Behavioral Health Integration:

Screening and IdentificationNeil Korsen, MD, MSc

Quality CountsApril 11, 2012

Outline

Identifying patients who may benefit from behavioral health integration:– Screening for common behavioral health problems

Depression Anxiety disorders Substance use disorders

– Supporting health behavior change for chronic illness care

– Evaluation and treatment of common symptoms such as headache, fatigue, other pain syndromes that are often associated with psychosocial factors.

Screening for Depression

High risk populations

People with chronic illnesses or chronic pain

People with a disability People with substance abuse problems Kids with school, sleep or behavior

problems People with persistent somatic complaints

and negative workup

PATIENT QUESTIONNAIRE (PHQ-9)

Name: Date: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “ ” to indicate your answer)

Not at all Several

days

More than half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling/staying asleep, sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead, or of hurting yourself in some way. 0 1 2 3

Add Columns: _____ + _____ + _____

(Healthcare professional: For interpretation TOTAL: of TOTAL, please refer to back of page) _______

Not difficult at all _______

Somewhat difficult _______

Very difficult _______

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Extremely difficult _______

Patient Health Questionnaire (PHQ) Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with

permission. PRIME-MD ® is a trademark of Pfizer Inc.

Scoring the PHQ-9

First 9 questions: add columns vertically, then tally across bottom of page

Total score: 0 to 27 10th question is “Function Score”: what degree

depression symptoms have made it difficult for the patient to function in their everyday life

Degree of functional difficulty can help determine whether to start active treatment in people with mild symptoms.

Guideline: Initial Management & Follow-upScore/

Symptom Level

Treatment Follow-up PHQ-9

0-4No

depression

Consider other diagnoses (Annual screen with chronic conditions or depression hx)

5-9Mild

Consider other diagnosesIf diagnosis is depression, watchful waiting is appropriate initial management

12 months

10-14Moderate

Consider watchful waitingIf active treatment is needed, medication or psychotherapy is equally effective; consider function score in choosing treatment

3 - 6 months

15-19Moderately

Severe

Active treatment with medication or psychotherapy is recommendedMedication or psychotherapy is equally effective

1 – 3 months

20-27Severe

Medication treatment is recommended For many people, psychotherapy is useful as an additional treatmentPeople with severe symptoms often benefit from consultation with a psychiatrist

1 – 3 months

What is Watchful Waiting? Est. 1/3 with mild symptoms will recover

without treatment. Watchful waiting:

– Seeing pt monthly and monitoring PHQ-9 score, but not starting active treatment.

– Encourage self-care activities such as exercise or relaxation.

If symptoms have not resolved after 2-3 mos, consider active treatment.

PHQ-9 as Outcome Measure Can be used to follow response to

treatment Validated as a measure of change

and can be used to create an algorithm to guide treatment decisions

PHQ-9 - Change from last score, measured monthly

TreatmentResponse

Treatment Plan

Drop of 5 or more points each month

Good Antidepressant &/or PsychotherapyNo treatment change needed. Follow-up in 4 weeks.

Drop of 2-4 points each month

Fair Antidepressant: May warrant an increase in dose.Psychotherapy: Probably no treatment change needed.

Share PHQ-9 with psychotherapist.Drop of 1 point, no change or

increase each monthPoor Antidepressant: Increase dose or

augment or switch; informal or formal psychiatric consult; add psychotherapy.

Psychotherapy: 1. If depression-specific psychotherapy

discuss with supervising psychiatrist, consider adding antidepressant.

2. For patients satisfied in other psychotherapy consider adding antidepressant.

3. For patients dissatisfied in other psychotherapy, review treatment options and preferences.

Interpreting Follow Up Scores

Goals of Treatment Remission: score of 0-4 after an

initial score >10 Clinical response: score <10 after an

initial score >10

Screening for Anxiety Disorders

Anxiety Disorders Anxiety disorders often accompany

depression. Common anxiety disorders include:

Generalized anxiety disorder (GAD)

Panic disorder Post–traumatic stress disorder (PTSD) Social phobia

Anxiety Disorders Very common

30% lifetime prevalence in women 20% lifetime prevalence in men

Often present with physical symptoms to primary care

GAD-7 - Scoring

GAD-7 Score

Symptoms Treatment Recommendations

5-9 Mild Watchful waiting

10-14 Moderate Psychotherapy – first line of treatment

>15 Severe Medication and/or psychotherapy

NICE Treatment Guidelines

Step 1 ID & assessment; education about GAD and tx options; active monitoring

Step 2 Low-intensity psychological interventions: non-facilitated or guided self-help, psycho-ed groups

Step 3 High-intensity psychological intervention: CBT/ applied relaxation or drug treatment

Step 4 Specialty treatment: drug and/or psychological treatment; input from multi-agency teams,

crisis services, day hospitals or inpatient care http://guidance.nice.org.uk/

Screening for Substance Use Disorders

Substance use disorders

An estimated 17.6 million American adults (8.5%) meet diagnostic criteria for an alcohol use disorder.

Approximately 4.2 million (2%) meet criteria for a drug use disorder.

Overall, 19.4 million of American adults (9.4%) meet clinical criteria for a substance use disorder - either an alcohol or drug use disorder or both.

About 20% of persons with a current substance use disorder experience a mood or anxiety disorder at the same time and vice versa.

MaineHealth Adult Wellbeing Screener – Substance Abuse

Question 7 is recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The single-question screen was 81.8% sensitive and 79.3% specific in the detection of unhealthy alcohol use.*

Question 8 was found to be 100% sensitive and 74% specific for identifying people with a drug use disorder in a 2007 study.

A “yes” answer to either question 7 or 8 is a positive screen for substance abuse.**

During the past year: No Yes7. Have you had 4 or more drinks (women) / 5 or more drinks (men) in a

day?

8. Have you used an illegal drug or used a prescription drug for a non-medical reason?

*Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. J Gen Intern Med 2009 **Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Arch Int Med 2010

Further Assessment after Positive Screen

Adults – alcohol AC-OK AUDIT CAGE

Adults – other drugs DAST

Adolescents CRAFFT

SAMHSA list of substance screening and assessment instruments:http://www.ncsacw.samhsa.gov/files/SAFERR_AppendixD.pdf

Implementing Screening

A script for the person distributing the tools Who will score forms and when? How will assessment follow screening? How will results get documented?

Consider a daily huddle:

Role of Behavioral Health Clinician with Chronic Medical Conditions

Chronic condition management involves self-management

Self-management involves behavior change

Behavioral health clinicians can play a role in supporting behavior change– Use of health and behavior codes

Impact of Integration on Outcomes of Chronic Medical Conditions

Improved outcomes for both medical and co-morbid mental health conditions

Improved patient experience Cost impact may be neutral or show

slight savings– E. Lin, personal communication, 2012

Integration and Common Physical Symptoms

Estimates range from 25-75% of people with common symptoms such as headache, other pain syndromes, and fatigue have no ‘medical’ cause found after reasonable evaluation (Kroenke, 2003)

Emerging literature that past or present psychosocial stress and/or common behavioral health conditions are commonly associated with these symptoms

Screening and Assessment ToolsScoring and Treatment Guidelines

Tools and guides to treatment posted: www.mainehealth.org/mentalhealthintegration

Located in Links under Clinical Tools

References Kroenke K, et al. Anxiety Disorders in Primary Care: Prevalence,

Impairment, Comorbidity, and Detection. Ann Intern Med. 2007;146:317-325.

Kroenke K, Patients Presenting with Somatic Complaints. International Journal of Methods in Psychiatric Research. 2003; 12: 34-43.

Kroenke, Spitzer, and Williams. The PHQ-9: Validation of a Brief Depression Severity Measure. Journal of General Internal Medicine. 2001; 16:606-613.

Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary Care Validation of a Single-Question Alcohol Screening Test. J Gen Intern Med 2009; 24:783-788

Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A Single Question Screening Test for Drug Use in Primary Care. Archives of Internal Medicine 2010; 170:1155-1160