Screening, assessment, and management of depression in VA primary care clinics. The Behavioral Health Laboratory.
ABSTRACT The purpose of this project was to assess the utility and feasibility of a telephone-based systematic clinical assessment service, the Behavioral Health Laboratory (BHL), in the context of primary care. The BHL is a clinical service that provides primary care providers with an assessment and a summary of mental health and substance abuse (MH/SA) symptoms and provides treatment decision support, including triage to specialty MH/SA services. The BHL was implemented to assist in the evaluation of patients who screened positively for depression at an annual clinical appointment or who were identified through routine care.
Results from systematic screening of primary care patients were extracted during a period of 6 months prior to implementation of the BHL and after implementation of the BHL. Descriptive results of the 580 evaluations conducted during this time were available.
Results suggest an association between the implementation of the BHL and an increase in the proportion of patients screened for depression in primary care. In addition, there was an increase in the proportion of patients who screened positively (2.8% vs 7.0%). The BHL was successful in providing a comprehensive assessment for 78% of those referred. Significant co-occurring mental illness and substance misuse were found among those assessed.
Introducing the BHL into primary care was associated with an apparent change in clinical practice in primary care at the Philadelphia VA Medical Center. Not only were more patients identified, the broad-based approach of the BHL identified significant comorbidity with alcohol misuse, illicit drugs, and suicidal ideation, symptoms likely to have been missed in routine clinical practice. The BHL offers a practical, low-cost method of assessment, monitoring, and treatment planning for patients identified in primary care with MH/SA needs.
- [Show abstract] [Hide abstract]
ABSTRACT: The aim of this hypothesis-generating pilot study was to assess prospectively the objective and subjective effects of treatment with quetiapine XR on sleep during early recovery from alcohol dependence (AD). Recovering subjects with AD and sleep disturbance complaints were treated with quetiapine XR (n = 10) or matching placebo pills (n = 10) for 8 weeks. Polysomnography was used to assess sleep objectively, and the Insomnia Severity Index and Pittsburgh Sleep Quality Index were used to measure subjective insomnia. Other assessment measures included the 10-minute psychomotor vigilance task (for neurobehavioral functioning), the time-line follow-back measure (for alcohol consumption), the Penn Alcohol Craving Scale (for alcohol craving), the Patient Health Questionnaire-9 item scale (for depressive symptoms), and the Beck Anxiety Inventory (for anxiety symptoms). Although there was no effect of quetiapine XR on sleep efficiency (time spent asleep/total recording time), there was a pre-to-post reduction in wake after sleep onset time (P = 0.03) and nonsignificant trends for increases in sleep onset latency (SOL) and stage 2 sleep time. A time × drug interaction was seen for the subjective insomnia, such that quetiapine XR-treated subjects reported greater initial improvement in their subjective insomnia, but the difference was not sustained. There were no differences between treatment groups on other measures or medication compliance. Quetiapine XR improves objective sleep continuity and transiently improves subjective insomnia early in recovery from AD.Journal of clinical psychopharmacology 04/2014; · 5.09 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Objective We conducted a pilot study comparing problem solving therapy for primary care (PST-PC) to a dietary education control condition in middle-aged and older veterans with symptoms of emotional distress and subsyndromal depression.Methods This was a two-site study at the VA Pittsburgh Healthcare System and Philadelphia VA Medical Center. Participants included veterans >50 years of age referred from primary care clinics who were eligible if they obtained a pre-screen score >11 on the Centers for Epidemiologic Studies Depression (CES-D) scale. Exclusions were a DSM-IV Major Depressive Episode within the past year, active substance abuse/dependence within 1 month, current antidepressant therapy, and a Mini mental status exam score <24. Participants were randomized to receive one of two interventions—either PST-PC or an attention control condition consisting of dietary education (DIET)—each consisting of six to eight sessions within a 4-month period.ResultsOf 45 individuals randomized, 23 (11 PST-PC and 12 DIET) completed treatment. Using regression models in completers that examined outcomes at end of treatment while controlling for baseline scores, there were significant differences between treatment groups in SF-36 mental health component scores but not in depressive symptoms (as assessed with either the 17-item Hamilton Rating Scale for Depression or the Beck Depression Inventory), social problem solving skills, or physical health status (SF-36 physical health component score).Conclusions These pilot study findings suggest that a six-to-eight session version of PST-PC may lead to improvements in mental health functioning in primary care veterans with subsyndromal depressive symptoms. Copyright © 2014 John Wiley & Sons, Ltd.International Journal of Geriatric Psychiatry 05/2014; 29(12). · 3.09 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Older individuals with emotional distress and a history of psychologic trauma are at risk for post traumatic stress disorder (PTSD) and major depression. This study was an exploratory, secondary analysis of data from the study "Prevention of Depression in Older African Americans". It examined whether Problem Solving Therapy-Primary Care (PST-PC) would lead to improvement in PTSD symptoms in patients with subsyndromal depression and a history of psychologic trauma. The control condition was dietary education (DIET). Participants (n=60) were age 50 or older with scores on the Center for Epidemiologic Studies -Depression scale of 11 or greater and history of psychologic trauma. Exclusions stipulated no major depression and substance dependence within a year. Participants were randomized to 6-8 sessions of either PST-PC or DIET and followed 2 years with booster sessions every 6 months; 29 participants were in the PST-PC group and 31 were in the DIET group. Mixed effects models showed that improvement of PTSD Check List scores was significantly greater in the DIET group over two years than in the PST-PC group (based on a group time interaction). We observed no intervention⁎time interactions in Beck Depression Inventory or Brief Symptom Inventory-Anxiety subscale scores.Psychiatry Research 06/2014; · 2.68 Impact Factor
Screening, Assessment, and Management of Depression in VA Primary Care Clinics
The Behavioral Health Laboratory
David W. Oslin, MD,1,2,3Jennifer Ross, BA,1,2Steve Sayers, PhD,1,2,3John Murphy, MD,1,4
Vince Kane, MSW,1Ira R. Katz, MD, PhD1,2
1Philadelphia VA Medical Center and VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, Pa, USA;
2Section of Geriatric Psychiatry, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pa, USA;3Center for the Study of
Addictions, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pa, USA;4Department of Medicine, Division of General
Internal Medicine, University of Pennsylvania Health System, Philadelphia, Pa, USA.
OBJECTIVES: The purpose of this project was to assess the utility and
feasibility of a telephone-based systematic clinical assessment service,
the Behavioral Health Laboratory (BHL), in the context of primary care.
The BHL is a clinical service that provides primary care providers with
an assessment and a summary of mental health and substance abuse
(MH/SA) symptoms and provides treatment decision support, includ-
ing triage to specialty MH/SA services. The BHL was implemented to
assist in the evaluation of patients who screened positively for depres-
sion at an annual clinical appointment or who were identified through
METHODS: Results from systematic screening of primary care patients
were extracted during a period of 6 months prior to implementation of
the BHL and after implementation of the BHL. Descriptive results of the
580 evaluations conducted during this time were available.
RESULTS: Results suggest an association between the implementa-
tion of the BHL and an increase in the proportion of patients screened
for depression in primary care. In addition, there was an increase in the
proportion of patients who screened positively (2.8% vs 7.0%). The BHL
was successful in providing a comprehensive assessment for 78% of
those referred. Significant co-occurring mental illness and substance
misuse were found among those assessed.
CONCLUSIONS: Introducing the BHL into primary care was associated
with an apparent change in clinical practice in primary care at the
Philadelphia VA Medical Center. Not only were more patients identified,
the broad-based approach of the BHL identified significant comorbidity
with alcohol misuse, illicit drugs, and suicidal ideation, symptoms like-
ly to have been missed in routine clinical practice. The BHL offers a
practical, low-cost method of assessment, monitoring, and treatment
planning for patients identified in primary care with MH/SA needs.
KEY WORDS: depression; primary care; adult; elderly.
J GEN INTERN MED 2006; 21:46–50.
in primary care settings is an important mechanism for reduc-
ing morbidity and mortality.1However, the USPSTF is clear
that screening is valuable only when assessment, treatment,
and monitoring are available. Recommendations for screening
in primary care acknowledge that depression is common, given
that 5% to 9% of patients have a major depressive disorder,
and that depression is a disabling illness leading to increased
health care utilization and costs of $17 billion in lost workdays
each year.1The recommended focus on assessment recognizes
the high rates of co-occurring MH conditions, while monitoring
he U.S. Preventive Services Task Force (USPSTF) recently
affirmed that routine screening for depressive disorders
recognizes the consistently low rates of follow-up of patients in
whom treatment is initiated. Indeed co-occurring problems in
the primary care setting have been recognized as increasing
and more relevant to patient management than in the past.2
Much of the contemporary literature on depression in pri-
mary care has focused exclusively on the management of
patients exhibiting mild-to-moderate severity without compli-
cating factors such as substance misuse or manic symptoms.
Numerous studies demonstrate the benefits of a collaborative
care model or disease management program for patients with a
depressive disorder.3–8These efforts are in recognition of low
rates of treatment and follow-up even in the context of recog-
nition. For instance, in 2002 quality performance measures
demonstrated that only 52% of veterans who screened positive
for depression had an assessment in the subsequent 6 weeks.9
Despite the efficacy demonstrated in these well-designed tri-
als, there has been limited capacity to implement this type of
model. In addition to the difficulty of financing, the research
trials provided a substantial infrastructure for screening and
assessing patients that is not available in most clinic settings.
In these trials, the research team conducted the screening and
provided initial comprehensive assessments leading to the ex-
clusion of many patients because of co-occurring conditions
such as drug or alcohol dependence or because of mild symp-
toms. Thus, the lack of formal comprehensive assessment
across multiple domains of psychopathology can be an impor-
tant barrier to implementing collaborative models and in de-
termining the proper level of care such as watchful waiting for
subsyndromal symptoms or specialty referral for severe or co-
Based on experience in conducting research in primary
care and at the request of primary care clinicians (PCCs), we
developed a clinical service, the Behavioral Health Laboratory
(BHL), to assist with providing comprehensive assessments for
patients potentially in need of MH care. Additionally, the serv-
ice was developed to allow ongoing monitoring of patients dur-
ing the initial phases of depression treatment. The BHL
functions much like a clinical radiology laboratory, such that
the BHL conducts specific tests when ordered by the PCCs,
interprets the results, and reports test results to the PCCs to-
gether with recommendations to assist in clinical decision
making. In order to maximize generalizability, the BHL com-
pletes assessments by telephone. However, other modalities
including in-person assessments or use of interactive voice-
recording technology are feasible. The purpose of this paper is
to describe the initial results of implementing the BHL in sev-
Manuscript received February 14, 2005
Initial editorial decision March 22, 2005
Final acceptance August 24, 2005
The authors have no conflicts of interest to report.
Address correspondence and requests for reprints to Dr. Oslin: Uni-
versity of Pennsylvania, 3535 Market Street, Room 3002, Philadelphia,
PA 19104 (e-mail: firstname.lastname@example.org).
eral VA outpatient primary care practices and to describe the
costs associated with the assessments.
Screening and Clinical Referral
Within all VA Medical Centers, screening for alcohol misuse
and depression is recommended on an annual basis for all
patients. The computerized medical record system tracks
screening and prompts providers to complete screening. Be-
ginning in March 2003 at the Philadelphia VAMC and associ-
ated community-based outpatient clinics (CBOCs), patients
who screened for depression could be referred by their PCCs to
the BHL for further assessment. The PCCs referred their pa-
tients through the use of a consult request and informed their
patients that someone from the BHL would be contacting them
for further assessment. The BHL served patients from 4 pri-
mary care clinics within the Philadelphia VAMC and 3 subur-
Procedures for Conducting the BHL Assessment
Upon receipt of the consult, the patient was registered and an
initial phone call was placed within 48 hours. When the health
technician (HT) reached the patient, they explained that the
call was being made at the request of the PCC. A minimum of 4
attempts were made for each patient, including evening hours
and at least once during a Saturday morning or early evening.
After the 4th call attempt, a letter was sent requesting that the
patient call to be assessed. Patients not able to be contacted
were declared unable to contact (UTC) and the clinician was
informed in the electronic medical record (ELM). Interviews not
completed because of refusals or communication problems
were also documented in the ELM. For all referrals regardless
of the outcome, a response was provided to the clinician in the
ELM or by fax or password protected e-mail.
As a clinical service, informed consent was not required for
participation in the interviews. The procedures for conducting
this review were approved by the Philadelphia VAMC Institu-
tional Review Board (IRB).
The assessments began with basic demographics and the
blessed orientation-memory-concentration test (BOMC). The
BOMC was administered to patients over the age of 54 to test
for cognitive impairment. If a patient made more than 16 er-
rors within the BOMC, the full interview was not completed, as
the self-reported information would be considered unrelia-
ble.10In cases of severe cognitive impairment, the clinician
was prompted to consider further evaluation of the cognitive
impairment. The remainder of the assessments conducted
were theMINI International
modules for mania, psychosis, panic disorder, generalized
anxiety disorder, post-traumatic stress disorder (PTSD), and
alcohol abuse/dependence11; the Patient Health Question-
naire-9 (PHQ-9) for depression12; current antidepressant med-
ications; alcohol use using a 7-day time line follow-back
method13; use of illicit substances; the 5-item Paykel scale
for suicide ideation14(patients were considered to have signif-
icant suicidal ideation if they answered yes to thinking about
taking one’s life, having made a plan, or having attempted su-
icide)15; history of past episodes of depression; the Medical
Outcomes Study (SF-12)16; and a 4-item patient satisfaction
All assessments were completed by direct entry using
software designed for ease of use with simple entry screens.
The BHL computer program used a variety of methods to limit
input errors, including real-time range checks, limited input
options, and error messages for incomplete responses.
Assessment Outcome and Characterization of
Cases into Risk Categories
The computer algorithm scored all assessments. For patients
who had either no or minor symptoms, the BHL report sug-
gested ongoing monitoring and no change in treatment. For
patients with minor depression (with or without current anti-
depressant treatment), specialty care was not recommended,
but follow-up and further treatment planning by the primary
care team was suggested. For patients with uncomplicated
major depression, an initial course of treatment was recom-
mended within primary care. All patients with a complex set of
symptoms, such as suicidal thoughts, mania, psychosis, sub-
stance misuse, PTSD, or panic disorder, were recommended
for a mental health and substance abuse (MH/SA) clinic re-
ferral. The BHL Director reviewed the reports providing an in-
terpretation prior to sending the report to the PCC.
Depression Treatment Monitoring
For patients in whom a new prescription for an antide-
pressant was initiated, the BHL conducted brief follow-up
assessments at 2, 6, and 9 weeks after treatment initiation.
Patients identified were enrolled in the monitoring program
using the initial examination as the baseline measure of
depression. The assessments included the PHQ-9 and self-re-
porting of adverse effects and medication adherence. Reports
were provided to the clinician outlining change in symptoms
and recommendations to adjust or change treatment when
Medical Record Data Abstraction
Results of the depression screening clinical reminder were re-
trieved from the electronic medical record in an anonymous
method. Only summary values for the screenings were obtain-
able. There was not a method for directly linking the results of
the screening to those referred to the BHL; thus, the screening
results were an approximation of the referral path.
Method used for Establishing Cost Estimates
For 20 consecutive consults, all activities required to complete
the consults were recorded. Additional administrative time
such as computer support, data management, and training
was estimated by recording all BHL-related activities from the
senior staff over the course of 2 weeks (a ‘‘time in motion’’
Oslin et al., Behavioral Health Laboratory
Statistical analyses were performed with SPSS Version 11.0 for
Windows. Descriptive analyses included means and standard
deviations for continuous variables, and frequencies for cate-
gorical variables. Unadjusted between-group comparisons of
continuous and categorical baseline, and follow-up outcome
variables were performed using Student’s t-tests and w2tests,
During the period between January and June 2004, 17,543
patients were screened using the depression clinical reminder,
representing 63.8% of the unique veterans seen in primary
care. Of those screened, 3,008 (17.1%) were marked as already
receiving MH/SA care, while 1,232 (7.0%) screened positively.
During the comparable period in 2002, 11,826 veterans were
screened, representing 52.0% of the unique patients seen dur-
ing that time frame. Thus, there was an 11.8% increase in the
number of veterans screened from 2002 to 2004. In addition,
there was a significantly greater proportion of patients who
screened positive in 2004 (7.0%) compared with 2002 (2.8%)
(w2=895.8, 1 df, Po.001).
During the 6 months in 2004, 740 referrals were made to
the BHL (approximately 60% of those screening positively). Of
those referred, 78.4% completed the assessment, with an ad-
ditional 7.6% refusing assessment and 14.1% being UTC. Old-
er veterans were more likely to refuse assessment, and a
greater proportion of younger veterans could not be contacted
(F=6.40, 1 df, Po.001). Figure 1 describes the flow of patients
from screening to referral.
Table 1 outlines the demographic and clinical character-
istics of assessed patients. Complex cases accounted for 44%
of all assessed patients. Severe cognitive impairment account-
ed for 5.2% of those assessed. Minor depression or distress
was present in 40.5% of the cases. A self-reported past history
of depression (59.5% overall) as well as significant suicidal
ideation (12.9% overall) was common. Overall, only 19.7% of
patients were in MH/SA care, with the majority being complex
cases. However, only 23.9% of the complex group was in MH/
SA care. Altogether, 261 patients had significant symptoms
warranting specialty MH/SA care either because of significant
suicidal ideation or presence of complex symptoms. In terms of
the complex cases, 67 met criteria for alcohol dependence
(11.6% of the total assessed sample), 44 used illicit drugs oth-
er than marijuana (7.6%), 128 met criteria for PTSD (22.1%),
51 had manic symptoms (8.8%), 86 had possible psychotic
symptoms (14.8%), and 26 met criteria for current panic dis-
The depression monitoring program identified 13 patients
with newly prescribed antidepressants. Of these patients, 12
completed at least 2 follow-up assessments. Reports were giv-
en to the clinician indicating change in depressive symptoms,
adverse events, and adherence.
Clinician acceptance was measured using a series of
focus groups with each primary care practice, except one
which was unavailable to meet. Feedback was invited with
discussion for improving the services. In all instances, provid-
ers commented on the rapid turnaround in assessment time,
the identification of symptoms other than depression, positive
FIGURE1. Patient flow from screening in the primary care clinic to
assessment and referral by the Behavioral Health Laboratory.
Table1. Characteristics of Patients Interviewed by the BHL
% of total
Past Hx depression
In MH care (last 12 mo)
PHQ total score
Disability from depression
(1 not at all to 4 extremely)
53.1 (12.8) 54.7 (12.8)
2.53 (0.83) 2.40 (0.81)
34.1% overall for minor depression
60.3 (15.0) F=11.86 o.001
1.44 (0.60) F=52.27 o.001
15.4 (2.1) 10.9 (2.4)
BHL, Behavioral Health Laboratory; MH, mental health; PHQ, Patient Health Questionnaire; MDD, Major depressive disorder.
Oslin et al., Behavioral Health Laboratory
comments from patients about the BHL staff, and improved
access to behavioral health. Providers have been particularly
positive about the depression-monitoring program. Negative
comments focused mostly on the formatting of reports,
desire for a face-to-face component, and desire to refer more
patients to the MH/SA clinic. The success of the program led to
the use of the BHL as the single point of entry for outpatient
Cost estimates were calculated first for bachelor’s level
HTs. The core baseline assessment takes an average of 30
minutes for the interview, with an additional 30 minutes of
scheduling appointments, filing, sending a letter to patients,
and sending the report to the provider. Additional depression
monitoring assessments take 30 minutes of the HT’s time.
Time for administrative and quality management activities, in-
cluding training and supervision, is estimated at 60 minutes/
day or 5 hours/week. Vacation/holiday/break time is 7.2
hours/weeks. Thus, there is approximately 27 hours (40 hours
?(517.2)) available to conduct interviews. An HT salary is
$36,092 with benefits or $695/week. Thus, the cost per unit
for initial evaluations is $695/27 or $25.74. The cost per unit
for depression monitoring assessments is $695/54 or $12.87.
Ongoing staffing for laboratory operations includes 0.20
FTE for the Medical Director, 0.30 FTE for the Behavioral
Health Specialist, 0.3 FTE for the HT Coordinator, and 0.1
Full Time Eqivalent (FTE) for IT support. These costs represent
the fixed costs for maintaining the laboratory as an entity and
are estimated based on the amount of administrative support
required for every 5 HTs. Other expenses include computer
upgrades, software license, supplies, and a toll free number.
These are estimated at $6,250/year or $120/week/HT. In to-
tal, the administrative costs translate into $527/week/HT.
This corresponds to approximately $19.52/initial assessment
or $12.26/follow-up assessment. Thus, the total costs are ap-
proximately $45.26/initial assessment and $25.13/follow-up
Recent media and Food and Drug Administration reports un-
derscored the importance of systematic assessments, includ-
ing assessment of suicidal ideation and co-occurring MH
problems during the initiation of depression treatment.17It is
especially important to consider models of care that assist in
the delivery of depression care in primary care settings, as na-
tionally, 37.3% of veterans with depression are managed solely
in primary care.18As described in this paper, the BHL offers a
practical and face-valid method of providing assessment and
monitoring for almost all MH/SA problems and not just for
selected patients. Moreover, the use of HTs rather than clinical
staff, and telephone rather than face-to-face assessment, led
to the relatively low cost of each assessment. The cost of a sin-
gle BHL assessment is lower than the clinical laboratory eval-
uation typical of a diabetic patient (lipid profile $18.72,
Hemoglobin A1c $18.33, and chemistry profile $19.96—based
on Medicare reimbursement). These results also suggest that
the BHL can be implemented across geographically distinct
primary care practices.
Implementation of the BHL was associated with a signif-
icant increase in screening and identification of patients need-
ing MH/SA services. While this association was evident over
the 2 years of implementation, other factors may have also
contributed to the improvement in screening. Other evidence
for the success of this model includes the substantial number
of patients with complex MH/SA needs identified and referred
for care who were not previously engaged in specialized treat-
ment. Moreover, in providing decision support for those pa-
tients with less severe symptoms, the BHL assisted in
prioritizing patients for appropriate use of specialty MH/SA
services, resulting in a potential reduction in health care costs
and patient burden. This finding is consistent with the man-
agement of other chronic diseases, such as diabetes or hyper-
tension, which are managed in primary care settings, unless
the illness is complex and therefore referred for management
in a specialty setting.
The BHL also offers the possibility of ongoing monitoring
for those patients requiring treatment. Monitoring patients
solely by telephone should not replace face-to-face clinical
management; however, telephone monitoring can provide sys-
tematic assessments at a relatively low cost and low burden to
the patient and highlight special circumstances such as
missed appointments, low adherence, and emerging suicidal-
ity. This practice increases the efficiency and effectiveness of
care consistent with results of face-to-face disease manage-
ment or quality improvement programs.19Monitoring can also
be an effective mechanism for following patients with subs-
yndromal depression to distinguish those with ephemeral
symptoms (false positive screens) from those with persistent
symptoms that may require formal treatment. Moreover, the
BHL can easily integrate with care management programs
or referral management programs. Indeed the BHL may be
ideally suited for determining which patient should be triaged
to specialty care and which patient could be sent to care
There are several limitations to note in understanding the
results. First, the study was conducted in a VA medical center
and associated outpatient clinics. The population is different
from most community-based primary care practices with a
higher prevalence of MH/SA problems. However, this may un-
derestimate the value of the BHL, in the sense that there would
be fewer expected false positive screens in a VA setting. More-
over, given the higher prevalence of MH/SA problems, the VA
may be the one health care system that can justify the costs of
having behavioral health specialists integrated in all primary
care practices. Veterans also have access to MH/SA services at
no or limited cost. Again, this may underestimate the role of
the BHL as non-VA settings may value BHL services more be-
cause of limited access to specialty care.
This study was conducted as a clinical demonstration
project, not as a randomized effectiveness trial. The use of his-
torical data for screening allows for the possibility that chang-
es in the process of screening are related to unmeasured
variance, rather than the introduction of the BHL. Finally,
there may be concern that evaluating complex illnesses such
as depression, mania, and psychosis cannot be adequately
completed by telephone or by nonclinicians. However, several
studies have compared telephone assessments with face-to-
face interviews and have found that telephone interviews can
be equally as effective and valid as face-to-face interviews.20–30
Telephone interviews can be more efficient, in both time and
logistically, than face-to-face interviews.
In summary, the initial experience with the BHL appears
to provide a platform to address many of the difficulties in
managing depression and other MH problems in primary care
Oslin et al., Behavioral Health Laboratory
settings. Specifically, the BHL allows for a rapid and system-
atic assessment of patients with possible behavioral health
needs. Particularly important was the identification of co-oc-
curring problems often missed or excluded in trials that focus
specifically on depression. The BHL can also function as an
adjunct to managing patients started on treatment in a man-
ner consistent with treatment guidelines. Consequently, the
BHL can overcome some of the problems in delivering quality
MH care, such as the already heavy demand on clinician time,
availability of clinicians to conduct brief but frequent follow-up
assessments, and the demand on patients for attending fre-
quent follow-up visits. Given the low burden for implementa-
tion and the ease of integration into existing primary care
practice, the BHL offers a tool for improving the efficiency of
managing depression and other MH problems common in pri-
mary care settings.
This work was supported, in part, by a grant from the National
Institute of Mental Health K08MH01599 & P30 MH66270, Nation-
al Institute of Alcohol Abuse and Alcoholism R01, Department
of Veterans Affairs HSRD Investigator Initiated Research IIR 02-
108, and the Mental Illness Research, Education, and Clinical
Center (MIRECC) at the Philadelphia VAMC. The success of the
BHL would not be possible without the dedication of the pri-
mary care staff at the Philadelphia VAMC. The staff clearly val-
ues the integration of behavioral health in the daily routine of
primary care. We also want to acknowledge the help of Joyce
Askew who was invaluable in developing the depression clin-
ical reminder for the electronic record and extracting data
from the electronic record.
1. Agency for Healthcare Research and Quality. U.S. Preventive Services
Task Force Now Finds Sufficient Evidence to Recommend Screening
Adults for Depression. Rockville, Md: Agency for Healthcare Research
and Quality; 2002.
2. Frisher M, Collins J, Millson D, Crome I, Croft P. Prevalence of comor-
bid psychiatric illness and substance misuse in primary care in England
and Wales. J Epidemiol Community Health. 2004;58:1036–41.
3. Bruce ML, Ten Have TR, Reynolds III CF, et al. Reducing suicidal ide-
ation and depressive symptoms in depressed older primary care patients:
a randomized controlled trial. JAMA. 2004;291:1081–91.
4. Levkoff SE, Chen H, Coakley E, et al. Design and sample characteris-
tics of the PRISM-E multisite randomized trial to improve behavioral
health care for the elderly. J Aging Health. 2004;16:3–27.
5. Unutzer J, Katon W, Callahan CM, et al. Collaborative care manage-
ment of late-life depression in the primary care setting: a randomized
controlled trial. JAMA. 2002;288:2836–45.
6. Simon GE, Von Korff M, Ludman EJ, et al. Cost-effectiveness of a pro-
gram to prevent depression relapse in primary care. Med Care. 2002;
7. Simon GE, Katon WJ, VonKorff M, et al. Cost-effectiveness of a col-
laborative care program for primary care patients with persistent depres-
sion. Am J Psychiatry. 2001;158:1638–44.
8. Oslin DW, Sayers S, Ross J, et al. Disease management for depression
and at-risk drinking via telephone in an older population of veterans.
Psychosom Med. 2003;65:931–7.
9. Department of Veterans Affairs. FY2002 end of year network perform-
ance measure report, 2002.
10. Blessed G, Tominson BE, Roth M. The association between quantita-
tive measures of dementia and of senile change in the cerebral gray mat-
ter. Br J Psychiatry. 1968;114:797–811.
11. Sheehan DV, Lecrubier Y, Sheehan K, et al. The Mini-International
Neuropsychiatric Interview (M.I.N.I): the development and validation of a
structured diagnostic psychiatric interview for DSM-IV and ICD-10. J
Clin Psychiatry. 1998;59(suppl 20):22–33.
12. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief de-
pression severity measure. J Gen Internal Med. 2001;16:606–13.
13. Sobell L, Sobell M, Gloria L, Cancilla A. Reliability of a timeline method:
assessing normal drinkers’ reports of recent drinking and a comparative
evaluation across several populations. Br J Addiction. 1988;83:393–402.
14. Paykel ES, Myers JK, Lindenthal JJ, Tanner J. Suicidal feelings in
the general population: a prevalence study. Br J Psychiatry. 1974;124:
15. Bartels SJ, Coakley E, Oxman TE, et al. Suicidal and death ideation in
older primary care patients with depression, anxiety, and at-risk alcohol
use. Am J Geriatric Psychiatry. 2002;10:417–27.
16. Ware J, Kossinski M, Keller S. How to score the SF-12 (R) pyshical and
mental health summary scales. 3rd edn. Lincoln, RI: QualityMetric In-
17. Food and Drug Administration. Worsening depression and suicidality
in patients being treated with antidepressant medications, 2004.
18. Department of Veterans Affairs. Unique SSN’s with a Dx of depression
in FY 2004 followed by primary care and/or mental health clinics,
19. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminat-
ing quality improvement programs for depression in managed primary
care: a randomized controlled trial. JAMA. 2000;283:212–20.
20. Revicki DA, Tohen M, Gyulai L, et al. Telephone versus in-person clin-
ical and health status assessment interviews in patients with bipolar
disorder. Harv Rev Psychiatry. 1997;5:75–81.
21. Williams S, Crouch R, Dale J. Providing health-care advice by tele-
phone. Prof Nurse. 1995;10:750–2.
22. Kawas C, Karagiozis H, Resau L, Corrada M, Brookmeyer R. Reliabil-
ity of the blessed telephone information-memory-concentration test. J
Geriatr Psychiatry Neurol. 1995;8:238–42.
23. Greist JH, Jefferson JW, Wenzel KW, et al. The telephone assessment
program: efficient patient monitoring and clinician feedback. MD Com-
24. Sobell LC, Brown J, Leo GI, Sobell MB. The reliability of the alcohol
timeline followback when administered by telephone and by computer.
Drug Alcohol Depend. 1996;42:49–54.
25. Rohde P, Lewinsohn PM, Seeley JR. Comparability of telephone and
face-to-face interviews in assessing axis I and II disorders. Am J Psychi-
26. Coon GM, Pena D, Illich PA. Self-efficacy and substance abuse: assess-
ment using a brief phone interview. J Subst Abuse Treat. 1998;15:
27. Simon GE, Revicki D, VonKorff M. Telephone assessment of depres-
sion severity. J Psychiatric Res. 1993;27:247–52.
28. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Telepsychiatry as a
routine service—the perspective of the patient. J Telemed Telecare.
29. Pulier ML, Ciccone DS, Castellano C, Marcus K, Schleifer SJ. Medical
versus nonmedical mental health referral: clinical decision-making by
telephone access center staff. J Behav Health Serv Res. 2003;30:444–51.
30. Gatz M, Reynolds CA, John R, Johansson B, Mortimer JA, Pedersen
NL. Telephone screening to identify potential dementia cases in a
population-based sample of older adults. Int Psychogeriatr. 2002;14:
Oslin et al., Behavioral Health Laboratory