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

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

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

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

    

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

• It’s up to all of us to know the signs and take action so that mental illnesses can be caught early and treated.

Resources

• Center for Integrated Healthcare

• VA Primary Care - Mental Health Integration

• NIMH - Integrated Care

• Other Integrated Care Links

• National Center for PTSD

• CDC - Mental Health

• Mental Health 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

Dworkin et al., 2018. Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations

Fuhrer and Keyes, 2019. Population Mental Health in the 21st Century: Time to Act

Gradus, 2019. Epidemiology of PTSD

Milanak et al., 2013. Prevalence and features of generalized anxiety disorder in Department of Veteran Affairs primary care settings

Possemato et al., 2018. Patient outcomes associated with primary care behavioral health services: A systematic review

Spoont et al., 2015. Does This Patient Have Posttraumatic Stress Disorder?

Wahlbeck, 2015. Public mental health: the time is ripe for translation of evidence into practice