Behavioral Health Integration:Screening and Identification Neil Korsen, MD, MSc Quality Counts April 11, 2012
Outline • Identifying patients who may benefit from behavioral health integration: • Screening for common behavioral health problems • Depression • Anxiety disorders • Substance use disorders • Supporting health behavior change for chronic illness care • Evaluation and treatment of common symptoms such as headache, fatigue, other pain syndromes that are often associated with psychosocial factors.
High risk populations • People with chronic illnesses or chronic pain • People with a disability • People with substance abuse problems • Kids with school, sleep or behavior problems • People with persistent somatic complaints and negative workup
Scoring the PHQ-9 • First 9 questions: add columns vertically, then tally across bottom of page • Total score: 0 to 27 • 10th question is “Function Score”: what degree depression symptoms have made it difficult for the patient to function in their everyday life • Degree of functional difficulty can help determine whether to start active treatment in people with mild symptoms.
What is Watchful Waiting? • Est. 1/3 with mild symptoms will recover without treatment. • Watchful waiting: • Seeing pt monthly and monitoring PHQ-9 score, but not starting active treatment. • Encourage self-care activities such as exercise or relaxation. • If symptoms have not resolved after 2-3 mos, consider active treatment.
PHQ-9 as Outcome Measure • Can be used to follow response to treatment • Validated as a measure of change and can be used to create an algorithm to guide treatment decisions
Goals of Treatment • Remission: score of 0-4 after an initial score >10 • Clinical response: score <10 after an initial score >10
Anxiety Disorders • Anxiety disorders often accompany depression. • Common anxiety disorders include: • Generalized anxiety disorder (GAD) • Panic disorder • Post–traumatic stress disorder (PTSD) • Social phobia
Anxiety Disorders • Very common • 30% lifetime prevalence in women • 20% lifetime prevalence in men • Often present with physical symptoms to primary care
NICE Treatment Guidelines • Step 1 ID & assessment; education about GAD and tx options; active monitoring • Step 2 Low-intensity psychological interventions: non- facilitated or guided self-help, psycho-ed groups • Step 3 High-intensity psychological intervention: CBT/ applied relaxation or drug treatment • Step 4 Specialty treatment: drug and/or psychological treatment; input from multi-agency teams, crisis services, day hospitals or inpatient care http://guidance.nice.org.uk/
Substance use disorders An estimated 17.6 million American adults (8.5%) meet diagnostic criteria for an alcohol use disorder. Approximately 4.2 million (2%) meet criteria for a drug use disorder. Overall, 19.4 million of American adults (9.4%) meet clinical criteria for a substance use disorder - either an alcohol or drug use disorder or both. About 20% of persons with a current substance use disorder experience a mood or anxiety disorder at the same time and vice versa.
MaineHealth Adult Wellbeing Screener – Substance Abuse • Question 7 is recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The single-question screen was 81.8% sensitive and 79.3% specific in the detection of unhealthy alcohol use.* • Question 8 was found to be 100% sensitive and 74% specific for identifying people with a drug use disorder in a 2007 study. • A “yes” answer to either question 7 or 8 is a positive screen for substance abuse.** *Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. J Gen Intern Med 2009 **Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Arch Int Med 2010
Further Assessment after Positive Screen • Adults – alcohol • AC-OK • AUDIT • CAGE • Adults – other drugs • DAST • Adolescents • CRAFFT SAMHSA list of substance screening and assessment instruments: http://www.ncsacw.samhsa.gov/files/SAFERR_AppendixD.pdf
Implementing Screening • A script for the person distributing the tools • Who will score forms and when? • How will assessment follow screening? • How will results get documented?
Role of Behavioral Health Clinician with Chronic Medical Conditions • Chronic condition management involves self-management • Self-management involves behavior change • Behavioral health clinicians can play a role in supporting behavior change • Use of health and behavior codes
Impact of Integration on Outcomes of Chronic Medical Conditions • Improved outcomes for both medical and co-morbid mental health conditions • Improved patient experience • Cost impact may be neutral or show slight savings • E. Lin, personal communication, 2012
Integration and Common Physical Symptoms • Estimates range from 25-75% of people with common symptoms such as headache, other pain syndromes, and fatigue have no ‘medical’ cause found after reasonable evaluation (Kroenke, 2003) • Emerging literature that past or present psychosocial stress and/or common behavioral health conditions are commonly associated with these symptoms
Screening and Assessment ToolsScoring and Treatment Guidelines • Tools and guides to treatment posted: www.mainehealth.org/mentalhealthintegration • Located in Links under Clinical Tools
References • Kroenke K, et al. Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection. Ann Intern Med. 2007;146:317-325. • Kroenke K, Patients Presenting with Somatic Complaints. International Journal of Methods in Psychiatric Research. 2003; 12: 34-43. • Kroenke, Spitzer, and Williams. The PHQ-9: Validation of a Brief Depression Severity Measure. Journal of General Internal Medicine. 2001; 16:606-613. • Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary Care Validation of a Single-Question Alcohol Screening Test. J Gen Intern Med 2009; 24:783-788 • Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A Single Question Screening Test for Drug Use in Primary Care. Archives of Internal Medicine 2010; 170:1155-1160