[Show abstract][Hide abstract] ABSTRACT: Inconsistent attendance and participant withdrawal limit the effectiveness of weight control programs, but little is known about predictors of initial and ongoing engagement. The purpose of this study was to identify these predictors with respect to the Veterans Affairs MOVE!® program, using medical record data. Logistic regression models were used to predict initial and ongoing engagement (n = 39,862 and 1985, respectively). Those who initially engaged in MOVE!® (vs. did not) were more likely to have high BMIs, to be female, live closer to the medical center, and receive health benefits from the VA; they also were less likely to use tobacco (ps < 0.02). Older veterans were more likely to continue to engage (p < 0.001), with trends toward continued engagement for those with (vs. without) benefits and higher BMIs (ps < 0.10). Findings highlight characteristics that may inform program improvements that promote ongoing engagement and prevent dropouts in a weight management programs.
Translational Behavioral Medicine 08/2015; DOI:10.1007/s13142-015-0335-y
[Show abstract][Hide abstract] ABSTRACT: Primary care-mental health integration (PC-MHI) is growing in popularity. To determine program success, it is essential to know if PC-MHI services are being delivered as intended. The investigation examines responses to the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to explore PC-MHI provider practice patterns. Latent class analysis was used to identify clusters of PC-MHI providers based on their self-report of adherence on the PPAQ. Analysis revealed five provider clusters with varying levels of adherence to PC-MHI model components. Across clusters, adherence was typically lowest in relation to collaboration with other primary care staff. Clusters also differed significantly in regard to provider educational background and psychotherapy approach, level of clinic integration, and previous PC-MHI training. The PPAQ can be used to identify PC-MHI provider practice patterns that have relevance for future clinical effectiveness studies, development of provider training, and quality improvement initiatives.
Translational Behavioral Medicine 06/2015; DOI:10.1007/s13142-015-0325-0
[Show abstract][Hide abstract] ABSTRACT: Purpose of the Review: Behavioral healthcare is being increasingly integrated into primary care settings. The Primary Care Behavioral Health (PCBH) model is one of the most common approaches to integrated care, but limited guidance exists to guide behavioral health providers in their everyday clinical practice. The purpose of this review is to summarize evidence-based assessment and intervention practices for PCBH providers and identify gaps for future research. Recent advances that can help support evidence-based practice among these providers include a measure of integrated behavioral health providers’ fidelity to the PCBH model, brief behavioral health assessment and outcome measures, and brief interventions.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To describe how behavioral activation (BA) for depression and stimulus control (SC) for insomnia can be modified to a brief format for use in a university primary care setting, and to evaluate preliminarily their effectiveness in reducing symptoms of depression and insomnia, respectively, using data collected in routine clinical care.
Chart review data were obtained for 11 patients treated between August 2009 and December 2010 with 1 session of brief BA for depression and 17 patients treated with 1 session of brief SC for insomnia.
At 2-week follow-up, patients reported significant decreases in symptoms of depression on the Patient Health Questionnaire-9, t(10) = 3.95, p < .05, and insomnia on the Insomnia Severity Index, t(16) = 5.43, p < .05, respectively.
This case report provides preliminary evidence of the external validity of brief BA and SC after they were adapted for use within university primary care.
Journal of American College Health 02/2015; 63(6). DOI:10.1080/07448481.2015.1015031 · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is little known regarding the typical trajectory of alcohol use following a positive screen for hazardous alcohol use. This information would help primary care providers as they attempt to determine the best use of patient visits that might include brief alcohol interventions versus other competing medical demands. This longitudinal observational study included 98 Veterans who screened positive on the Alcohol Use Disorders Identification Test-Consumption (>3) and were asked to report on their alcohol use every 3 months for 1 year. Using latent class growth modeling, we identified the best fitting latent class structure for each outcome of high-risk and heavy drinking, respectively. There was a class of participants with increased probability of having a high-risk week or episode of heavy drinking as well as a group of participants who appeared to maintain their current drinking pattern. Although the latent class growth modeling suggested that none of the groups of participants reduced the likelihood of occurrence of heavy drinking days, two groups did significantly reduce the probability of having a hazardous alcohol use week. These results suggest that there are specific classes of patients who are less likely to change their alcohol use following a positive screen, especially those patients who report engaging in heavy drinking.
Military medicine 11/2014; 179(11):1198-206. DOI:10.7205/MILMED-D-14-00071 · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Insomnia is common, but undertreated, among primary care patients. Within the Veterans Health Administration (VA), increasing attention has been given to the treatment of insomnia within primary care settings, but little research has examined Veterans' treatment preferences. We examined preferences for sleep treatment among VA primary care patients. Participants (N = 126: 98% male, 89% white; M age = 60 years) completed a brief survey. On the basis of Insomnia Severity Index scores, 22% reported subthreshold and 13% moderate insomnia. Fifty percent reported having issues with sleep (falling asleep, staying asleep, or sleeping too much) in the past 12 months; among these, only 44% reported any discussion of medication (34%) or other strategies (32%) to improve sleep with medical providers. The most preferred treatment approach was to work it out on one's own, followed by consulting the primary care provider (PCP). The most preferred modality was a one-on-one meeting with the PCP, followed by a one-on-one meeting with the behavioral health provider. In conclusion, VA primary care patients preferred handling sleep problems on their own, but if seeking help, they preferred working with PCPs over behavioral health providers. The majority of Veterans preferred individual treatment and strategies other than medication.
Military medicine 10/2014; 179(10):1072-1076. DOI:10.7205/MILMED-D-14-00011 · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As researchers examine the efficacy of interventions that simultaneously target more than 1 symptom, it is important to identify ways to help guide research and program development. This study used electronic medical record data to examine the covariation of multiple risk factors regularly assessed among primary care patients. It also examined the health care utilization of those patients identifying where the health care system came in contact with them to help identify the ideal locations these interventions may be most often used. We obtained data for six risk factors, as well as the number of primary care, mental health, and emergency department visits, from Veteran patients with a primary care visit. There were three main groups of primary care patients, identified using latent class analysis and regression. Although the smallest group, the "High Treatment Need" group, had an increased probability of screening positive for all four risk factors, the post-traumatic stress disorder screen was a significant discriminator of this group from the others. Results show that this group had the greatest number of encounters in all health care locations suggesting significant opportunities for intervention. However, future research is needed to examine the current interventions offered and potential avenues where risk factors may be addressed simultaneously.
Military medicine 10/2014; 179(10):1119-1126. DOI:10.7205/MILMED-D-14-00119 · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reviews the website, The Academy: Integrating Behavioral Health and Primary Care http://integrationacademy.ahrq.gov. This website was created by the Agency for Healthcare Research and Quality. It was constructed and is maintained by a project team (Benjamin Miller, PsyD, Garrett Moran, PhD, and Deborah Cohen, PhD), who are advised by the National Integration Academy Council, which is a group of integrated health care experts that help direct strategic initiatives. The overall mission of this website is to serve as a centralized resource to allow easy access to tools and materials that advance the field of behavioral health and primary care integration. The review presented here provides an overall impression of the layout/structure of the website; a page guide and descriptions of the page structure and content. Overall, this website includes a wealth of information on integrated health care and can easily be seen as a great resource to a variety of professionals contemplating implementation of integrated health care or currently working within an integrated system. It is expertly formatted so that the information is all included, but each individual page is not too overwhelming. In addition, it is comprehensive, leaving very little that may be helpful to readers interested in integrated health care not discussed or at least identified as area that the project team is developing. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Families Systems & Health 09/2014; 32(3):357-360. DOI:10.1037/fsh0000063 · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Universal screening at university health centers can facilitate early identification and treatment of behavioral health problems common among college students. This article describes the (a) process of implementing behavioral health screening at a university health center and (b) results of universal screening for depression, suicidal ideation, alcohol misuse, tobacco use, and sleep problems. We discuss the decision points involved in screening, including what to screen for, whom to screen, how to implement the screening measure, and how to deal with patients who screen positive. During the Spring and Fall 2010 academic semesters, 4,126 screening questionnaires were completed by students (62 % female) accessing a university health center. Each semester, 9-13 % of students screened positive for depression, 2.5-3 % for suicidal ideation, and 33-38 % for alcohol misuse, while 10 % wanted help with smoking cessation and 12-13 % with sleep problems. The results suggest that behavioral health screening in a university health center can help identify students with behavioral health concerns to increase access to care.
Journal of Clinical Psychology in Medical Settings 07/2014; 21(3). DOI:10.1007/s10880-014-9401-8 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A significant number of military personnel report engaging in or experiencing intimate partner violence (IPV). To advance current research and understanding of this behavior, we conducted a methodological review of the literature on IPV in military personnel and veterans. Research from 1980 to the present, which consisted of 63 empirical studies, was objectively coded by two independent raters on a number of variables important to the methodological quality of research on IPV in the military. In addition, areas of importance to the future of IPV research are presented.
[Show abstract][Hide abstract] ABSTRACT: Overweight and obesity are growing problems for primary care. Although effective weight management programs exist, these programs experience significant attrition, which limits effectiveness.
This study examined provider and staff perceptions of attrition from the Veterans Health Administration MOVE!® Weight Management Program as an initial step toward understanding attrition from primary care-based programs. Participants MOVE!® clinicians, primary care providers, and other staff members who interacted with patients about participating in MOVE!® (n=754) from Department of Veterans Affairs medical centers throughout the United States. Respondents were predominantly female (80.8%), Caucasian (79.2%), and trained as nurses (L.P.N., R.N., or N.P.; 50%). Measure Participants completed a web-mediated survey; items assessed agreement with personal and programmatic reasons for dropout, and allowed respondents to indicate the number one reason for dropout in an open-ended format. This survey was adapted from an existing tool designed to capture patient perceptions.
Respondents indicated that veterans experienced practical barriers to attendance (eg, transportation and scheduling difficulties) and desire for additions to the program (eg, a live exercise component). Low motivation was the primary factor identified by respondents as associated with dropout, particularly as noted by MOVE!® clinicians (versus other providers/staff; P<0.01).
These findings suggest that programmatic changes, such as adding additional meeting times or in-session exercise time, may be of benefit to MOVE!®. In addition, increasing the use of techniques such as Motivational Interviewing among providers who refer patients to MOVE!® may improve participant engagement in MOVE!® and other primary care-based weight management programs. Further research is needed to effectively identify those likely to withdraw from weight management programs before achieving their goals, and the reasons for withdrawal.
Primary Health Care Research & Development 03/2014; 16(02):1-10. DOI:10.1017/S1463423614000139
[Show abstract][Hide abstract] ABSTRACT: The goals of this study were to identify characteristics of both behavioral health providers (BHPs) and the patients seen in a primary care behavioral health (PCBH) model of service delivery using prospective data obtained from BHPs. A secondary objective was to explore similarities and differences between these variables within the Veterans Health Administration (VHA) and United States Air Force (USAF) primary care clinics. A total of 159 VHA and 23 USAF BHPs, representing almost every state in the United States, completed the study, yielding data from 403 patient appointments. BHPs completed a web-based questionnaire that assessed BHP and setting characteristics, and a separate questionnaire after each patient seen on one day of clinical service. Data demonstrated that there are many similarities between the VHA and USAF BHPs and practices. Both systems tend to use well-trained psychologists as BHPs, had systems that support the BHP being in close proximity to the primary care providers, and have seamless operational elements (i.e., shared record, one waiting room, same-day appointments, and administrative support for BHPs). Comorbid anxiety and depression was the most common presenting problem in both systems, but overall rates were higher in VHA clinics, and patients were significantly more likely to meet diagnostic criteria for mental health conditions. This study provides the first systematic, prospective examination of BHPs and practices within a PCBH model of service delivery in two large health systems with well over 5 years of experience with behavioral health integration. Many elements of the PCBH model were implemented in a manner consistent with the model, although some variability exists within both settings. These data can help guide future implementation and training efforts. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Families Systems & Health 12/2013; 31(4):341-53. DOI:10.1037/a0032770 · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Adherence to protocol among behavioral health providers working in co-located, collaborative care or Primary Care Behavioral Health settings has rarely been assessed due to limited measurement options. Development of psychometrically sound measures of provider fidelity may improve the translation of these service delivery models into every day practice. One hundred seventy-three integrated behavioral health providers in VA primary care clinics responded to an online questionnaire to assess the reliability and validity of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Psychometric assessment resulted in a reliable 48-item measure with two subscales that specified essential and prohibited provider behaviors. The PPAQ demonstrated strong convergent and divergent validity when compared to another measure of health care integration. Known-group comparisons provided partial support for criterion validity. The PPAQ is a reliable and valid self-report of behavioral health provider fidelity with implications for improving provider training, program monitoring, and clinical research.
Translational Behavioral Medicine 12/2013; 3(4). DOI:10.1007/s13142-013-0216-1
[Show abstract][Hide abstract] ABSTRACT: What is already known about this subject:
Depressive symptoms and obesity are highly prevalent in primary care settings. Depressive symptoms and obesity are positively related; as body weight increases, individuals are more likely to display depressive symptoms.
What this study adds:
This study examines the moderating roles of health behaviours (alcohol use, smoking status and vigorous exercise) on the relationship between body mass index and depressive symptoms. Exercise attenuates the relationship between depressive symptoms and obesity. Primary care patients often report multiple health risk behaviours and symptoms, including obesity and depressive symptomatology. This study examined the relationship between body mass index (BMI) and depressive symptomatology among primary care patients and tested its moderation by health behaviours. Primary care patients (n = 497) completed self-report questionnaires. Using three multilevel models, we tested the moderation of health behaviours on the BMI-depressive symptoms relationship. After controlling for relevant covariates, BMI was positively related to depressive symptoms. Smokers reported more depressive symptoms (P < 0.01), whereas vigorous exercisers reported fewer (P < 0.001). Alcohol consumption was not related to depressive symptoms (P > 0.05). Only vigorous exercise significantly moderated the BMI-depression relationship (P < 0.05). BMI is positively related to depressive symptoms among patients who do not participate in vigorous activity, suggesting that vigorous activity reduces the risk for depressive symptoms among patients with higher BMI.
[Show abstract][Hide abstract] ABSTRACT: It is important to find ways to identify prevalent co-occurring health risk factors to help facilitate treatment programming. One method is to use electronic medical record (EMR) data. Funderburk et al. (J Behav Med 31:525-535, 2008) used such data and latent class analysis to identify three classes of individuals based on standard health screens administered in Veterans Affairs primary care clinics. The present study extended these results by examining the health-related outcomes for each of these identified classes. Follow-up data were collected from a subgroup of the original sample (N = 4,132). Analyses showed that class assignment predicted number of diagnoses associated with the diseases that the health screens target and number of primary care behavioral health, and emergency room encounters. The findings illustrate one way an EMR can be used to identify clusters of individuals presenting with multiple health risk factors and where the healthcare system comes in contact with them.
Journal of Clinical Psychology in Medical Settings 10/2013; 21(1). DOI:10.1007/s10880-013-9376-x · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The success of any secondary prevention effort in identifying those in need for further services depends on the primary care team following all positive screening results with additional assessment or intervention. Initial research suggests possible differences in primary care responses to positive screens for hazardous alcohol use compared to depression. Therefore, the purpose of this study was to examine current practices of Veterans Affairs healthcare providers following a positive screen for hazardous alcohol use or depression. Chart reviews were conducted for a random sample of 98 Veterans who screened positive for hazardous alcohol use using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questions and a separate sample of 99 Veterans who screened positive for depression using the 2-item Patient Health Questionnaire (PHQ-2) over a 1-year period. Findings suggest multiple discrepancies in screening practices between the AUDIT-C and the PHQ-2. These include a higher likelihood of further depression assessment or referral after a positive PHQ-2 screen. Scores on the AUDIT-C that indicate heavier alcohol consumption were more likely to result in assessment or intervention than did lower but still positive AUDIT-C scores. Overall, these data suggest that many opportunities are missed, especially in regards to hazardous alcohol use, for prevention and intervention.
[Show abstract][Hide abstract] ABSTRACT: Major depressive disorder (MDD) is the most common psychiatric disorder in breast cancer patients. The prevalence of suicidal ideation in breast cancer patients is considerable, and relative to the general population, the prevalence of completed suicide is elevated, particularly in cancer patients with MDD. A major component of suicide prevention is effective treatment of MDD. Although some research has explored the utility of psychotherapy with breast cancer patients, only three trials have explored the benefits of behavior therapy in patients with well-diagnosed MDD and there has been no systematic investigation of the potential benefits of psychotherapy toward reducing suicidal ideation in breast cancer patients. As a follow-up to a recently completed randomized trial, this study examined the efficacy of 8 weeks of behavioral activation treatment for depression (BATD) and problem-solving therapy (PST) in reducing depression and suicidal ideation, as well as increasing hopefulness in breast cancer patients with MDD (n = 80). Across both treatments, GEE analyses revealed decreased depression and suicidal ideation and increased hopefulness at posttreatment, results that were maintained at 12-month follow-up. Moreover, follow-up patient contact at approximately 2 years posttreatment yielded no indication of completed suicide. Although these data are preliminary, BATD and PST may represent practical approaches to decrease suicidal ideation in depressed breast cancer patients.
[Show abstract][Hide abstract] ABSTRACT: There is a well-known association between mood disorders and substance use disorders (SUD), but little research has been conducted on SUDs as risk factors for the development of subsequent mood disorders.
We analyzed data from the National Comorbidity Survey Replication study. Diagnoses were determined using DSM-IV criteria. Odds ratios (aORs) of subsequently developing mood disorders were adjusted for age, sex and race/ethnicity.
Data from 5217 individuals were included (6.6% male; mean age 45.3 years; 72.6% White, 11.2% Black, 12.5% Hispanic and 3.7% other). Subsequent mood disorders developed in 26.4% of individuals with primary adolescent-onset SUD (12-17 years), 21.7% of those with SUD onset at 18-25 years, and 14.0% of those with SUD onset between the ages of 26 and 34 years. The mean lagtime between SUD onset and development of a mood disorder was about 11 years. Controlling for demographic variables, the aORs of developing a mood disorder in these three age groups were 2.44, 3.65, and 3.25. Substance dependence was associated with higher odds of mood disorders than was abuse. Among the specific mood disorders, the increased odds of developing bipolar disorder were particularly high among individuals with drug dependence.
Individuals with adolescent and young adult-onset SUD had increased odds of developing a secondary mood disorder. This indicates that adolescents and young adults with SUD should be closely monitored for both positive and negative mood symptoms. SUD treatment and aftercare offer opportunities for the early identification of secondary mood disorders.
Drug and alcohol dependence 07/2013; 133(2). DOI:10.1016/j.drugalcdep.2013.06.011 · 3.42 Impact Factor