Jennifer S. Funderburk, Ph.D., Clinical Research Psychologist

1. Session #_H2b__ Friday, October 11, 2013 Symptom Presentation and Intervention Delivery by Veterans Administration (VA) and US Air Force (USAF) Behavioral Health Providers in a Primary Care Behavioral Health Model of Service Delivery Jennifer S. Funderburk, Ph.D., Clinical Research Psychologist Robyn L. Fielder, Ph.D., Postdoctoral Fellow Christopher Hunter, Ph.D., Anne Dobmeyer, Ph.D. Stephen A. Maisto, Ph.D., Professor and Director of the VA Center for Integrated Healthcare Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

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

3. Objectives • Discuss the most prevalent presenting symptom combinations reported by BHPs in VA and USAF primary care clinics • Describe the types of clinical interventions employed by BHPs to target these symptom combinations • Examine the use of empirically-based interventions within this dataset • Discuss the implications of these results on the clinical practice of BHPs within integrated primary care settings as well as potential avenues for future clinical intervention research

4. Background • VA and USAF have adopted co-located, collaborative care (CCC) within primary care • Based on Primary Care Behavioral Health or Behavioral Health Consultant model (Strosahl, 1998; Robinson & Reiter, 2007) • Integrated behavioral health providers (BHPs) see patients on a short-term basis

5. Background • Many BHPs use elements of empirically-supported, CBT-based interventions (Bryan, Morrow, & Appolonio, 2009; Corso et al., 2012; Funderburk et al., 2011) • Interventions usually developed to target a single disorder (Strosahl, 1998; Robinson & Reiter, 2007) • Yet many patients have multiple presenting symptoms(Funderburk, Dobmeyer, Hunter, Walsh, & Maisto, in press)

6. Goals of the Study • Assess the prevalence of comorbid symptom presentations among patients seen by VA & USAF integrated BHPs • Describe the types of interventions used by BHPs for common symptom presentations • Examine the extent to which BHPs use empirically-support interventions

7. Method • National study of VA & USAF BHPs • Prospective data collection using web-based survey • Descriptive data from 1 day of clinical practice • N = 75 VA BHPs, response rate 35% • N = 23 USAF BHPs, response rate 43% • Research staff oriented interested BHPs via phone • Measures: Background on BHP, Appointment

8. Appointment Questionnaire • Presenting Symptoms at Visit • Depression, Anxiety, Mania, Psychosis, Suicidal Ideation, Behavior change (e.g., alcohol, weight, exercise, smoking, medication compliance), adjustment to a life change, coping with a medical condition, bereavement, pain, sleep problems

9. Appointment Questionnaire • Education about Medicine either Taking or Prescribed • Psycho-education about a diagnosis • Education about the relationship between thghts/feelings/beh • Discuss what the patient is already doing that provides relief of symptoms •  Discuss communication style within a certain relationship (i.e., assertiveness skills) •  Discuss the importance of interpersonal relationships (i.e., increase social support) • Discuss increases in the patient’s pleasurable activities • Discuss behavior change • Discuss relaxation training • Education about pain

10. Appointment Questionnaire • Problem solving skills training (i.e., education about relationship between symptoms and problems, discuss problems and potential resolutions) • Cognitive reframing (i.e., discussing thghts, change distortions) • Discuss cognitive distortions (i.e., all or none thinking, etc.) • Discuss relapse prevention • Discuss referral to specialized care • Develop a pain management plan •  Discuss sleep restriction (i.e., only being in bed for the typical number of hours the patient reports sleeping) •  Education about healthy sleep habits (i.e., sleep hygiene: go to bed when sleepy, get out of bed if not asleep in 15 minutes) •  Provide education about hazardous/high risk drinking

11. Results • 98 BHPs • Working in PC for 4 years on average • Orientation most commonly cognitive-behavioral or behavioral • 403 patients/visits • 74% male • Mean age = 49 (SD = 16, median = 51, range: 2-90) • 42% initial sessions, 58% follow-up sessions • Mean session length = 38 minutes (SD = 16, median = 30, range: 2-120)

12. Results: Symptoms

13. Results • 57% (n = 222) of patients reported multiple symptoms at their visit • 78% male • Mean age = 50 (SD = 15, median = 53, range: 19-84) • Visits • 44% initial visits, 56% follow-up visits • Mean length = 40 minutes (SD = 17, median = 33, range: 3-120)

14. Results • Among the 222 patients reporting >1 symptom • Mean = 3.5 symptoms (SD = 1.5, median = 3, range: 2-11)

15. Results

16. Results Most common interventions used for depression/anxiety * * *

17. Results Less common interventions for depression & anxiety * * *

18. Most Common Clusters of Interventions • Psychoeducation on diagnosis • Psychoeducation on medications • Psychoeducation on CBT concepts • Medication adherence • Review what already provides relief • Increase social support • Psychoeducation on diagnosis • Psychoeducation on medications • Psychoeducation on CBT concepts • Medication adherence • Review what already provides relief • Assertiveness skills 11% 7% 18% • Psychoeducation on diagnosis • Psychoeducation on CBT concepts • Review what already provides relief • Assertiveness skills • Increase social support • Increase pleasurable activities 9% 11%

19. Results • Common combinations of interventions within clusters • Psychoeducation about diagnosis & CBT concepts, review what already provides relief (52% I, 58% F) • Psychoeducation about diagnosis & medications (47% I, 44% F) • Psychoeducation about CBT concepts, review what already provides relief, increase social support (42% I, 42% F) • Psychoeducation about diagnosis & medications, medication adherence (40% I, 35% F) • Psychoeducation about diagnosis, CBT concepts, & medications (37% I, 37% F) I = initial visit, F = follow-up visit

20. Limitations • Limited to those BHPs and Patient experiences within VA and DoD • Based on BHP Report • Mean # of interventions: 9.1 +/- 3.7 • Median: 9

21. Discussion • The majority of patients reported multiple symptoms • Depression and anxiety were most common with depression/behavioral change; anxiety/behavioral change coming in 2nd • Evidence base for brief interventions that can be used to target these symptoms is limited at best • BHPs report using a variety of interventions • Many with empirical support for depression and anxiety, but many without specific support • BHPs are using numerous intervention approaches within brief sessions

22. Learning Assessment Does the symptom clusters that came out match with your experience as a clinician or as an administrator overseeing an integrated practice? What things do you think might affect the types of patients a BHP might see? What types of interventions do you gravitate towards in clinical practice? Why? How do you incorporate evidence into your daily practice?

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