The case for behavioral health integration into primary care

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Behavioral Health

The case for behavioral health integration into primary care

J Fam Pract. 2019 June;68(5):278-284

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References

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13. Integrating physical and behavioral health care: promising Medicaid models. The Henry J. Kaiser Family Foundation. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf. Published February 2014. Accessed May 29, 2019.

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The care manager’s functions include systematic follow-up with structured monitoring of symptoms and treatment adherence, coordination and communication among care providers, patient education, and self-management support, including the use of motivational interviewing. The behavioral health care manager performs this systematic follow up by maintaining a patient “registry”—case-management software used in conjunction with, or embedded in, the practice electronic health record to track patients’ data and clinical outcomes, as well as to facilitate decision-making.

The care manager communicates with the psychiatrist, who offers suggestions for drug therapy, which is prescribed by the primary care physician. The care manager also regularly evaluates the patient’s status using a standardized scale, communicates these scores to the psychiatrist, and transmits any recommendations to the primary care physician (FIGURE 2).¹⁷

EVIDENCE FOR CCM

Collaborative and routine care were compared in a 2012 Cochrane review that included 79 randomized controlled trials (RCTs) involving 24,308 patients worldwide.¹⁶ Seventy-two of the 79 RCTs focused on patients with depression or depression with anxiety, while 6 studies included participants with only anxiety disorders.¹⁶ One additional study focused on mental health quality of life. (To learn about CCM and severe mental illness and substance use disorder, see “Less well studied: CCM and severe mental illness, alcohol dependence.”^18-20)

SIDEBAR
Less well studied: CCM and severe mental illness, alcohol dependence

Evidence for collaborative care in severe mental illness (SMI) is very limited. SMI is defined as schizophrenia or other schizophrenia-like psychoses (eg, schizophreniform and schizoaffective disorders), bipolar affective disorder, or other psychosis.

A 2013 Cochrane review identified only 1 RCT involving 306 veterans with bipolar disease.¹⁸ The review concluded that there was low-quality evidence that collaborative care led to a relative risk reduction of 25% for psychiatric admissions at Year 2 compared with standard care (RR = 0.75; 95% CI, 0.57-0.99).¹⁸

One 2017 RCT involving 245 veterans that looked at a collaborative care model for patients with severe mental illness found a modest benefit for physical health-related quality of life, but did not find any benefit in mental health outcomes.¹⁹

Alcohol dependence. There is very limited, but high-quality, evidence for the utility of CCM in alcohol dependence. In one RCT, 163 veterans were assigned to either CCM or referral to standard treatment in a specialty outpatient addiction treatment program. The CCM group had a significantly higher proportion of participants engaged in treatment over the study’s 26 weeks (odds ratio [OR] = 5.36; 95% CI, 2.99-9.59). The percentage of heavy drinking days was significantly lower in the CCM group (OR = 2.16; 95% CI, 1.27-3.66), while overall abstinence did not differ between groups.²⁰

For adults with depression treated with the CCM, signiﬁcantly greater improvement in depression outcome measures was seen in the short-term (standardized mean difference [SMD] = -0.34; 95% confidence interval [CI], -0.41 to -0.27; risk ratio [RR] = 1.32; 95% CI, 1.22-1.43), in the medium term (SMD = -0.28; 95% CI, -0.41 to -0.15; RR = 1.31; 95% CI, 1.17–1.48), and in the long term (SMD = -0.35; 95% CI, -0.46 to -0.24; RR = 1.29; 95% CI, 1.18–1.41).¹⁶

Comparisons of mental health quality of life over the short term (0-6 months), medium term (7-12 months), and long term (13-24 months) did not show any significant difference between CCM and routine care.¹⁶ Comparisons of physical health quality of life over the short term and medium term did not show any significant difference between CCM and routine care.¹⁶

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