In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.
With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.
PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.
In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hang to screen for additional conditions, such as:
Intimate partner violence
Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these cools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.
Thanksgiving is a time for giving thanks and expressing gratitude. I am so grateful for the increasing focus on integrated care. There seems to have been a surge in collaborative spirit among the healthcare industry. Policy changes have enabled more collaborative approaches to care as well. As healthcare providers increased their focus on integrating behavioral health and primary care services and adopting a whole health/wellness approach to healthcare, we have the opportunity for making a greater impact on the health outcomes of the people we serve.
I would also like to express my deep gratitude to all of the outstanding thought leaders who have taken the time to share their expertise with us over the past year. It is through the sharing of ideas that enables us to foster those changes in thinking and in practice that are necessary for transformation. I’m happy to announce that we have several new integrated care thought leaders lined up for the months to come, each with a unique perspective on an aspect of integration. If you have a recommendation of an integrated care thought leader who we might feature in this blog, please forward the details to me at email@example.com.
I can’t begin to express my thanks to each and every one of you who has taken the time to stop by Behavioral Health Integration Blog to read the posts and offer your thoughts. And thank you to all of you who have subscribed to the blog as well. I look forward to the opportunity to continue to share my insights on integrated care and hope that you will find the content to continue to meet your expectations. It is my sincere hope that each of you has a Thanksgiving filled with loved ones, good health, and happiness.
In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, marking an important step forward in efforts to end discrimination in insurance coverage for mental health and substance use disorder treatment. While the act closed several loopholes left by the 1996 Mental Health Parity Act, it has taken five years to finalize the law. The 2008 act lacked clarity on how parity is to be achieved, particularly when treatment involves intensive care at physician offices or long-term hospital stays.
Today’s ruling provides clarification on how parity applies to residential treatments and outpatient care. It also ensures that copayments, deductibles, and limits on mental health benefits are not more restrictive or provide less coverage than those for medical and surgical benefits, including geographic or facility limitations. These have been tremendous barriers to treatment thus far and represent a significant triumph for the behavioral health community.
“This is the largest expansion of behavioral health coverage in a generation,” declared Secretary Sebelius. Addressing the need for adequate care for mental health has been a goal for more than 50 years, when President John F. Kennedy signed the Community Mental Health Center Act of 1963 into law.
At long last, treatment for behavioral health disorders is regarded as equal to other types of healthcare. This represents a significant achievement in behavioral health and should contribute to the ongoing effort to reduce the stigma. Millions fail to follow up with needed treatment because of stigma. With this final ruling and with movement toward integrated care, we will finally be able to improve access.
What will the world be like when people begin to actually receive that needed treatment?
“If we really think about how to change healthcare to make it more accommodating for integration, we must have comprehensive payment reform that pays for the whole, and not the part. We must recognize that administrative structures in health policy entities often perpetuate fragmentation inadvertently. And we must have a way to collect data that can inform not only the clinical case for why integration is good, but the business case for why integration is inevitable.”
Healthcare policy plays a crucial role in integrated care. Our current healthcare system contains barriers that prevent successful implementation of behavioral health and primary care integration. We will not be able to effectively adopt whole-health approaches to healthcare until critical changes are made in existing health policy. Thankfully, we can be grateful for those who are out there, tirelessly advocating for changes daily.
Dr. Benjamin Miller has graciously agreed to offer his insights on this important topic for the Integrated Care Thought Leader Series. He has made significant contributions to the healthcare industry and health policy, and continues to collaborate with a number of organizations focused on driving the necessary change for creating a more effective healthcare system. Dr. Miller has been the source of considerable inspiration to many (including me). It seems very appropriate, somehow, that I first met him through Twitter. His many tweets on healthcare, policy, and integration, with excellent links to current resources, provide me and many others with an education like no other. I have learned the value of Live Tweeting and Tweet Chats through his example (see Figure 1 below). Thank you, @miller7!
Having long been a firm believer in the need to provide healthcare in a unified manner, Dr. Miller has determined that three barriers prevent integrated care from becoming more widespread: Financing, policy, and data.
Dr. Miller: If you ask people why integration is or is not making a larger stand in healthcare, it usually comes out that they aren’t able to sustain their clinical innovation. So practices try to figure out ways that they can sustain themselves through all kinds of workarounds. Here in Colorado about three years ago we did a survey of integrated practices and found that 77% of those we surveyed were solely funding their integrated efforts through grants. I don’t think that’s uncommon. Actually, I think it’s very common across the country. A lot of practices that are doing this got funding from foundations, federal government, etc., to make it work. They’re only able to keep their doors open for the program while they’ve got those dollars. I wanted to figure out, why is that such a big deal? Why can’t we just pay for health? We proposed a project to test out a global payer model for primary care that includes the cost of mental health, just to see if we were to pay primary care a lump-sum of money that includes the cost of that primary care provider, could they sustain themselves? That’s where the Sustaining Healthcare Across Integrated Primary Care Efforts or SHAPE came from. We wanted to see if paying for primary care differently with mental health, behavioral health, substance abuse providers, working in that integrated context could be sustained. We’re about a year into that and the answer is going to be unanimously, yes.
Large Scale Policy Issues and History
Dr. Miller: If you look at how healthcare is set up, it’s set up to continue to perpetuate fragmentation. It’s set up so that administratively, it’s easier to manage pieces rather than a whole. Our states, communities, and government have done something, in an attempt to manage multiple systems, which has really hurt our attempts to integrate. I’ll give you a very high-level example of that: If you just look at most states, they usually have a different department or division for mental health. We decided to take all the dollars that were going into institutions for folks that had mental health issues and put it back into the community in established community mental health centers. The dollars didn’t really follow the patients in that experiment. Community mental health centers actually didn’t get a whole lot of money to do the job that they were intended to do. And so you have entire systems at state levels that manage mental health. When you want to try and integrate, whether it be in primary care or in the community mental health center with primary care, there are multiple administrative structures that you have to figure out how to align. And often, from a policy perspective, it doesn’t make sense fiscally as to how to align these and what to do with the administrative entities. There are a lot of policy issues. Mainly, how we’ve set up our systems to deliver care at the policy level.
Data, Research, and Infrastructure
Dr. Miller: The other reason I think integration hasn’t been taken to scale nationally as much as we would like, is that practices are relatively immature in their ability to collect data, especially as it relates to collecting that informs the outcome around the whole person and not just a physical health outcome or mental health outcome. If you go into a primary care practice and want to determine how effective a behavioral health provider is, often the electronic medical record and how they are tracking the data are in forms that don’t allow you to extract those data. They’re in free-text notes, or they’re in something that just makes it difficult to get at the data to show what they did and how effective it was. In the same vein, if you look at community mental health centers, it’s even worse. With vast amounts of EHRs, if they even have an EHR, are built around this old-fashioned, almost antiquated, “I need to tell the whole story for the patient” model. That’s good on the clinical level. However, if you’re looking at making a case for something, you need to be able to extract data from those electronic medical records and then tell a story with your data. Many of the community mental health centers simply are not there. They have an opportunity here to advance themselves by collecting better data at the practice level.
Though many in the healthcare industry see policy as something beyond their responsibility and concern, the reality is that it has an impact on each of us. Unless we collectively express our concerns, voice our professional opinions, demand the necessary changes, legislators will continue to make uninformed decisions that have significant impact on healthcare delivery.
While there remains a long way to go before the needed changes outlined by Dr. Miller are in place, the industry as a whole is making significant strides in the right direction. Policies are slowly beginning to change.
Perhaps the perfect storm is approaching for healthcare.
Today marks the 50th anniversary of the date that President John F. Kennedy signed the 1963 Community Mental Health Act into law. It was to be the last before his death on 11/22/63. The Act represents a monumental turning point in the treatment of psychiatric disorders. President Kennedy’s call to action in 1963 was based on a belief that all Americans – including those with mental illnesses, intellectual disabilities, and addictions – have a right to lead dignified lives and to share in the benefits of our society. Patrick Kennedy, nephew of President Kennedy and former U.S. Representative of Rhode Island, is steadfast in his efforts to continue this important work via the Kennedy Forum.
Act of October 31, 1963 “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, 77 STAT 282, “to provide assistance in combating mental retardation through grants for construction of research centers and grants for facilities for the mentally retarded and assistance in improving mental health through grants for construction of community mental health centers, and for other purposes.”, 10/31/1963 (Figure 1 below)
History of Psychiatric Treatment
Early attempts to treat mental illness are thought to date back to 5000 B.C. or earlier, based on the discovery of trephine skulls. A series of barbaric practices followed for millennia. It is suspected that the first asylums were established around the sixteenth century. These early facilities offered no real treatment despite their primitive attempts at cures, consisting of the use of leeches, purges, barbaric contraptions, and the use of chains and other restraints. Conditions gradually began to improve by the mid 1800s thanks to efforts led by humanitarians such as Dorothea Dix. Treatment reform in the asylums offered a more humane approach to the care of people with mental illness.
New treatment options followed in the early twentieth century, including psychoanalysis, introduced by Austrian neurologist, Sigmund Freud, and electroconvulsive therapy, introduced by Italian neuropsychiatrists, Ugo Cerletti and Lucio Bini. Psychopharmacology followed, arguably providing the single most significant change in treatment to date. A former colleague, psychiatrist, Dr. John Wolaver, remarked that when Thorazine was introduced in the psychiatric hospitals, the facilities were suddenly calm and quiet for the first time. It seemed to be a miracle cure. Psychopharmacology provided the next necessary step that led to deinstitutionalization.
The introduction of the Mental Retardation and Community Mental Health Centers Construction Act of 1963, Public Law 88-164, a bold new effort, forever changed the face of mental health treatment. Prior to this, it was not uncommon for individuals with behavioral health conditions to be hospitalized for many years; hundreds of thousands lived their lives in institutions and were buried on the grounds. Unfortunately, this deinstitutionalization effort fell short of its goal. The USA Today report, Kennedy’s Vision for Mental Health Never Realized, takes a candid look at this.
Figure 2 below illustrates the decrease in inpatient treatment between 1950 and 1995. As the psychiatric hospitals decreased in size, the homeless population grew. The jails and prisons began to fill with the individuals with behavioral health conditions. According to the 10/24/13 article, Why Are The Three Largest Mental Health Care Providers Jails? published by NewsOne: The three largest mental health providers in the nation are the following jails: Cook County in Illinois, Los Angeles County and Rikers Island in New York.
Many thought-leaders believe that we have embarked upon another pivotal point in mental health (or more broadly, behavioral health) treatment. Mental Health: A Report of the Surgeon General published in 1999 called for the integration of behavioral health and primary care. And the 2006 NASMHPD report, Morbidity and Mortality in People with Serious Mental Illness has prompted the movement toward a whole health approach to treatment that integrates behavioral health and primary healthcare. This promising trend offers hope for improved access for individuals who live with mental health and/or substance use disorders, improved health outcomes, and controlling healthcare spending.
Let us work together to address health conditions wherever the individual presents for treatment. Healthcare must be redefined to include behavioral health. By removing the healthcare silos, providers will begin to recognize and treat the comorbid conditions in their patients. Mind-body integration improves patient outcomes and reduces costs.
Integrated care is necessary for improving the lives of of those who might have spent his or her life chained in a dungeon centuries ago. It is a key element in our efforts to achieve the Triple Aim.
This is Mental Illness Awareness Week and today has been designated as both World Mental Health Day and National Depression Screening Day. Social media has numerous posts this week promoting mental health awareness and related topics as we try to educate the general public. We strive for increased awareness of the importance of good mental health as well as the challenges related to the stigma surrounding mental illness.
Integrating mental health and substance use disorder treatment with primary healthcare provides the opportunity to both increase awareness and decrease the stigma associated with behavioral health issues. Integrated care helps to improve access, reduce costs, and improve outcomes. Integrated care is better care!
In 1990, the U.S. Congress established the first full week of October as Mental Illness Awareness Week (MIAW) in recognition of the National Alliance on Mental Illness’s (NAMI) efforts to raise mental illness awareness. Since then, mental health advocates across the country have joined with others in their communities to sponsor activities, large or small, for public education about mental illness.
Today, 10/10/13, is designated as World Mental Health Day. This year’s theme is “Mental Health and Older Adults.” The day is celebrated at the initiative of the World Federation of Mental Health (WFMH) and the World Health Organization (WHO) supports this initiative through raising awareness on mental health issues using its strong relationships with the Ministries of Health and civil society organizations across the globe.
Today is also National Depression Screening Day. National Depression Screening Day raises awareness and screens people for depression and anxiety disorders. NDSD is the nation’s oldest voluntary, community-based screening program that gives access to a validated screening questionnaire and provides referral information for treatment. More than half a million people each year have been screened for depression since 1991.
Let us work together to promote good mental health locally and around the world.