Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.     

Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations

Pragmatic trials testing the effectiveness of interventions under “real world” conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.

     

Beyond stigma: Understanding the “inclined abstainers” in military behavioral health-care utilization

ABSTRACT

Low treatment utilization in Soldiers with combat-related Posttraumatic Stress Disorder (PTSD) is an ongoing issue. The critical concern is to better understand factors which prohibit a Soldier with PTSD who wants help from seeking treatment (an “inclined abstainer”). A total of 537 Active Duty Soldiers on a US Army post completed a brief survey comprising psychometrically validated measures of stigma, behavioral health treatment beliefs, resilience, PTSD symptoms, and treatment intentions. Health-care records were prospectively tracked for 12 months to determine the relation between survey answers and treatment utilization. Sixty-three percent of those who acknowledged having a mental health-related problem did not seek help within a one-year period. Greater severity of PTSD symptoms was associated with an increased likelihood of behavioral health engagement. Soldiers that were classified as “inclined abstainers” were also more likely to endorse negative beliefs about psychotherapy and report higher levels of resilience as compared to “inclined actors.” These results suggest that a treatment model of PTSD emphasizing self-efficacy and self-reliance, while addressing negative beliefs about psychotherapy, may help promote engagement of behavioral health services among Active Duty Soldiers.     

Small Unit Leader Perceptions of Managing Soldier Behavioral Health and Associated Factors

This investigation explored squad leaders’ perceptions of their roles managing subordinate soldiers’ behavioral health (BH) needs. The data were obtained through an anonymous survey of 458 squad leaders (i.e., small unit leaders who oversee 4–10 soldiers). More than 80% of squad leaders perceived management of soldier BH needs before, during, and after treatment as their responsibility, and felt comfortable and capable of executing these roles. Latent class analysis was used to determine groups of “most active,” “moderately active,” and “least active” leaders. Multinomial logistic regression was used to compare the least and most active classes. The most active leaders were more likely to report high BH knowledge, dedication to a common purpose, and low levels of “associative” stigma. These results should inform leader management of soldier BH. Future research should examine active leader characteristics and whether evidence-based training can increase support for preventing and managing BH issues.     

Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series

Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.     

Aids-risk behavior among homosexual males: The role of attitudes and substance abuse

Abstract

This paper reports the results of a broad survey of homosexual males regarding AIDS-risk behavior. A very high proportion reported both anxiety over possible HIV infection, and a high probability of exposure to HIV. Although over 80% of respondents reported changes in sexual behavior, the frequency of monogamous, stable relationships is unchanged from that found 16 years ago, and 19% reported continued frequent sexual partners. Consistent with “health belief” models, fear of future exposure and perceived control over behavior were strongly related to behavioral change. However, those who felt they had already been exposed were not substantially more likely to decrease current AIDS-risk behavior, which may have important public health ramifications. Alcohol and drug abuse were related to “high risk” behavior, particularly among respondents who are generally motivated to use substances to decrease “tension” or self-monitoring. Thus, using substances to decrease stress may not only relate to substance abuse itself, but to the role of substances in increasing AIDS-risk behavior.     

Beyond community analysis: A response to Dr Borg

Abstract

Medicine, psychology, and psychiatry are not only modes of scientific knowledge or professional practice, but also means of social control that participate in regulating behavior. The “re-pathologizing” of psychiatry during the past 25 years bears witness to an anthropological mutation that reduces the human being to the sum of his or her conduct. In order to get to this “medico-economic” civilization of the subject, postmodern psychiatry has needed to deconstruct and reconstruct its normative landscape for the benefit of “fickle” notions and “behavioral disorders,” at the expense of the concept of “psychological suffering.”     

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth’s mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: (1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth’s mental health problems are misdiagnosed? (2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included “race”, “ethnicity”, “minority”, “culture”, “children”, “youth”, “adolescents”, “mental health”, “psychopathology”, “diagnosis”, “misdiagnosis”, “miscategorization”, “underdiagnosis”, and “overdiagnosis”. Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth’s emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.     

The Impact of Integrated Behavioral Healthcare on Glycemic Control

Integrated behavioral healthcare (IBH) is the “standard of care” to address psychosocial factors impacting diabetes outcomes; it is not standard in practice. This longitudinal, retrospective, chart-review examines IBH impact on glycemic control in an adult diabetes clinic. Adults (n?=?374) with?≥?1 behavioral health encounter,?≥?2 hemoglobin A1c (HbA1c) values, and HbA1c value?>?8% at initial IBH visit were included. Mixed effects linear piecewise models examined differences in slope trajectories for 365 days pre- and post-IBH intervention. Pre-intervention slope was not significant (z?=?? 1.09, p?=?0.28). The post-intervention slope was significant (z?=?? 6.44, p?<?0.001), indicating a significant linear decrease in HbA1c values. Results demonstrated that prior to engaging with behavioral health, there was no change in HbA1c. After initial IBH visit, there was a predicted reduction of?>?1% in HbA1c over the following year. These results suggest that IBH significantly improves patients’ metabolic status. Next steps for IBH research are offered.

     

Latino Foster Parent Health Perceptions of Chronic Conditions: A Qualitative Exploration

Prior work using nationally representative data of children in the child welfare system suggested that Latino foster parents were less likely to identify children in their care as having chronic conditions. Hispanics comprise over one-fifth of children in foster care, the majority of whom have special health care needs, and there is a growing need to recruit qualified Latino families into the child welfare system. Little is known about Latino parents’ health perceptions regarding chronic conditions, and potential reasons for differing identification rates of children with special health care needs. We conducted 17 home-based, in-depth interviews with Latino foster parents to explore health perceptions and cultural beliefs for children in their care around the concept of chronic illness. We found that Latino foster parents’ understanding of conditions that occurred “over and over again” related to emotional and behavioral health problems. In contrast, their perception of “chronic” was associated with terminal, biological conditions that had limited treatment options, such as cancer, HIV, and hepatitis. Latino foster parents did not interpret the survey question on chronic illness as it was intended, and their view of recurrent conditions did not reflect chronic health conditions. Developing survey questions that are culturally sensitive should improve accuracy in assessing chronic health conditions for this high-risk population. Sensitivity to cultural interpretation for this high-needs population is vital to enhancing communication between families and health providers caring for children in foster care.     

Primary Care Behavioral Health Provider Training: Systematic Development and Implementation in a Large Medical System

The expansion of integrated, collaborative, behavioral health services in primary care requires a trained behavioral health workforce with specific competencies to deliver effective, evidence-informed, team-based care. Most behavioral health providers do not have training or experience working as primary care behavioral health consultants (BHCs), and require structured training to function effectively in this role. This article discusses one such training program developed to meet the needs of a large healthcare system initiating widespread implementation of the primary care behavioral health model of service delivery. It details the Department of Defense’s experience in developing its extensive BHC training program, including challenges of addressing personnel selection and hiring issues, selecting a model for training, developing and implementing a phased training curriculum, and improving the training over time to address identified gaps. Future directions for training improvements and lessons learned in a large healthcare system are discussed.     

Adaptations of an Integrated Behavioral Health Program During COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has consistently been described as an “unprecedented” global health crisis. While the focus has been primarily on the medical and economic impact of the pandemic, psychological sequelae are anticipated. Primary care is the main point of access for mental health care in the United States, making it the ideal locale to provide psychological services for a larger proportion of the population than traditional mental health care settings. The aim of this paper is to describe how our multi-state, multi-site integrated primary care program adapted and applied cognitive behavioral therapy in the context of COVID-19. Access to mental health care was disrupted despite burgeoning mental health concerns, necessitating novel approaches to providing care. A stepped-care approach was implemented within our primary care practice, which consisted of a combination of low-intensity, high-yield stress management and resiliency building resources and cognitive behavioral therapy that were delivered flexibly based on patient preference, technological capabilities, state ordinances, insurance coverage, and institutional policies. The lessons learned from this experience can inform other integrated primary care clinics in responding to the current and future pandemics.     

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

Introduction

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

Methods

We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.

Results

1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values?>?0.05). Agreement with cost-containment was associated with higher mean “harm” (3.6) and “fairness” (3.5) intuitions compared to “in-group” (2.8), “authority” (3.0), and “purity” (2.4) (p?<?0.05). In multivariate models adjusted for age, sex, region, and specialty, both “harm” and “fairness” were significantly associated with judgments about cost-containment (OR?=?1.2 [1.0-1.5]; OR?=?1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR?=?1.2 [1.0-1.4]; OR?=?0.9 [0.7-1.0]).

Conclusions

Moral intuitions shed light on variation in physician judgments about cost issues in health care.

     

Measurements, Morality, and the Politics of “Normal” Infant Growth

Although the birth and early life of an infant is similar throughout the world, meanings ascribed to infants differ according to cultural values and beliefs. This essay describes how scholars and healers have come to see the infant as distinct from other types of people, and what implications this distinction carries for how health care is practiced. The first portion of this essay explores how understanding of the infant, particularly the well-accepted notion of “normal” infant growth and development, came to prominence. Drawing from the history of medicine, philosophical thought and colonial practice, this essay demonstrates that the roots of thinking about the infant in terms of his growth are deep and well-defined in North American and European ideologies. The second portion of this essay describes the practical applications and political implications of beliefs about the “normal” infant. In the arena of applied health, policy makers measure infant growth in light of assumptions about the “normal.” A case study of indigenous populations in Irian Jaya, Indonesia, shows that these measurements are highly political. Here government health officials create and manipulate statistics to ensure that indigenous infant health is represented as being below “normal.” The “normal” infant can thus be understood as a subtle and effective construct which, in Irian Jaya, at the least, is used to assimilate indigenous people into the nation-state.     

Psychological Support for Children with Diabetes: Are the Guidelines Being Met?

The significant role of psychosocial factors in the management of type 1 diabetes in youth has been well documented. The International Society for Pediatric and Adolescent Diabetes (ISPAD) therefore published the Clinical Practice Consensus Guidelines for psychological care of young patients. However, it is unclear if and how these guidelines are being implemented. A questionnaire was created to assess implementation of the guidelines and directed to physicians through the ISPAD listserve via a web-based survey. One hundred fifty-five participants from 47 countries completed the survey. Ninety-six percent of respondents reported that they work in a team with other professionals, and 95 % of teams discuss psychological difficulties associated with diabetes management. Seventy-two percent of respondents reported having “easy access” to a mental health specialist (MHS). In 56 % of practice settings, the MHS is considered to be part of the team; 43 % participate in routine clinic visits and 26 % see all patients. Seventy percent screen for psychological problems and 57 % assess family functioning. Psychosocial or behavioral interventions addressing psychosocial and regimen adherence difficulties are offered by 79 % of teams. Psychological care is available for many children with diabetes worldwide. Yet, nearly 30 % of teams do not have access to a MHS. More training in the recognition of psychosocial problems and counseling skills is warranted. More advocacy is needed to increase availability and utilization of psychological services in routine diabetes care.     

From Theory to Practice: One Agency’s Experience with Implementing an Evidence-Based Model

As evidence-based practice is becoming integrated into children’s mental health services as a means of improving outcomes for children and youth with severe behavioral and emotional problems, therapeutic foster care (TFC; a specialized treatment approach for such youth) is one of few community-based programs considered to be evidence-based. “Together Facing the Challenge” (TFTC) which was tested in a randomized trial of TFC has been identified as an evidence-based model. We describe the experiences reported by one of the agencies that participated in our study and how they have incorporated TFTC into their on-going practice. We highlight key implementation strategies, challenges faced, and lessons learned as the agency moved forward towards full implementation of TFTC.     

Comment

ABSTRACT

Comments on the role of greed at all levels of the managed care system, from individual patients to corporations. It is suggested that couples therapists not seek inclusion as “health care providers.”     

Toward a Pellegrino-inspired theory of value in health care

Contemporary medical practice and health policy are increasingly animated by the concept of providing high value care. Nevertheless, there can be disagreements about how value is defined and from whose perspective. Individual patients suffering from terminal cancer, for example, may have a different perception of the value of an expensive chemotherapy when compared to health policymakers, insurers, or others responsible for the financial solvency of health care organizations. Thus it seems reasonable to ask what is meant by “value” in high value care. In light of Edmund Pellegrino’s significant contributions to the philosophy of medicine, medical humanities, and bioethics, it seems equally reasonable to examine how he might answer it. This paper describes a Pellegrino-inspired theory of (health care) value that is instrumental, agent relative, and pluralistic. It then compares and contrasts this to the contemporary view and argues that only when individual patients incorporate concern for societal-level value into their conceptions of the highest good can the Pellegrino-inspired and contemporary views of value be reconciled.