David R.M. Trotter, Ph.D. University of Massachusetts Medical School Kevin M. McKay, Ph.D.

1. Session # October 5, 2012 Behavioral Health Assessment in Integrated Primary Care:Conventions, Alternatives, and Mini International Neuropsychiatric Interview David R.M. Trotter, Ph.D. University of Massachusetts Medical School Kevin M. McKay, Ph.D. Veterans’ Affairs Medical Center, Providence, RI / Brown University, Alpert Medical School Eric S. Zhou, Ph.D. Dana Farber Cancer Center Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Describe current approaches to behavioral health assessment in Integrated Primary Care (IPC) as well as the associated strengths and limitations • Discuss the potential advantages and disadvantages associated with utilizing brief semi-structured clinical interviews in IPC • Identify the basics of administration/interpretation of the Mini International Neuropsychiatric Interview (MINI) and be able to cite the psychometric properties thereof

4. Learning Assessment A learning assessment is required for CE credit. Attention Presenters: Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

5. Overview • Background & Introduction • Behavioral Health Assessment in IPC and Associated Limitations • An Alternative Approach to Behavioral Health Assessment in IPC Settings • The Mini International Neuropsychiatric Interview • Summary

6. Background & Introduction • Culture and operations of primary care • Population-based vs. Patient-based care • Behavioral health providers (BHP) face unique challenges in primary care settings

7. Background & Introduction • Enculturating into primary care settings • BHP Competencies • Clinical practice • Practice management • Consultation • Team performance • Documentation • Administration

8. Behavioral Health Assessment in Primary Care Settings and Associated Limitations • Brief functional assessments • Typically completed in 30 minutes • Includes presenting problem and screening measures as well as recommendations to patient and PCP • Hunter, Goodie, Oordt, & Dobmeyer (2009) prototype • Understanding of referral question • Describing role to patient / clarifying problem • Assessing presenting problem • Guided open-ended questions

9. Behavioral Health Assessment in Primary Care Settings and Associated Limitations • Advantages associated with functional assessment • Efficient collection of data • Can use information to formulate treatment recommendations • Potential disadvantages associated with functional assessment • Assessment is guided by the referral question. • Referrals may not be based on a comprehensive understanding of the patient’s diagnostic profile • Example

10. An Alternative Approach to Behavioral Health Assessment in Integrated Primary Care Settings • Empirical evidence supporting the use of semi-structured clinical interviews • Close alignment with consensus diagnoses (vs. unstructured interviews) • Possibly related to the inclusion of specific questions about specific symptom profiles • Why don’t we use them? • We assume that they are intrusive, disruptive, and generally interfere with therapeutic alliance • Clinicians criticize semi-structured interviews on the grounds that they take too long to administer • TRUE

11. The Mini-International Neuropsychiatric Interview (MINI) • The MINI meets the clinician’s need for a semi-structured interview that can facilitate an accurate diagnostic assessment. • Assesses 17 Axis I diagnoses (prioritizes current vs. historical diagnosis) • Administration: • Clinician asks screening questions to rule-out diagnosis • Indorsed rule-out items trigger administration of a diagnostic module (e.g. MDD, OCD, PTSD) • Clinician rates patient responses, uses an algorithm/clinical judgment, and determines a diagnostic profile

12. The Mini-International Neuropsychiatric Interview (MINI) • Validity • 310 participants stratified by age and gender • High inter-rater (k = 0.88 to 1.0) and test-retest reliability (k = 0.76 to 0.93) • Acceptable concordance with the SCID (k > .70) • High concordance with the CIDI • Limitations: limited positive predictive value for GAD; limited ability to differentiation between specific psychotic diagnoses; produces more false positives than the SCID • Clinical utility, feasibility, acceptability • 111 patients admitted to a partial hospitalization program • Most participants said that they were not bothered by the format (89%), that it was not lengthy (84%) and than it covered all of their symptoms (94%)

13. The Mini-International Neuropsychiatric Interview (MINI) • Strengths • May improve clinicians’ accuracy • Practical: Mean administration time ranging from 16.4 to 21 minutes • Limitations • Trade off between speed and comprehensiveness (e.g. excludes some Axis I disorders) • Does not assess for lifetime diagnoses (except depression and mania) • Limited utility in diagnosing Axis II disorders • Prioritizes diagnostic features over contextual features • Uses a “yes-no” response format (limited opportunity for in-depth exploration) • Acceptability in primary care settings has not been examined • Time is required to score and interpret results

14. Summary • Primary care differs from specialty mental health • BHPs must adapt clinical skills to effectively conduct brief assessments • BHP models typically prioritize behavioral/functional assessment over diagnostic assessment; however, this approach has limitations • Brief semi-structured interviews may enhance diagnostic accuracy • The MINI is one example of a brief semi-structured interview that may improve assessment practices for individuals presenting in primary care

15. Questions? • For questions or additional information regarding this presentation, please contact Kevin McKay, Ph.D. at: kevin.mckay@va.gov kevin_mckay@brown.edu 401-273-7100 x 2199

16. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!

17. Background & Introduction Purpose: To enhance the practice of integrated primary care by introducing an alternative approach to behavioral health assessment in these settings. In order to realize this goal we will first provide an overview of the current approach to assessment in integrated primary care and continue by examining the strengths and potential limitations to this approach. We then described an alternative approach to assessment, introduce an existing assessment tool, examine the strengths and potential limitations thereof, and advocate for its use in integrated primary care settings.