CBPRA-00528; No of Pages 5: 4C

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ScienceDirectCognitive and Behavioral Practice xx (2014) xxx-xxx

SPECIAL SERIES: CBT in Medical Settings

Guest Editors: Risa B. Weisberg and Jessica F. Magidson

www.elsevier.com/locate/cabp

Integrating Cognitive Behavioral Therapy Into Primary Care Settings

Risa B. Weisberg, Alpert Medical School of Brown UniversityJessica F. Magidson, Massachusetts General Hospital/Harvard Medical School

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This article serves as an introduction to the first issue of the Cognitive and Behavioral Practice special series on cognitive-behavioralpractice in medical settings. This first issue of our two-part series focuses on strategies and recommendations for integrating cognitivebehavioral therapy (CBT) into primary care settings and the unique challenges primary care in particular presents. Our subsequentissue will focus on the implementation of CBT in other, more specialized forms of medical care, including cancer treatment and HIVcare.

Why Focus on Behavioral Health in Primary Care?

In recent years, the movement to integrate behavioralhealth into primary care has been rapidly growing. Thepassing of the Affordable Care Act in 2010, the wideadoption of a patient-centered medical home model inprimary care, and the advent of the Accountable CareOrganization (ACO) Medicare Shared Savings Programhave led primary care sites throughout the U.S. to fur-ther consider comprehensive, “whole person” (AmericanAcademy of Family Physicians, 2008) care of their patients,including a focus on behavioral health. This policy focuson behavioral health care in primary care settings reflectsthe current needs of primary care patients and providers.Data shows that the majority of individuals seeking mentalhealth services turn to primary care as their first or onlysource of treatment (Cauce et al., 2002; Wang et al., 2005;Wang et al., 2006). As a result, more than half of commonmental health problems are treated exclusively in primarycare (Bea & Tesar, 2002). In 2007, in the U.S., nearly halfof all prescriptions for antidepressants and anxiolytics werewritten in primary care settings (Schappert & Rechtsteiner,2011).

However, these estimates do not include the propor-tion of patients who present in need of behavioral mod-ification of health risk lifestyle factors, or who mightbenefit from the assistance of a behavioral health provider

ords: cognitive behavioral therapy; medical settings; primary care

-7229/14/© 2014 Association for Behavioral and Cognitiveapies. Published by Elsevier Ltd. All rights reserved.

ase cite this article as: Weisberg & Magidson, Integrating Cognitivavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.002

in learning how to adjust to and manage chronic physicalillness. As readers of Cognitive and Behavioral Practice knowwell, there are numerous empirically supported cognitiveand behavioral interventions for chronic disease man-agement and lifestyle modification, including programstargeting chronic pain (e.g., Allen et al., 2012; Hoffmanet al., 2007; Thorn, Boothby, & Sullivan, 2002), diabetes(e.g., Amsberg et al., 2009; Safren et al., 2014), insomnia(e.g., Bélanger, LeBlanc, &Morin, 2012; Espie, et al., 2012),obesity (e.g., DiLillo, Siegfried, & Smith West, 2003; Unicket al., 2013), smoking cessation (e.g., Stanton & Grimshaw,2013), and adherence to treatment regimens (e.g.,Demonceau et al., 2013; Newcomb et al., 2014). Tradition-ally, mental health treatment in primary care settings hasfocused on provision of psychopharmacotherapy andpsychosocial treatments have been managed via referralsto providers in the community. However, research showsthat one-third to one-half of primary care patients referredto mental health specialists do not attend even a first visit(Fisher & Ransom, 1997). Primary care patients citeinaccessible offices, inconvenient office hours, difficultyfinding providers who take their insurance, and/or the factthey do not have insurance, as some of the key barriers fornot following up on these referrals (Fisher & Ransom). As aresult, many patients who may benefit from psychosocialtreatments do not receive this care.

For example, one of us (R.W.) found that nearly half(47%) of a sample of primary care patients in NewEngland who had a current anxiety disorder diagnosiswere not receiving any mental health treatment. Only32% had received any form of psychotherapy in the past3 months (Weisberg et al., 2007). Further, only 14% hadreceived psychotherapy that reportedly contained key

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components of CBT such as exposure and/or cognitiverestructuring (Weisberg et al., 2013). When we followedthe primary care patients for up to 5 years, we found thatunder 37% ever, at any time during the follow-period,received psychotherapy containingCBTelements (Weisberget al., 2013). Thus, though efficacious CBT treatments haveexisted formany years for the treatment of anxiety disorders,approximately two-thirds of primary care patients with anx-iety disorders in our sample did not receive this type of careat any time over a 5-year period.

Embedding mental health services within the primarycare site may help foster receipt of behavioral health treat-ment. There are a number of models for bringing be-havioral health into primary care settings. In co-location,the behavioral health provider functions as an independentprofessional, but is geographically located within the sameservice as the primary care team and may have basic orclose consultation and collaboration with the primary careproviders. In integration, the behavioral health provider ispart of the primary care team. There is close collaborationwithin an integrated system. All providers are part of thebusiness of the practice, attend teammeetings, and use thesamemedical record system. As noted below, the articles inthis series present treatments that primarily are co-located,in that the treatment research team brought in servicesfrom their homeorganizations and performed themon-sitein collaboration with the primary care team. In a few ofthese papers, the work approached integration, in that thebehavioral health staff was part of the same organizationand a collaborative treatment team (e.g., Bryan, Corso, &Macalanda, this issue; Gomez et al., this issue; Goodie &Hunter, this issue) and/orused a shared electronicmedicalrecords (Pigeon & Funderburk, this issue).

Whether co-located or more fully integrated, agrowing body of research indicates that collaborativebehavioral–primary care results in improved patientoutcomes (e.g., Archer et al., 2012; Bower et al., 2006;Craske et al., 2011; Gilbody et al., 2006, Rollman et al.,2005; Roy-Byrne et al., 2010). However, collaborative caredoes not always include the provision of psychotherapy.The key defining elements of collaborative care arethat health professionals work with primary care pro-viders to serve as caremanagers and/or behavioral healthclinicians, and that these professionals monitor patienttreatment adherence and outcomes over time in a sys-tematic manner, and provide feedback to the primarycare provider. The health professional may be a nursewho monitors adherence to hypertension medicationsand home blood pressure checks and reports problems tothe provider, or they may be a psychologist who providesbrief psychotherapy to primary care patients with de-pression, while also monitoring outcomes and reportingthese to the primary care providers. This is important tonote, because recent meta-analyses of collaborative care

Please cite this article as: Weisberg & Magidson, Integrating CognitivBehavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.002

for depression—the disorder/problem with the largestprimary care collaboration research base—found thatwhile collaborative care was overall associated withdecreased depressive symptoms, and care managerswith a mental health background were associated withbetter outcomes than those without such education,whether or not the collaboration included psychotherapyservices was not predictive of outcomes (Bower et al.,2006; Gilbody et al., 2006).

As cognitive-behavioral therapy researchers, we findthis information troubling. A wealth of data from con-trolled trials in tertiary care shows that we have efficaciouspsychotherapies for the treatment of depression, so itis puzzling that the addition of psychotherapy to othercollaborative care (primarily care management) was notassociated with improved outcomes for depressed patients.However, further examination of the meta-analyses citedabove (Bower et al., 2006; Gilbody et al., 2006) shows thatpsychotherapy was considered as one broad variable inthese analyses. That is, there was no differentiation betweencognitive behavioral therapy and other therapies with lessof an evidence base. Similarly, Funderburk and colleagues(2011) examined the chart notes of primary care patientswho had received behavioral health services as part of anintegrated behavioral health–primary care program in theVeteran’s Administration Medical Centers in upstate NewYork. A random sample of 10% of the 1,870 patients whohad at least one visit with a behavioral health provider wasreviewed. Although the behavioral health providers wereall trained in the functions of their role and in the ideaof providing brief, co-located interventions, the BHPs didnot receive training or guidance as to the specific inter-ventions to use during these brief therapy sessions. Theauthors found that chart notesmade infrequentmentionofthe use of CBT techniques. Within the VA medical centersunder study, only 18% of primary care patients seen by abehavioral health provider (BHP) for depression receivedpsychotherapy that included cognitive therapy techniques,and only approximately 25% received behavioral activa-tion. Patient education and supportive treatments werecommonly used. Thus, it is possible that the provision ofpsychotherapy has not been found to predict outcomesin meta-analyses of collaborative care, in part because thespecific interventions used in the psychotherapy are notalways those with an evidence base. Improving the in-tegration of CBT into primary care settings may thereforebe crucial for improving patient outcomes and demon-strating the important role of brief psychotherapies in thiscontext.

Providing CBT in primary care settings is challenging.As Blount and Miller (2009) point out, there are a greatnumber of differences between working as a psychother-apist in a specialty mental health setting and being a BHPin primary care. As a BHP, you are the ancillary, rather

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than primary, health care provider. The goal is typically tomanage the needs of the population of patients, and thusto effectively manage resources, short-term or episodictreatment is often provided, and each session is often only30 minutes. The goal of treatment is thus often improvedfunctioning rather than full recovery, and, importantly,mental/behavioral health is the specialty, rather thanbeing a depression, anxiety, HIV, ADHD specialist. Thesedifferences make it challenging for BHPs to adapt andapply our CBT evidence base to patients in primary care.

Moreover, guidance for BHPs regarding how to adaptand apply CBT interventions to primary care patientsacross a range of presenting problems is hugely lacking.Additional resources that are accessible and applicable toreal-world primary care settings are needed for BHPs toshift current practices and create a sustainable integrationof evidence-based CBT approaches in these settings. Assuch, this special series aims to begin to fill in these gapsby providing specific examples and practical guidelinesfor using CBT strategies across a range of commonlypresenting behavioral health and psychological symptomsin primary care settings.

Overview of the Special Issue

The papers in this issue provide a range of recommen-dations for integrating cognitive behavioral approaches inprimary care to address insomnia, depressive symptoms,and child externalizing symptoms, to manage suicide risk,and to improve medication adherence. Pigeon andFunderburk (this issue) present a brief cognitive behav-ioral treatment for insomnia (CBT-I) tailored for theVA primary care setting for veterans who present withco-occurring insomnia and depression. The interventiondescribed is a four-session protocol consisting of brief15- to 30-minute sessions, two of which were telephonesessions, delivered by doctoral students. This work hasimportant implications for increasing access to behavioralsleep interventions for depressed veterans. Goodie andHunter (this issue) also provide guidance for addressinginsomnia in the primary care setting. In line with anintegrated model, they present an approach in whichBHPs assess and treat insomnia using brief, evidence--based, cognitive behavioral techniques. They use a caseexample to illustrate practical recommendations for assess-ment and delivery of brief evidence-based CBT techniquesin this context.

Bryan et al. (this issue) present a model for managingsuicide risk in the context of a patient-centered medicalhome (PCMH), a setting in which behavioral health careis integrated into primary care, and where behavioralhealth is a critical component of the treatment model.Despite the explicit integration of behavioral health careinto this model, there have been few efforts to presentguidelines for managing suicide risk in this setting. The

Please cite this article as: Weisberg & Magidson, Integrating CognitivBehavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.04.002

authors describe a model for managing suicide risk in thissetting, which includes screening and targeted assess-ment, delivery of brief CBT interventions, and ongoingcollaboration between treatment team providers, includ-ing the PCP, nurse, and an integrated behavioral healthconsultant. Specific guidelines and example case materialis provided for readers interested in implementing thesepractice in a PCMH.

Sheldon and colleagues (this series; in press) presenta model for addressing depression and psychotropicmedication adherence in the context of a large, urbanpublic health system of eight primary care clinics treatingan underserved, largely low-income minority population.Their model, the Telephonic Assessment, Support andCounseling Program (TASC), uses evidence-based assess-ment methods and CBT strategies, including behavioralactivation (BA) and motivational interviewing (MI), toaddress depressive symptoms and medication adherence,delivered over five brief telephone sessions by master’s-or doctoral-level mental health providers. Telephonedelivery may have important implications for feasibility,access, and cost-effectiveness for addressing depression andmedication nonadherence, particularly in low-resourcesettings.

As an example of integrating evidence-based principlesinto primary care for pediatric populations, Gomez et al.(this issue) describe the delivery of parent managementtraining (PMT) strategies by behavioral health consul-tants (BHCs) in primary care to address externalizingsymptoms. Approximately 15% to 16% of childrenpresent to their pediatrician with emotion or externaliz-ing symptoms (Briggs-Gowan et al., 2003; Polaha, Dalton,& Allen, 2011; Williams, Klinepeter, Palmes, Pulley, & Foy,2004), and integration of CBT into primary care settingsmay improve access to evidence-based treatments forthese symptoms. Gomez and colleagues describe a trulyintegrated model using BHCs in primary care deliveringevidence-based approaches for PMT (mean 2.38 visits).Their paper illustrates the process from triage to inter-vention for these children, and pilot data presentedprovides initial support for the acceptability, feasibility,and effects of the intervention on reducing children’slevels of distress.

Conclusion

In summary, the articles in this series offer behavioralproviders a guide for how to deliver evidence-basedtreatments within primary care settings, and also includepilot data to add to the growing literature showing thatwhen CBT is delivered in primary care, it improves patientoutcomes. This data is important both at a clinical and apolicy level. As more and more mental and behavioralhealth care will be provided in these settings in the nearfuture, insurance companies, policy makers, and other

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stakeholders will soon be determining what the standardof this care should be, and what will be reimbursed. Thereis thus a strong need for the development and empiricalevaluation of CBT, evidence-based interventions in primarycare settings. Further, improving access to resources andtrainings for BHPs in primary care is important to promoteadoption of evidence-based resources in this setting. Wehope this series is a first step in illustrating delivery ofevidence-based approaches in primary care and in provid-ing hands-on recommendations for providers in thesesettings.

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Address correspondence to Risa B. Weisberg, Ph.D., Brown University,Department of Psychiatry & Human Behavior, Box G-BH,Duncan Building, Providence, RI 02912; e-mail address:Risa_Weisberg@Brown.edu.

Received: March 31, 2014Accepted: April 5, 2014Available online xxxx

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