class: center, middle, inverse, title-slide # Behavioral Health Research in Primary Care ### <br /> Jake Hedges, LMHC CPS <br /> Ivan Castro, MSPH <br /> <br /> VISN2 Center for Integrated Healthcare --- ## What is the Center for Integrated Healthcare? -- __Mission__ >To improve the healthcare of Veterans by integrating mental health prevention and treatment services into the primary care setting. __Vision__ >To be a national resource regarding the integration of mental health in primary care. --- ### Two cores of CIH __Education and Implementation Services__ - Train providers of integrated primary care nationally and advise on best practices. - Promote implementation of evidence-based primary care mental health services. -- __Research__ - Focuses on discovering more effective and efficient ways to identify and treat mental health concerns in primary care. - Brief assessment and intervention - High priority areas include: substance use, PTSD, depression, sleep disturbances --- class: title-slide # Primary Care Mental Health Integration (PCMHI) --- ## Why PCMHI? - Population-based care - Brief: 30 minute appts, 1-5 sessions - Improves Identification - Identification of depression, psychiatric co-morbidities, and substance misuse _in primary care_. - Improves Access - Reduces wait time for mental health services - Reduces no-show rates - Engagement in Care - Same-day services in PCMHI increase the odds of attending future mental health appointments and engaging in specialty treatment (OMH, PCT, STS). -- >*VA primary care patients with a positive PTSD screen who receive same-day PC-MHI services are 3 times more likely to initiate PTSD treatment.* > >Bohnert et al. (2016) --- __Examples of PCMHI interventions__ - Brief Cognitive Behavioral Therapy (CBT) for Chronic Pain - Tobacco Use Cessation: A Brief Primary Care Intervention - Prolonged Exposure for Primary Care (PE-PC) - Brief CBT for Insomnia --- class: title-slide # Conducting research within primary care --- ## Why primary care? - Mental health disorders are common among patients in VA primary care - Many don't seek treatment - Referrals to specialty mental health services often lapse - Around 11% meet diagnostic criteria for alcohol use disorder (AUD) - 12% meet criteria for generalized anxiety disorder (GAD) - Up to 20% of patients in VA primary care clinics experience PTSD symptoms - 40% also meet criteria for AUD -- - Mental illness is associated with negative outcomes across all aspects of well-being - Co-morbidity between disorders: PTSD, depression, AUD and anxiety - Associated with physical health: CVD, diabetes, hypertension - Impaired functioning: unemployment, relationship problems, poverty --- ## Clinical Research - Safety assessments - Blessed Orientation-Memory-Concentration Test - P4 Suicide Screener - Breathalyzer - Diagnostic assessments - Clinician Administered PTSD Scale - Self-report assessments - PTSD Checklist for DSM-5 - Alcohol Use Disorders Identification Test - Patient Health Questionnaire - Substance Use Motives Questionnaire --- ## Recruitment - Patients are recruited from VA primary care clinics - Recruitment letters - Phone screens - In-person interviews at baseline - Those eligible for a study are randomized to experimental treatment or treatment-as-usual. - *Inclusion criteria* - Diagnostic level (or subthreshold) PTSD - PCL-5 >= 30 - Hazardous alcohol use - AUDIT 6-25 (women) or 8-25 (men) - *Exclusion criteria* - Gross cognitive impairment - Recent suicidal intent or attempt - Current psychotherapy for PTSD - Medication: - changes in last 2 months for PTSD - or current prescription for substance use (alcohol studies) - Desire to begin specialty care --- ## Some studies we're involved in - **Clinician-supported PTSD Coach** - Study incorporates use of a mobile app and focuses on increasing patient's ability to manage symptoms, and preparing them for further treatment if needed. - **Primary Care Brief Mindfulness Training** - Mindfulness training is not psychotherapy, but these classes are meant to help veterans increase emotional regulation skills. - **Primary Care Treatment Integrating Motivation and Exposure** - Study focuses on decreasing alcohol use _and_ PTSD symptoms by integrating PE-PC and motivational interviewing for alcohol use. - **Peer-Delivered Whole Health Coaching** - Intervention is _not_ focused on PTSD symptoms, and is ideal for Veterans with PTSD who are reluctant to talk about behavioral problems. --- ## Challenges to recruitment and engagement - Reluctance to talk about trauma - Stigma/Motivation to change - Denying PTSD symptoms or under-reporting substance use -- - Perceptions - *Don't waste resources on me* - *This should go to someone who really needs it* - *I don't have a drinking problem* -- - Assessments can be exhausting and frustrating - Studies may require 'homework', or use of tools at home -- - Meeting criteria for PTSD and severity cut-offs - Misconception that index trauma, or PTSD, has to be combat-related - Scheduling conflicts, not enough time to participate in study --- ## How we address challenges - Motivational interviewing - Help clarify understanding of PTSD or AUD - Help reframe their perceived barriers - Explaining that participation may help other veterans - Some are more motivated to help others than themselves - Rewording/rephrasing interventions in order to reduce stigma - Mindfulness **class** or **training**, instead of *group* - Talk about **low mood**, instead of *depression* - **Avoid** framing alcohol use as *drinking to cope* - Clarify as much as possible, keep veteran connected with the bigger picture of the study --- class: title-slide # Mental Illness Awareness Week <br /> <br /> ### October 6-12, 2019 --- # You Are Not Alone - 19.1% of US adults experienced mental illness in 2018 - 1 in 5 adults or 47.6 million people - 4.6% of US adults experienced *serious* mental illness in 2018 - 1 in 25 adults or 11.4 million people - 16.5% of US youth (age 6-17) experienced a mental health disorder in 2016 - 7.7 million children - 3.7% of US adults experienced co-occurring substance use disorder and mental illness in 2018 - 9.2 million people .pull-right[ ] .footnote[ ➥ Source: [National Alliance on Mental Illness](https://www.nami.org/learn-more/mental-health-by-the-numbers) ] --- <img src="pics/signs.PNG" style="display: block; margin: auto;" /> **Change the way we think about mental health** - When we think about cancer, heart disease, or diabetes, we don’t wait years to treat them. - Encourage people to [get screened](https://screening.mhanational.org/screening-tools) - It’s up to all of us to know the signs and take action so that mental illnesses can be caught early and treated. .footnote[ ➥ Source: [Mental Health America](https://mhanational.org/infographic-b4stage4-changing-way-we-think-about-mental-health) ] --- ## Resources - [Center for Integrated Healthcare](https://www.mirecc.va.gov/cih-visn2/) - [VA Primary Care - Mental Health Integration](https://www.patientcare.va.gov/primarycare/PCMHI.asp) - [NIMH - Integrated Care](https://www.nimh.nih.gov/health/topics/integrated-care/index.shtml) - [Other Integrated Care Links](https://www.mirecc.va.gov/cih-visn2/other_integrated_care_links.asp) - [National Center for PTSD](https://www.ptsd.va.gov/index.asp) - [CDC - Mental Health](https://www.cdc.gov/mentalhealth/learn/index.htm) - [Mental Health Screening Tools](https://screening.mhanational.org/screening-tools) --- ### References Bohnert et al., 2016. [Same-Day Integrated Mental Health Care and PTSD Diagnosis and Treatment Among VHA Primary Care Patients With Positive PTSD Screens](https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201500035) Dworkin et al., 2018. [Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561402/) Fuhrer and Keyes, 2019. [Population Mental Health in the 21st Century: Time to Act](https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305200) Gradus, 2019. [Epidemiology of PTSD](https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp) Milanak et al., 2013. [Prevalence and features of generalized anxiety disorder in Department of Veteran Affairs primary care settings](https://www.ncbi.nlm.nih.gov/pubmed/23659756) Possemato et al., 2018. [Patient outcomes associated with primary care behavioral health services: A systematic review](https://www.sciencedirect.com/science/article/abs/pii/S016383431830063X) Spoont et al., 2015. [Does This Patient Have Posttraumatic Stress Disorder?](https://jamanetwork.com/journals/jama/fullarticle/2422547?resultClick=1) Wahlbeck, 2015. [Public mental health: the time is ripe for translation of evidence into practice](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329888/)