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

1. Rost K, Nutting P, Smith J, et al. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150-154.

2. Rush A, Trivedi M, Carmody T, et al. One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies. Biol Psychiatry. 2004;56:46-53.

3. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting. JAMA. 2002;288:2836-2845.

4. Department of Veterans Affairs. Bradford DW, Slubicki MN, McDuffie J, et al. Effects of care models to improve general medical outcomes for individuals with serious mental illness. 2011. https://www.hsrd.research.va.gov/publications/esp/smi-REPORT.pdf. Accessed August 22, 2018.

5. Druss BG, von Esenwein S. Improving general medical care for persons with mental and addictive disorders: systematic review. Gen Hosp Psychiatry. 2006;28:145-153.

6. Druss BG, Walker ER. Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation; February 2011.

7. Reed SJ, Shore KK, Tice JA. Effectiveness and value of integrating behavioral health into primary care. JAMA Intern Med. 2016;176:691-692.

8. Young AS, Klap R, Sherbourne CD, et al. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61.

9. Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK38632/. Accessed March 2, 2019.

10. Unützer J, Schoenbaum M, Druss B, et al. Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatr Serv. 2006;57:37-47. doi: 10.1176/appi.ps.57.1.37.

11. Peek CJ; the National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus. AHRQ. https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Published April 2013. Accessed May 29, 2019.

12. Heath B, Wise Romero P, Reynolds K. A standard framework for levels of integrated healthcare and update throughout the document. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf. Published March 2013. Accessed May 29, 2019.

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.

14. Vanderlip ER, Rundell J, Avery M, et al. Dissemination of integrated care within adult primary care settings: the collaborative care model. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf. Published 2016. Accessed May 29, 2019.

15. Gerrity M. Evolving models of behavioral health integration: evidence update 2010-2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf. Published May 2016. Accessed May 29, 2019.

16. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10.1002/14651858.cd006525.pub2.

17. Team Structure. University of Washington AIMs Center. https://aims.uw.edu/collaborative-care/team-structure. Published 2017.Accessed May 29, 2019.

18. Reilly S, Planner C, Gask L, et al. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev. 2013;(11):CD009531.

19. Kilbourne AM, Barbaresso MM, Lai Z, et al. Improving physical health in patients with chronic mental disorders. J Clin Psychiatry. 2017;78:129-137.

20. Oslin DW, Lynch KG, Maisto HSA, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Intern Med. 2013;29:162-168.

21. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.

22. Rossom RC, Solberg LI, Magnan S, et al. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2017;15:77-85.

23. Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2009-2110.

24. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.

25. Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions. Med Care. 2013;51:922-930.

26. Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry. 2012;11:790-804.

27. U.S. Department of Veterans Affairs. Rubenstein LV, Williams JW Jr, Danz M, et al. Determining key features of effective depression interventions. 2009. http://www.hsrd.research.va.gov/publications/esp/depinter.cfm. Accessed August 22, 2018.

28. Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One. 2014;9:e108114.

29. Institute for Clinical and Economic Review. Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf. Accessed August 27, 2018.

30. Rubenstein LV, Chaney EF, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91-113.

31. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.

32. Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev. 2009;(1):CD000532.

33. Druss BG, Rohrbaugh RM, Levinson CM, et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen Psychiatry. 2001;58:861-868.

34. Davis M, Balasubramanian BA, Waller E, et al. Integrating behavioral and physical health care in the real world: early lessons from advancing care together. J Am Board Fam Med. 2013;26:588-602.

35. Gold SB, Green LA, Peek CJ. From our practices to yours: key messages for the journey to integrated behavioral health. J Am Board Fam Med. 2017;30:25-34.

36. Institute for Clinical and Economic Review. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/02/CTAF_BHI_Action_Guide_060215.pdf. Accessed April 25, 2019.

Signiﬁcantly greater improvement in anxiety outcomes was seen for adults treated with CCM in the short term (SMD = -0.30; 95% CI, -0.44 to -0.17; RR = 1.50; 95% CI, 1.21–1.87), in the medium term (SMD = -0.33; 95% CI, -0.47 to -0.19; RR = 1.41; 95% CI, 1.18-1.69), and in the long term (SMD = -0.20; 95% CI, -0.34 to -0.06; RR = 1.26; 95% CI, 1.11–1.42).¹⁶

A 2016 systematic review of 94 RCTs involving more than 25,000 patients also provided high-quality evidence that collaborative care yields small-to-moderate improvements in symptoms from mood disorders and mental health-related quality of life.¹⁵ A 2006 meta-analysis of 37 RCTs comprising 12,355 patients showed that collaborative care involving a case manager is more effective than standard care in improving depression outcomes at 6 months (SMD = 0.25; 95% CI, 0.18-0.32) and up to 5 years (SMD = 0.15; 95% CI, 0.001-0.31).²¹

Better care of mental health disorders also improves medical outcomes

Several trials have focused on jointly managing depression and a chronic physical condition such as chronic pain, diabetes, and coronary heart disease,²² demonstrating improved outcomes for both depression and the comanaged conditions.

Chronic pain. When compared with usual care, collaborative care resulted in moderate reductions in both pain severity and associated disability (41.5% vs 17.3%; RR = 2.4; 95% CI, 1.6-3.2).²³
Diabetes. Patients managed collaboratively were more likely to have a decrease of ≥ 1% in the glycated hemoglobin level from baseline (36% vs 19%; P = .006).²⁴
Cardiovascular disease. Significant real-world risk reduction was achieved by improving blood pressure control (58% achieved blood pressure control compared with a projected target of 20%).²²

IS THERE A COMMON THREAD AMONG SUCCESSFUL CCMs?

Attempts to identify commonalities between the many iterations of successful CCMs have produced varying results due to differing selections of relevant RCTs.^25-29 However, a few common features have been identified:

care managers assess symptoms at baseline and at follow-up using a standardized measure such as the Patient Health Questionnaire (PHQ-9);
care managers monitor treatment adherence;
follow-up is active for at least 16 weeks;
primary care and mental health providers actively engage in patient management; and
mental health specialists regularly supervise care managers.

The one feature that is consistent with improved outcomes is the presence of the care manager.^25-29

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