older adults. Further research at the population level as to the type and level of burden of caregiving is needed.     

Evolution of an Inpatient Pediatric Psychology Consultation Service: Issues Related to Reimbursement and the Use of Health and Behavior Codes

The purpose of this study was to evaluate an inpatient pediatric psychology consultation service, with particular focus on issues related to financial reimbursement for services. Information was gathered over a four year period (2001–2005) regarding number of consults, referral source and referral question, type of insurance, and reimbursement rates for health and behavior codes versus mental health codes. The financial impact of hiring an insurance verification specialist was also explored. Results indicated that reimbursement rates for health and behavior codes were higher than reimbursement rates for mental health codes. Health and behavior codes were rejected in 31% of cases that they were billed; the primary reason for rejection was that these codes were not a covered service by Medicaid. Hiring an insurance verification specialist was found to be a cost-effective method for improving the financial “bottom-line” for psychology services. Implications for practice are discussed.     

Meta‐Analysis of Integrated Primary and Behavioral Health Care Interventions for Treating Substance Use Among Adults

This meta‐analysis detected low effects in reducing substance use (Hedges's g = –0.11) in favor of using integrated primary and behavioral health care (IPBH) compared with treatment‐as‐usual approaches for adult patients with substance use. The impact of IPBH was limited.     

The Reinvention of Behavioral Health Services in the VA System

The Veterans Health Administration under the direction of Kenneth Kizer, M.D., has faced the challenge of providing high-quality health care while controlling costs. Under Dr. Kizer's direction, VA hospitals are moving toward managed patient centered primary care. Hospital organization, funding, and clinical practices have been changed. Reorganization has meant a variety of possibilities for psychologists employed in the VA system.     

The Future of Psychology in Academic Health Care Centers

A promising opportunity exists to continue psychology's move beyond its traditional mental health emphasis into a general health care discipline. Abundant empirical evidence supports that psychologists treat a wide array of physical disorders as well as psychological components of medical problems. The immediate issues confronting psychology's full emergence into the health care world are discussed and recommendations are offered to assure the success of this initiative. Office of the Senior Vice President and Provost     

医师协会行业自律：医学伦理建设的一个有效机制

中国医师协会自2002年成立以来,做了大量工作,但其主要集中在维护医师权益方面,在自律建设方面却作为不够。医师协会加强行业自律方可有效维权,这是医师协会开展工作的一种策略。在此基础上,进一步研究了"加强行业自律"这个医学伦理建设的有效机制。     

Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes

Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.     

The Role of Functions of Aggression in Associations Between Behavioral Inhibition and Activation and Mental Health Outcomes

While the behavioral acitivation system (BAS) has been most consistently linked to externalizing behaviors, the behavioral inhibition system (BIS) has been more closely related to internalizing outcomes. Proactive and reactive aggression have demonstrated a similar pattern of association, with proactive aggression more closely linked to externalizing behavior and reactive aggression more consistently linked to internalizing symptoms. Despite theoretical links, few studies have examined associations between these constructs. Accordingly, the current study examined associations between the BAS and BIS and proactive and reactive aggression, and the role of proactive and reactive aggression in the link between the BAS and BIS and mental health outcomes. The BAS was associated with both proactive and reactive aggression, while the BIS was uniquely related to reactive aggression. Both proactive and reactive aggression appear to be playing a role in associations between the BAS and indicated mental health outcomes. Implications and future directions are discussed.     

中国家庭中的亲子互动行为与儿童行为抑制性的发展

本研究采用家庭录像的方法对53名中国4岁儿童在家庭自由游戏和拼图游戏小与父母的交往行为进行了观察,并在这些儿童7岁时任实验室里的行为抑制性进行了录像观察,从而考察了在家庭自然环境中的亲子互动行为与儿童行为抑制性发展之间的关系。结果发现：在以上家庭录像的两个情境中,随着年龄的变化,母亲的控制行为越多,儿童抑制倾向的发展速度越快,作抑制倾向发展得越慢;儿童顺从行为越多,儿童的非抑制倾向发展得越慢,抑制倾向发展得越快。父母之间的情感表达越亲密,父亲在身体上对儿童的积极情感越多,儿童的非抑制倾向发展得越快。     

The Mistreatment of My People: Victimization by Proxy and Behavioral Intentions to Commit Violence Among Muslims in Denmark

Islamist extremism is often explained by the suffering endured by Muslims in Islamic countries as a result of Western‐led wars. However, many terrorist attacks have been carried out by European Muslims with no personal experiences of war. Across two studies among Danish Muslims, we tested if what we call “victimization‐by‐proxy processes” motivate behavioral intentions to commit acts of violence. We used Muslim identification, perceived injustice of Western foreign policies, and group‐based anger to predict violent and nonviolent behavioral intentions. More importantly, we compared path models of Danish Muslims from conflict zones with those without direct personal experience of Western‐led occupation. We found similar effects among the participants in each category, that is, vicarious psychological responses mimicked those of personally experienced adversity. In fact, participants born in Western Europe were, on average, more strongly identified with Muslims, more likely to perceive Western foreign policy as more unjust, reported greater group‐based anger, and were more inclined to help Muslims both by nonviolent and violent means.     

关于耳蜗传出神经系统功能研究的启示

对卫生管理中具有战略地位的卫生政策的理论与实践领域的背景和文献进行分析,认为卫生政策基本理论与方法论研究、卫生政策分析方法及技术研究、卫生决策科学化研究、卫生决策体制与过程的研究,社会公众参与卫生决策的研究等,是当前我国卫生政策的理论与实践中值得研究的主要问题。     

Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System

Integrating mental health care in the primary care setting has been identified in the literature as a model for increasing access to mental health services and has been associated with enhanced clinical and functional patient outcomes and higher patient satisfaction. The Department of Veterans Affairs (VA), which operates the nation’s largest integrated health care system, has taken a leadership role in creating a health care system in which mental health care is provided in the primary care setting. This article examines VA’s efforts and progress to date in implementing evidence-based models of integrated mental health services nationally in community based outpatient clinics, home based primary care, and outpatient primary clinics at medical facilities. Psychology plays an important role in this progress, as part of an overall interdisciplinary effort, in which all professions are crucially important and work together to promote the overall well-being of patients. This article is based in part on a presentation by the first author at the 3rd National Conference of the Association of Psychologists in Academic Health Centers (APAHC) in May of 2007 in Minneapolis, Minnesota.     

The Development and Validation of the Health Proneness Questionnaire

This series of studies describes the development, validation and potential use of the Health Proneness Questionnaire (HPQ). Recent health, wellness and illness studies focus upon the dynamic interaction between psychological and physical well-being. This newly developed scale allows practitioners to quickly screen psychological characteristics related to health and a patient's perception of their quality of life. Participants were patients in university research clinics for vision problems. Through exploratory factor analysis three factors evolved related to the hypothesized psychological characteristics involved in health related quality of life: adaptability, self-efficacy and subjective well-being. In a confirmatory factor analysis, the best fit model yielded a higher-order health-proneness factor with the original three categories as sub-factors. Further criterion-related validity comparisons and discriminant and convergent validity studies indicated a psychometrically sound short survey for examining psychological characteristics of patients with mild chronic health conditions.