ONE CENTER’S JOURNEY INTO PRIMARY CARE MENTAL HEALTH

KIRSTEN GING, PSY.DJACARANDA PALMATEER, PSY.D

CHRIS WERA, CPASCOTT CYPERS, PH.D

Behavioral Health Behavioral Health ConsultationConsultation

INTRODUCTIONINTRODUCTION

DU – ~ 11,500 Students (Spring 2011) ~5,250 Undergraduate ~4,600 Traditional Graduates ~1,650 Non-Traditional Students ~1000 International Students

Health and Counseling Center (2010-11 Academic) ~12,659 Primary Care Medical Visits ~2,800 Nurse Visits ~6,000 Mental Health Visits

ORGANIZATION ORGANIZATION

WHYWHY

Suicide Prevention:Suicide Prevention: In 2007, there were 34,598 documented suicides in the United

States, the 11th highest cause of death (CDC Annual Report) Over 4000 in the 15-24 age range die by suicide each year Suicide is the second leading cause of death in college

students Only 20% of suicide victims had contact with a mental health

provider in the month prior to their suicide compared to 45% had contact with a medical provider (Luoma et al, 2002)

Only 15% of college aged people have seen a mental health provider in the last month, and only 24% in the past year; 77% of people who commit suicide have seen a medical provider in the last year (Luoma et al, 2002)

WHYWHY

Access and early intervention issues:Access and early intervention issues: Access issues are said to be the most significant reason why

someone seeks a medical versus mental health appointment for psychological issues (Pomerantz, et al, 2004)

The window of opportunity of effective treatment may be missed if treatment is delayed

Only 1/3 of people with diagnosable mental health disorders EVER meet with a mental health professional (Gunn & Blount, 2009)

Approximately 32% of undiagnosed adults with mental health issues report that they would first seek assistance from a primary care medical professional; only 4% stated that they would seek treatment with a psychologist (National Mental Health Association, 2000)

Decreased wait time for specialty care: in one VA study, wait time for a mental health appointment decreased from 3-6 weeks to 19 minutes (Pomerantz, et al, 2004)

WHYWHY

Integration:Integration: The HCC has shared office space for around 8 years

and has been functionally integrated for approximately 6 years

Increased collaboration between mental health and medical staff

Improved crisis support for medical appointments Improved understanding of treatment options and

approaches Multidisciplinary meetings and increased

collaborative care with complicated cases

WHAT IS A BEHAVIORAL HEALTH WHAT IS A BEHAVIORAL HEALTH CONSULTANTCONSULTANT

Mental health provider

Housed with the PC providers

Performs short-term, solution-focused interventions

Current, primary stress and trigger? Patient’s reaction? Patient’s resources (individual, familial, social)? Coping strategies ? Intervention Referral (longer-term counseling or hospitalization)?

IMPLEMENTATIONIMPLEMENTATION

• Brainstorming• Selection of screening tool(s)• “How do we ____?”

• Training• Roll out• Graduate Students

Trainees• Re-evaluation of

process• Added substance

use/abuse screening

• Trying to make it permanent

• Future areas of development

FIRST STAGEFIRST STAGE

Brainstorming Identify the vision/goals Development Roadblocks and hiccups

Selection of screening tool(s) PHQ-9 Supplemental suicide screen

How/when would it be administered Interrupt patient visit/cumbersome Would students be offended/honest

“How do we . . .?” Administer the screen(s) Address self-harm/suicidal ideation Offer versus require consultations for high risk patients Handle coverage issues

• 10-question survey• Computer administration/scoring• Scoring guidelines for severity of depression and

functional impairment• Identifies self-harm/suicidal ideation risk

• (KROENKE AND SPITZER, 2001)

Patient Health Questionnaire – Patient Health Questionnaire – 9 9

(PHQ-9)(PHQ-9)

SECOND STAGE: TRAININGSECOND STAGE: TRAINING

Met as a full staff (medical, counseling, administration) Discussed how to use the PHQ-9 and scoring Established “cut-off” scores (ranges) for referral Discussed process for patients with self-harm/suicidal

ideation risk Suggested ways to refer and the “warm handoff” Walked through the process from beginning to end

A Sample “Script” For How To ReferA Sample “Script” For How To Refer

“I noticed your answers on the survey, and it seems like you are having a hard time. I have a colleague that can come, spend some time with you and help you figure some things out. Would you be willing to meet with her right now?”

SECOND STAGE: ROLL OUTSECOND STAGE: ROLL OUT

Started with only two providers Started with only two providers Trouble-shootingTrouble-shooting

What happens if scores get “missed” Moved my notes to mental health in EHR Decided not to use supplemental survey for SI Random answering International students/translation difficulties

Gradually added in the rest of the providersGradually added in the rest of the providersInterviewed and selected two Graduate Interviewed and selected two Graduate

Student Trainees (GSTs)Student Trainees (GSTs)

THIRD STAGETHIRD STAGE

Re-evaluationRe-evaluation Statistical analysis Weren’t seeing the high scores we anticipated Use a different screening instrument?

Added substance use/abuse screeningAdded substance use/abuse screening Added four questions that were incorporated into the

survey Problems encountered:

Scoring Pushback

FOURTH STAGEFOURTH STAGE

Trying to make it permanentTrying to make it permanent

Ideas for future developmentIdeas for future development How can we make it more robust Biofeedback Translate into different languages Continue screening for substance use/abuse

INTERVENTIONSINTERVENTIONS

Motivational interviewingBehavioral activationCognitive-Behavioral Therapy“Third-wave”

How can we “suffer better?”

Coping strategiesPsycho-education

CULTURAL CONSIDERATIONSCULTURAL CONSIDERATIONS

International students: ~1000 Translation of PHQ-9

Common for international students to misinterpret questions

Guess at what the question asked High scores

However, the BHC reached international students who might not otherwise come in

CASE PRESENTATIONCASE PRESENTATION

• “Jane” is a 27-year-old female graduate student

• Presented for a women’s annual exam• PHQ-9 score: 13

• “Jane” is a 27-year-old female graduate student

• Presented for a women’s annual exam• PHQ-9 score: 13

“More than half the days”1.Little interest/pleasure2.Feeling down, depressed, or hopeless3.Having little energy4.Feeling bad about yourself5.Troubles concentrating

“More than half the days”1.Little interest/pleasure2.Feeling down, depressed, or hopeless3.Having little energy4.Feeling bad about yourself5.Troubles concentrating

“Several days”1.Troubles falling asleep2.Poor appetite3.Feeling fidgety and restless

“Several days”1.Troubles falling asleep2.Poor appetite3.Feeling fidgety and restless

CASE PRESENTATIONCASE PRESENTATION

Referral information:Referral information:Had been “stressed out” since beginning graduate schoolExperienced low libido

Additional information:Additional information:Spent almost all of her time focusing on schoolFelt like she was neglecting her relationshipsAbout to graduate and worried about post-graduation plansDescribed herself as “high strung, perfectionistic, and always anxious”

Case Presentation

First Meeting:Collaboratively established what to target Self-care and behavioral activation (BA)

Boyfriend: talk without distractions go for a walk holding hands sensate focus

Rewarding experiences: Museums cooking/baking bike riding

Diet and exercise: eat healthier yoga

Made specific goals (how often, how long)

CASE PRESENTATIONCASE PRESENTATION

First Meeting:Collaboratively established what to target BA and self-care

Boyfriend Rewarding

experiences Diet and

exercise

Made specific goals (how often, how long)

First Meeting:Collaboratively established what to target BA and self-care

Boyfriend Rewarding

experiences Diet and

exercise

Made specific goals (how often, how long)

Second Meeting:Reviewed what helpedDiscussed tendency to ruminate

Cognitive distortions Rules vs consequences Mindfulness/grounding/breathing

Second Meeting:Reviewed what helpedDiscussed tendency to ruminate

Cognitive distortions Rules vs consequences Mindfulness/grounding/breathing

Third Meeting:Reviewed what helpedDiscussed new stressors

Fears of post-graduation plans On-going family issues

Explored benefits of therapy for deeper issues

Third Meeting:Reviewed what helpedDiscussed new stressors

Fears of post-graduation plans On-going family issues

Explored benefits of therapy for deeper issues

Handouts:Handouts:* Anxiety

* Panic Attacks

* Depression

* Sleep hygiene

* Nutrition

* Fatigue

* Cognitive distortions

* Counseling FAQs

* Diaphragmatic breathing

* Reduced risk drinking

MEDICAL PROVIDER : HER MEDICAL PROVIDER : HER PERSPECTIVEPERSPECTIVE

Advantages:Advantages: Same day, same time Avoids future

scheduling issues Helps to identify

somatizing Reduces, “Oh, by the

way …” Reduces chances of

missing mental health issues

Handles patients in acute crisis

Drawbacks:Drawbacks: Irritation with repeated

surveying Scores can be more

indicative of medical illness vs mental health

Difficult for international students which leads to inaccurate information

Haven’t used survey as a measure of treatment, just screening

Fall Quarter:Fall Quarter: Winter Quarter:Winter Quarter:

OVERALL SCORE ANALYSISOVERALL SCORE ANALYSIS

Mean SD Normal1 0.36 0.673 N2 0.32 0.604 N3 0.73 0.897 Y4 0.84 0.851 Y5 0.43 0.734 M6 0.23 0.594 N7 0.35 0.707 N8 0.12 0.439 N9 0.03 0.198 N10 0.39 0.644 N

Total Score 3.79 4.668 N

Mean SD Normal1 0.33 0.651 N2 0.28 0.59 N3 0.69 0.859 Y4 0.76 0.799 Y5 0.39 0.668 N6 0.19 0.518 N7 0.32 0.672 N8 0.1 0.367 N9 0.03 0.214 N10 0.33 0.564 N

Total Score 3.41 4.273 N

N=1752 N=1916

Spring Quarter:Spring Quarter: Quarter by Quarter 10-11Quarter by Quarter 10-11

OVERALL SCORE ANALYSISOVERALL SCORE ANALYSIS

Mean SD Normal1 0.364 0.67 N2 0.28 0.66 N3 0.69 0.86 Y4 0.76 0.86 Y5 0.39 0.77 M6 0.20 0.54 N7 0.33 0.69 N8 0.10 0.41 N9 0.03 0.30 N10 0.33 0.60 N

Total Score 3.43 4.36 N

N=1919

Fall Quarter:Fall Quarter: Winter Quarter:Winter Quarter:

OVERALL SCORE ANALYSISOVERALL SCORE ANALYSIS

Fall Quarter:Fall Quarter: Winter Quarter:Winter Quarter:

OVERALL SCORE ANALYSISOVERALL SCORE ANALYSIS

PHQ-9 Score FrequencyValid

PercentCumulative

Percent

0 479 27.3 27.3

1 204 11.6 39.0

2 232 13.2 52.2

3 184 10.5 62.7

4 139 7.9 70.7

5 100 5.7 76.4

6 87 5.0 81.3

7 55 3.1 84.5

8 54 3.1 87.6

9 42 2.4 90.0

10 28 1.6 91.6

11 19 1.1 92.6

12 11 .6 93.3

13 23 1.3 94.6

14 10 .6 95.1

15 17 1.0 96.1

16 17 1.0 97.1

17 12 .7 97.8

18 6 .3 98.1

19 7 .4 98.5

20 6 .3 98.9

21 2 .1 99.0

22 3 .2 99.1

23 3 .2 99.3

24 4 .2 99.5

25 2 .1 99.7

26 2 .1 99.8

27 1 .1 99.8

28 2 .1 99.9

30 1 .1 100.0

Total 1752 100.0  

PHQ-9 Score FrequencyValid

PercentCumulative

Percent

0 594 31.0 31.0

1 242 12.6 43.6

2 232 12.1 55.7

3 181 9.4 65.2

4 133 6.9 72.1

5 108 5.6 77.8

6 78 4.1 81.8

7 74 3.9 85.7

8 68 3.5 89.2

9 48 2.5 91.8

10 24 1.3 93.0

11 30 1.6 94.6

12 17 .9 95.5

13 18 .9 96.4

14 9 .5 96.9

15 10 .5 97.4

16 14 .7 98.1

17 7 .4 98.5

18 5 .3 98.7

19 3 .2 98.9

20 4 .2 99.1

21 7 .4 99.5

22 2 .1 99.6

23 1 .1 99.6

24 2 .1 99.7

25 1 .1 99.8

26 2 .1 99.9

30 2 .1 100.0

Total 1916 100.0  

Score Summary

Non-Acute Fall Quarter – 90% Winter Quarter – 91.8% Spring Quarter – 93.1%

Intervention by PHQ-9 Score Fall Quarter – 10% Winter Quarter – 8.2% Spring Quarter – 6.9%

Acute Fall Quarter – 1.5% Winter Quarter – 1.1% Spring Quarter – 1.1%

Total Visits to Number of BHC Visits

Total Visits - Fall – Spring Quarter N=5587

Actual BHC Visits N = 216 3.87% Expected as much at 10%

About 6% that decline BHC Consult

BHC Visit Initiation 43% from PHQ-9 Score 57% with scores 11 and below

1. Increased medical provider awareness about mental health issues

2. Allowed PCPs to briefly address mental health issues because they had someone who could follow up immediately

3. Provided students with instant access to a mental health provider who could briefly intervene or facilitate referral

4. Established a more efficient system for handling crises on the medical side

5. Aided in our suicide prevention efforts6. Facilitated collaboration and integration of medical and

mental health issues, especially for complicated cases7. Reached a larger number of international students8. Improved the relationship between the medical and

mental health providers

CONCLUSIONS & CONCLUSIONS & QUESTIONSQUESTIONS

REFERENCES & RESOURCESREFERENCES & RESOURCES

Gunn, W. B., & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psychology, 65 (3), 235-252.

James, L. C., & O’Donohue, W. T. (2009). The Primary Care Toolkit: Practical Resources for the Integrated Behavioral Care Provider. New York: Springer. 

Hunter, C. L., Goodie, J. L., Ooordt, M. S., & Dobmeye, A. C. (2009) Integrated Behavioral Health in Primary Care. Washington, D. C.: American Psychological Association.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). Validity of a brief depression severity measure. Journal of General Internal Medicine, 16 (9), 606-613.

Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. The American Journal of Psychiatry, 159 (6), 909-916. 

Pomerantz, A., Cole, B. H., Watts, B. V., & Weeks, W. B. (2008). Improving efficiency and access to mental health care: combining integrated care and advanced access. General Hospital Psychiatry, 30 (6), 546-551.

Robinson, P. J., & Reiter, J. T. (2007). Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York: Springer.