how do integrated behavioral health providers treat anxiety in routine clinical practice? robyn l....

How do integrated behavioral health providers treat anxiety in

routine clinical practice?Robyn L. Shepardson, Ph.D., Clinical Research PsychologistJennifer S. Funderburk, Ph.D., Clinical Research Psychologist

VA Center for Integrated Healthcare

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # H1aFriday, October 16, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Research Funding:This research was supported by the 2014 Research and Evaluation Fellowship from CFHA and a VA VISN 2 Center for Integrated Healthcare pilot grant.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• List the intervention techniques most commonly used by integrated behavioral health providers to treat anxiety symptoms

• Identify the most common comorbid symptoms among primary care patients referred for anxiety symptoms

• Discuss different approaches to handling presentations of comorbid anxiety and depression

Bibliography / Reference

1. Auxier, A., Runyan, C., Mullin, D., Mendenhalll, T., Young, J. & Kessler, R. (2012). Behavioral health referrals and treatment initiation rates in integrated primary care: A Collaborative Care Research Network study. Translational Behavioral Medicine, 2, 337-344.

2. Combs, H., & Markman, J. (2014). Anxiety disorders in primary care. Medical Clinics of North America, 98, 1007-1023. doi:10.1016/j.mcna.2014.06.003

3. Funderburk, J. S., Dobmeyer, A. C., Hunter, C. L., Walsh, C. O., & Maisto, S. A. (2013). Provider practices in the primary care behavioral health (PCBH) model: An initial examination in the Veterans Health Administration and United States Air Force. Families, Systems, & Health, 31, 341-353.

4. Funderburk, J. S., Sugarman, D. E., Maisto, S. A., Ouimette, P., Schohn, M., Lantinga, L., … Strutynski, K. (2010). The description and evaluation of the implementation of an integrated healthcare model. Families, Systems, & Health, 28, 146-160.

5. Funderburk, J. S., Sugarman, D. E., Labbe, A. K., Rodrigues, A., Maisto, S. A., & Nelson, B. (2011). Behavioral health interventions being implemented in a VA primary care system. Journal of Clinical Psychology in Medical Settings, 18, 22-29.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

VETERANS HEALTH ADMINISTRATION

Overview

• Anxiety in primary care

• Approach to treating anxiety within PCBH

• Study methods

• Study results

• Group discussion

6


Anxiety in Primary Care

• Prevalence of 15-20% for any anxiety disorder

• Subthreshold anxiety is also common

• High comorbidity with depression and other symptoms/problems

7(Ansseau et al., 2004; Kaufman & Charney, 2000; Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007; Niesenson, Pepper, Schwenk, & Coyne, 1998; Rodriguez et al. 2004; Rucci et al., 2003)



• Impairment

– Decreased quality of life

– Worse psychosocial functioning

– High burden of disability

– Over and above comorbid MDD

– Even subthreshold symptoms

8(Batelaan et al., 2007; Beard, Weisberg, & Keller, 2010; Kessler et al., 2005; Mendlowicz & Stein, 2000; Olatuni, Cisler, & Tolin, 2007; Sherbourne et al., 2010; Stein et al., 2005)



• Recent growth of integrated care, including the Primary Care Behavioral Health (PCBH) model

• Integrated behavioral health providers (BHPs) in primary care to provide brief treatment

• Anxiety is 2nd most common reason for referral to BHPs

9

(Auxier et al., 2012; Bryan, Morrow, & Appolonio, 2009; Cigrang et al. 2006; Funderburk et al., 2010, 2011)



• Strong need for effective brief interventions for anxiety

• But little available for 1-6 30-minute session format

• BHPs likely adapting interventions designed for specialty mental health

• But how?

10



• How exactly are BHPs treating anxiety in clinical practice?

• Chart review study (N = 180 Veterans)• Most common interventions for patients with anxiety

– 23% patient education– 20% behavioral activation– 20% supportive therapy– 14% cognitive techniques– 12% relaxation training

11

(Bryan et al. 2012; Funderburk et al., 2011)


Primary Aim

• Examine how BHPs treat patients with anxiety in integrated primary care settings

• What types of interventions are used?

12


Secondary Aims

• Assess the type and prevalence of comorbid mental and behavioral health symptoms among patients presenting with anxiety

• Examine how BHPs approach treatment of comorbid anxiety and depression

13


Methods

• National web-based survey of integrated BHPs

• Focused on PCBH model of integrated care

• Recruited from 6 relevant email list servs

• Participants completed eligibility screener, provided informed consent, then completed 15-minute survey

• Compensation: handout on free clinical resources helpful with treating anxiety in IPC

14


Eligibility Criteria

Inclusion criteria: • has worked in IPC setting for at least 6 months

• currently practicing integrated BHP (at least 1 day/week over last month)

• working in PCBH model of integrated care

• has at least Master’s degree or equivalent graduate training (≥2 years) in a relevant field (e.g., psychology, social work, MFT, counseling)

• has Internet access and working email address

Exclusion criteria:• psychiatric prescriber

15


Survey

• Participant demographics

• Patient and session characteristics

• Patient symptoms/problems

• Interventions used in last session

• General approach to handling comorbid anxiety and depression

16


Definition of AnxietyWe are interested in how integrated behavioral health providers (BHPs) assess and treat patients who have a primary presenting complaint of non-PTSD anxiety.

By non-PTSD anxiety we mean symptoms of: • generalized anxiety disorder• panic disorder• agoraphobia• social anxiety disorder• specific phobia• anxiety not otherwise specified / unspecified or other specified anxiety disorder• adjustment disorder with anxiety or with mixed anxiety and depressed mood

Symptoms can be: • subthreshold – not reaching the threshold for a clinical diagnosis based on DSM-

IV/DSM-5 or • threshold – reaching the level of a clinical diagnosis

17


Sample Size

• 329 providers accessed survey– 8% did not meet eligibility criteria– 92% were eligible

• Of those eligible, 96% participated

• N = 291 participants

18


Participant Demographics

• Age M = 40.2 years (SD = 10.9), range: 26-72

• 76% Female

• 9% Hispanic or Latino

• 88% White

19


Participant Characteristics

20

Psychologist Social worker Master's level counselor

RN or other nurse

Other0%

25%

50%

75%

100%

59%

26%

11%1% 2%

Type of Provider

other: 4 MFTs, 3 other



21

Cogni

tive-

beha

viora

l

Eclecti

c or i

nteg

rativ

e

Accep

tanc

e & C

omm

itmen

t The

rapy

Behav

iora

l

Family

syste

ms

Psych

odyn

amic/

psy

choa

nalyt

ic

Human

istic/

exis

tent

ial

Insig

ht-o

rient

ed

Inte

rper

sona

l

Other

0%

25%

50%

75%

100%

52%

21%9% 6% 3% 3% 2% 1% 1% 2%

Theoretical Orientation



22

VA FQHC Outpatient clinic or hospital

CMHC DOD Other0%

25%

50%

75%

100%

41%

21% 25%

3% 1%10%

Primary Work Setting

other: 6% primary care practice, 1% academic medical center, 3% other


Patient Demographics

• Age M = 41 years (SD = 16), range: 7-99

– 6% (n = 16) under age 18

• 44% Female

• 12% Hispanic or Latino

• 74% White, 12% Black

• 46% on medication for anxiety

23


Session Characteristics

• 95% individual

• 97% face-to-face

• M = 38 minutes (SD = 12), median = 35, range: 10-73

24


Anxiety

• Severity of anxiety symptoms– 20% subthreshold/mild– 65% moderate– 16% severe

• DSM-5 anxiety diagnoses– 96% met criteria for dx– 18% had >1 dx– Most common were 32% GAD, 26% Anxiety NOS, 20% Panic

disorder, 16% Adjustment disorder with anxiety

25


Comorbid Symptoms/Problems

26

Sleep

Depress

ion

Stress

/adju

stm

ent

Chronic

pain

Medica

l pro

blem

s

Obesit

y

Tobacco u

se

Alcohol m

isuse

Oth

er

Substance

misu

se

Med a

dherence

None

Suicidality

PTSD

Mania

/hyp

omania

Psych

osis

Dementia

0%

10%

20%

30%

40%

50%

60%

70%

61% 59%56%

23%19%

16%12% 11%

7% 7% 6% 5% 5% 4% 2% 2% 1%

95% at least 1 other symptom besides anxietyM = 2.9 (SD = 1.5), median = 3, range: 0-8


Depression

• Severity of depression symptoms– 14% not applicable– 52% subthreshold/mild– 29% moderate– 5% severe

• DSM-5 depression diagnoses– 53% met criteria for dx– 16% Depression NOS, 16% Adjustment disorder with

depressed mood, 12% MDD

27


Most Common Interventions

28

Technique Prevalence Mean (SD) # of minutes

(among users)

Psycho-education about anxiety 85% 9.2 (7.3)

CBT education 80% 9.2 (6.2)

Relaxation training 66% 7.8 (5.2)

Supportive therapy 66% 10.3 (10.7)

Cognitive therapy 47% 8.4 (6.2)

Behavioral activation 44% 5.0 (3.0)

Stress management 41% 4.9 (3.8)

Self-monitoring 33% 5.5 (3.4)


Less Common Interventions

29

Technique Prevalence Mean (SD) # of minutes

(among users)

Mindfulness/meditation training 32% 6.3 (4.4)

Motivational interviewing 28% 8.4 (10.4)

Medication information 28% 3.5 (2.4)

Problem-solving training 24% 6.2 (4.5)

Crisis/risk assessment 24% 3.8 (2.9)

Exposure 24% 9.1 (7.8)

Sleep interventions 17% 5.1 (2.4)

ACT-based interventions 16% 7.2 (6.2)

Other 17% 6.0 (6.6)


Interventions

• Total number of interventions used – Mean = 6.6 (SD = 2.1), median = 6, range: 1-14

30

1 2 3 4 5 6 7 8 9 10 11 12 13 140

10

20

30

40

50

60

Total Number of Interventions Used

Nu

mb

er

of

Pro

vid

ers


Approach to Handling Comorbid Anxiety & Depression

• General approach– 87% I typically target both at the same time– 13% I typically target one at a time

• How?– 50% I explain the inter-relationship between anxiety and depression– 36% I offer one intervention that can target both conditions– 12% I offer one intervention for anxiety and one intervention for

depression– 1% Other

31


Approach to Handling Comorbid Anxiety & Depression

• General approach– 87% I typically target both at the same time– 13% I typically target one at a time

• Assuming suicidality is not a concern, which first?– 55% Whichever condition the patient prefers to target first– 29% Whichever condition causes more functional impairment based

on my clinical opinion– 6% Depressive symptoms– 6% Anxiety symptoms– 3% Other

32


Discussion: Patient Presentation

• Complex patients– 80% had moderate to severe anxiety– 95% also had (~3) other symptoms/problems– Insomnia, depression, stress/adjustment– Problems related to chronic medical conditions

• Challenges for BHPs? PCPs?

• Implications of comorbidity & complexity for development and implementation of anxiety treatments?

33


Discussion: Interventions• BHPs are using many interventions

– Mean = 6.6 techniques– 50% used 6 or more techniques– Little time (3-10 minutes) spent on any 1 technique

• Most BHPs (87%) try to target anxiety and depression at the same time

• Implications of this brevity for quality / fidelity?• Pros and cons of using so many different techniques?• Implications for research – how to identify key ingredients?

34


Discussion: Interventions• Types of interventions

– Psycho-education about anxiety & CBT, supportive therapy, relaxation training used by 2/3

– Exposure, cognitive therapy, mindfulness/meditation less common

• Training deficits vs. deliberate adjustments?

• How does evidence-based treatment fit in the real-world PCBH context?

• How can PCPs and medical providers use this information?

35


Questions

VA Center for Integrated Healthcare

visit us at

http://www.mirecc.va.gov/cih-visn2/

36



Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!


Relaxation & Mindfulness/Meditation

38

Relaxation exercise Prevalence Mindfulness/ meditation exercise

Prevalence

Deep breathing 79% Mindful breathing 55%

Progressive muscle relaxation

28% Meditation 25%

Guided imagery 27% Other mindfulness technique

39%

Autogenic relaxation 4% Other 14%

Other 9%

how do integrated behavioral health providers treat anxiety in routine clinical practice? robyn l....

Documents

health care

integrated primary care

behavioral health referrals

anxiety symptomsidentify

anxiety disorders

research funding

primary care patients

behavioral learning