Screening, assessment, and management of depression in VA primary care clinics - The Behavioral Health Laboratory

William Penn University, Filadelfia, Pennsylvania, United States
Journal of General Internal Medicine (Impact Factor: 3.42). 02/2006; 21(1):46-50. DOI: 10.1111/j.1525-1497.2005.0267.x
Source: PubMed


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.

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    • "The BHL is an integrated primary care/mental health care service at the PVAMC that provides comprehensive substance use and psychiatric assessments by technicians under the supervision of psychologists, nurses and a psychiatrist. The laboratory assessments included a telephonic interview consisting of socio-demographic and psychiatric measures (Oslin et al., 2006). The interview assesses information in the following domains: baseline demographic data, Mini International Neuropsychiatric Interview (MINI) modules for mood disorders, anxiety disorders, and alcohol abuse/dependence (Sheehan et al., 1998); Patient Health Questionnaire-9 item scale (PHQ-9) (Kroenke, Spitzer, & Williams, 2001), PTSD Check List (PCL) (Blanchard, Jones- Alexander, Buckley, & Forneris, 1996), history of past episodes of depression, current antidepressant medications, alcohol consumption, smoking, use of illicit substances, 5-item Paykel Scale for suicidal ideation (Paykel, Myers, Lindenthal, & Tanner, 1974), Blessed, Tominson, & Roth, (1968) (Katzman et al., 1983), Short Form-12 item scale (SF-12) (Ware, Kossinski, & Keller, 1998), Work Limitation Questionnaire (Lerner et al., 2001), treatment satisfaction, insomnia, social support, bodily pain and diet. "
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    ABSTRACT: The aim of this investigation was to assess the relationships between suicidal ideation and insomnia symptoms in Veterans misusing alcohol. Data were extracted in this retrospective chart review of Veterans referred from primary care for a behavioral health evaluation (N=161) based on evidence of heavy drinking, drug use or another behavioral problem. Suicidal ideation (SI) was assessed using the Paykel questionnaire. Insomnia symptoms were assessed with standard diary questions in an interview format and pertained to sleep latency (SL), wake after sleep onset time (WASO), sleep quality (SQ), and habitual sleep duration (HSD). The relations between suicidal ideation and insomnia symptoms were assessed using ordinal regression analyses adjusted for socio-demographic, psychiatric and addiction-related variables. Suicidal ideation was reported in 62 (39%) of the Veterans interviewed. In a multivariable model, only inadequate SQ was associated with suicidal ideation. Short sleepers were more likely to endorse suicidal ideation and have attempted suicide in the past year. In addition, older age, inadequate financial status, and the presence of a psychiatric disorder were also significantly associated with suicidal ideation in most of the adjusted models. Given their association with suicidal ideation, insomnia symptoms in Veterans misusing alcohol should prompt an assessment of underlying psychiatric and social factors.
    Addictive behaviors 10/2013; 39(2). DOI:10.1016/j.addbeh.2013.09.022 · 2.76 Impact Factor
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    • "The mission of the BHLs is to provide comprehensive psychosocial assessments (with efficient, same-day feedback summaries provided to each patient's clinician) for VHA patients in need of mental health care during primary care visits (Oslin et al., 2006). The BHLs have increased the detection of problematic substance use and suicidal ideation, symptoms which may have been missed in routine clinical practice, among veterans using VHA primary care services (Oslin et al., 2006). These existing and successful screening procedures and integrated care models make VHA primary care better equipped than perhaps any other healthcare system to implement universal IPV screening. "
    Women s Health Issues 02/2013; 23(2). DOI:10.1016/j.whi.2012.12.004 · 1.61 Impact Factor
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    • "These two components are care management and co-located, collaborative care (CCC) [5]. Although definitions of these forms of care vary considerably, in general, care management includes algorithm-based, protocol driven assessment and monitoring of symptoms, patient education, and motivational enhancement for specific mental health disorders, such as depression [6,7]. In contrast, CCC embeds an independent behavioral health provider (BHP) into the primary care clinic where he or she is expected to work collaboratively to support the PCP's care of the Veteran around a broad range of mental health diagnoses and behavioral concerns [8-10]. "
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    ABSTRACT: Background Co-located, collaborative care (CCC) is one component of VA’s model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified. Methods This secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory. Results Six main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP’s role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments. Conclusions This study provided a contextualized account of the experiences of BHP’s in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.
    BMC Health Services Research 09/2012; 12(1):337. DOI:10.1186/1472-6963-12-337 · 1.71 Impact Factor
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