Behavioral Health Consultation

1. Behavioral Health Consultation One Center’s Journey Into Primary Care Mental Health Kirsten Ging, Psy.d Jacaranda Palmateer, Psy.D Chris Wera, CPA SCOTT CYPERS, Ph.D

2. Introduction • 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

3. Organization

4. Why • 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)

5. Why • 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)

6. Why • 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

7. What is a Behavioral Health Consultant • 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)?

8. Implementation • 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

9. First 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. Patient Health Questionnaire – 9 (PHQ-9) 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)

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13. Dailyscoresummary

14. Second 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 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?”

15. Second Stage: Roll Out • Started with only two providers • Trouble-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 providers • Interviewed and selected two Graduate Student Trainees (GSTs)

16. Third Stage • Re-evaluation • Statistical analysis • Weren’t seeing the high scores we anticipated • Use a different screening instrument? • Added substance use/abuse screening • Added four questions that were incorporated into the survey • Problems encountered: • Scoring • Pushback

17. Fourth Stage • Trying to make it permanent • Ideas for future development • How can we make it more robust • Biofeedback • Translate into different languages • Continue screening for substance use/abuse

18. Interventions • Motivational interviewing • Behavioral activation • Cognitive-Behavioral Therapy • “Third-wave” • How can we “suffer better?” • Coping strategies • Psycho-education

19. Cultural 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

20. Case Presentation • “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” • Little interest/pleasure • Feeling down, depressed, or hopeless • Having little energy • Feeling bad about yourself • Troubles concentrating “Several days” • Troubles falling asleep • Poor appetite • Feeling fidgety and restless

21. Case Presentation Referral information: • Had been “stressed out” since beginning graduate school • Experienced low libido Additional information: • Spent almost all of her time focusing on school • Felt like she was neglecting her relationships • About to graduate and worried about post-graduation plans • Described herself as “high strung, perfectionistic, and always anxious”

22. 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)

23. Case 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) Second Meeting: • Reviewed what helped • Discussed tendency to ruminate • Cognitive distortions • Rules vs consequences • Mindfulness/grounding/breathing Third Meeting: • Reviewed what helped • Discussed new stressors • Fears of post-graduation plans • On-going family issues • Explored benefits of therapy for deeper issues

24. Handouts: * Anxiety * Panic Attacks * Depression * Sleep hygiene * Nutrition * Fatigue * Cognitive distortions * Counseling FAQs * Diaphragmatic breathing * Reduced risk drinking

25. Medical Provider : Her perspective • 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: • 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

26. Overall Score Analysis Fall Quarter: Winter Quarter: N=1752 N=1916

27. Overall Score Analysis Spring Quarter: Quarter by Quarter 10-11 N=1919

28. Overall Score Analysis Fall Quarter: Winter Quarter:

29. Overall Score Analysis Fall Quarter: Winter Quarter:

30. 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% Score Summary

31. 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 Total Visits to Number of BHC Visits

32. Conclusions & Questions Increased medical provider awarenessabout mental health issues Allowed PCPs to briefly address mental health issues because they had someone who could follow up immediately Provided students with instant access to a mental health provider who could briefly intervene or facilitate referral Established a more efficient system for handling crises on the medical side Aided in our suicide prevention efforts Facilitated collaboration and integration of medical and mental health issues, especially for complicated cases Reached a larger number of international students Improved the relationship between the medical and mental health providers

33. References & 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.