Behavioral Health in Idaho…Opportunities for Pioneering

1. Behavioral Health in Idaho…Opportunities for Pioneering Alex J. Reed, PsyD, MPH Director of Behavioral Science, Mental Health and Research Family Medicine Residency of Idaho Clinical Assistant Professor, Department of Family Medicine Clinical Assistant Professor, Department of Psychiatry and Behavioral Science University of Washington School of Medicine

2. Objectives • Review the behavioral health and primary care outlook for Idaho • Discuss an innovative model for behavioral health here in Idaho!

3. MH In Idaho • In 2010, 36.3% of Idahoans report poor mental health, compared to 34% of U.S. citizen. • 54,000-84,000 Idahoans live with serious mental health conditions

4. Boun Bonner Idaho Mental Health Professional Shortage AreaService Areas Kootenai Benewah Benewah Shoshone Latah Latah Clearwater Clearwater Nez Perce Geographic HPSA Lewis Facility Idaho Lemhi Adams Valley Valley Washington Custer Clark Fremont Payette Boise Gem Jefferson Madison Teton Canyon Butte Ada Blaine Bonneville Camas Elmore Bingham Lincoln Gooding Caribou Jerome Minidoka Power Bannock Owyhee Twin Falls Cassia Bear Lake Oneida Franklin State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 4/07 – please contact (208) 334-5993 for updates

5. MH Training in Idaho • Idaho has several programs for training mental health professionals • SW – BSU • Counseling – ISU, NNU • Counseling Ph.D.- ISU • Clinical Ph.D. – none

6. Mental Illness in Primary Care • Most patients with mental health disorders initially present to their PCP • Often, the PCP is the first point of contact for patients who often present with a variety of physical complaints, somatic symptoms, and sub threshold psychiatric symptoms that vary in number, intensity and duration • 80% of all psychotropic medications are prescribed by nonpsychiatric medical providers Druss, B. G. (2002). The mental health/primary care interface in the United States: History, structure & context. Gen Hosp Psychiatry, 24: 197-202. Katon, W., Reis, R.K., Kleinman, A. (1984). The prevalence of somatization in primary care. Compr Psychiatry, 25 (2)., 208-215

7. Mental Health & Primary Care • Primary care is the “def facto” mental health system for 70% of the population. • Rates of mental health problems are significantly higher for patients with chronic conditions. • Public mental health patients die 25 years younger than the national average Colton, C.W., Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life los, and causes of death among public mental health clients in eight states. PrevChron Dis. http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed Sept 20, 2012. .

8. Chronic Conditions and MH Agency for Healthcare Research and Quality (2003). Medical Expenditure Panel Survey, Rockville, MD.

9. Boundary Bonner Idaho Primary Care Health Professional Shortage AreaService Areas Kootenai Benewah Benewah Shoshone Latah Clearwater Nez Perce Geographic HPSA Lewis Population Group HPSA Idaho Lemhi Adams Valley Washington Custer Clark Fremont Payette Boise Gem Jefferson Madison Teton Butte Canyon Blaine Ada Bonneville Camas Elmore Bingham Lincoln Gooding Caribou Minidoka Jerome Power Bannock Owyhee Twin Falls Cassia Oneida Bear Lake Franklin State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 5/12 – please contact (208) 334-5993 for updates

10. Leading Causes of Death in Idaho 2009 Beh. Factors Cause% of All Deaths Malignant Neoplasms22.1 Heart Disease 21.6 Chronic Lower Resp Disease 6.5 Accidents 6.0 Cerebrovascular Disease5.6 Diabetes Mellitus3.4 Alzheimer’s Disease 2.3 Suicide 2.7 Influenza and Pnuemonia1.9 Nephritis 1.7 Smk/Diet/Etoh Diet/Sed/Smk Smoking Alcohol Diet/Sed/Smk Diet/Sed/Smk Diet/Sed/Smk Alcohol Smoking Diet/Sed from diabetes

11. Typical Morning in FM Practice 56 y.o. diabetic w/ poor control 19 y.o. smoker for annual exam 33 y.o. w/ multiple somatic issues 7 y.o. with otitis media 67 y.o. with insomnia 70 y.o. with sinusitis 52 y.o. with HTN 28 y.o with chest pain & SOB Anxious Smoking Cessation Depression Enuresis Alcohol Abuse Family Violence Cardiac Risk Factors Panic Disorder Gunn, W. B. & Blount, A. (2009). Primary care mental health: A new frotier for psychology. Journal of Clinical Psycholog, 65 (3), 235-252.

12. Determinants of Health Schroeder, Steven A., We Can Do Better -- Improving the Health of the American People, N Engl J Med 2007 357: 1221-1228

13. Effects of Unrecognized Psychiatric Disorders in PC • High medical utilization • Nonadherence to treatment • Physician frustration “heartsink” • Increased risk for tobacco/substance use Colton, C.W., Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life los, and causes of death among public mental health clients in eight states. PrevChron Dis. http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed Sept 20, 2012.

14. EXTREME INTEGRATED PRIMARY CARE!!!!

15. Integrated Primary Care • PCP’s are under significant pressure to diagnose and treat a broad spectrum of biomedical and psychosocial problems. • Yet they lack time to manage behavioral problems. • Patient preference for collaboration between physician and MH Provider

16. Integrated Primary Care • Physician satisfaction in integrated settings • After collaboration, physician satisfaction increased from 54% to more than 90%. • Collaborative care model for treatment of panic disorder more effective than tx by a physician alone. Unutzer, J, Katon, W, Callahan, CM, Williams, JW, Hunkeler, E, Harpole, L, Hoffing, M, Della Penna, RD, Noel, PH, Lin, EH, Arean, PA, Hegel, MT, Tang, L, Belin, TR, Oishi, S, Langston, C (2002). Collaborative care management of late life depression in the primary care setting: a randomized control trial. JAMA, 288 (22), 2836-45. Levine, S., Utuzner, J, Yip, JY, Hoffing, M, Leung, M, Fan, MY, Lin, EH, Grypma, L, Katon, W, Harpole, LH, Langston, CA. (2005). Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary care. Gen Hosp Psychiatry, 27 (6), 383-91. Roy-Byrne, PP, Katon, W., Cowley, DS., Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Arch Gen Psychiatry, 58, 869-876.

17. Traditional Mental Health

18. Primary Care

19. Traditional Mental Health • Patients seek help themselves or are referred • 45-50 minutes session for 8-10 visits (short term) or long term (indefinitely) • 20 sessions/week @ 46 weeks = 920 hours • 102 patients served in 1 year

20. Primary Care • 10-15 minute visits • 15-20 visits per day • 15 visits x 4 days = 60 visits per week • 46 weeks = 2760 patient visits • These are two very different models

21. Integrated Care • PCP refers behavioral health consultant (BHC) to patient for behavioral issue • BHC sees patient for 15-30 minutes, develops behavioral change plan, reviews with PCP • BHC may implement, monitor, or change intervention in 1-4 focused visits, or refer for extended mental health care.

22. Integrated Care • 20 hours of 20 minute visits per week = 60 visits per week • 46 weeks = 2760 visits per year • 4 visits per patient, serve 690 patients per year • Imagine the public health impact of such a system!

23. Why Consider a New Model? • Nearly 50% of all patients in specialty mental health drop out of therapy without consulting their therapist • 50-60% non-adherence to psychoactive medications within first 4 weeks. • Only 1 in 4 patients referred to SMH make the first appointment • Yet primary care patients would complete treatments that were brief and pragmatic.

24. Depression Anxiety Insomnia Tobacco Use Weight loss Physical Inactivity Irritable Bowel Syndrome Parenting COPD Asthma CV disease Chronic Pain Sexual Dysfunction Hypochondriasis Stress Management What issues can the BHC address?

25. Integrated training at FMRI • FM and Psychiatry residents are trained in integrated model • We are training SW and Counseling Students in integrated care models. • One of our graduates is the first BHC in an outpatient primary care clinic here in Idaho!

26. Training Needs for Idaho: Integrated Care • Increase training opportunities for Behavioral Health in Primary Care • Certificate Programs • Reduce financial/ insurance barriers for fellowship training for psychologists in primary care.