Publications (38)53.84 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Evidence-based treatments for adult patients with anxiety are greatly needed within primary care settings. Psychotherapy protocols, including those for cognitive-behavioral therapy (CBT), are often disorder-specific and were developed for specialty mental health settings, rendering them infeasible in primary care. Behavioral health consultants (BHCs) integrated into primary care settings are uniquely positioned to provide anxiety treatment. However, due to the dearth of empirically supported brief treatments for anxiety, BHCs are tasked with adapting existing treatments for use in primary care, which is quite challenging due to the abbreviated format and population-based approach to care. CBT protocols are highly effective in the treatment of anxiety and fit well with the self-management emphasis of integrated primary care. We review the rationale and procedure for 6 evidence-based CBT intervention techniques (psycho-education, mindfulness and acceptance-based behavioral techniques, relaxation training, exposure, cognitive restructuring, and behavioral activation) that can be adapted for use in the brief format typical of integrated primary care. We offer tips based on our clinical experience, highlight resources (e.g., handouts, websites, apps), and discuss 2 case examples to aid BHCs in their everyday practice. Our goal is to provide BHCs with practical knowledge that will facilitate the use of evidence-based interventions to improve the treatment of anxiety in primary care settings. (PsycINFO Database Record
- [Show abstract] [Hide abstract] ABSTRACT: Background: Few studies have measured addiction-specific barriers to treatment. A measurement of barriers with psychometric support that has been tested in diverse samples and that assesses multiple components of addiction treatment barriers is needed to inform providers and treatment programs. Objectives: This paper aims to provide an initial psychometric investigation of a measure of barriers to seeking addictions treatment. Methods: Data were collected from 196 Veterans Affairs primary care patients with Alcohol Use Disorder that participated in a randomized clinical trial. Results: A Principal Components Analysis revealed that the 32-item Treatment Barriers Scale (TBS) can be reduced to 14 items, measuring 4 factors: stigma, dislike of the treatment process, alcohol problem identification, and logistical concerns. Acceptable internal consistent reliability (α = .64-.76) and excellent precision of alpha (α = 0.001-0.009) was found for each subscale. Support for the measure's concurrent validity was found, for example, participants who reported more motivation to reduce their drinking perceived significantly fewer barriers to care. Support for the measure's predictive validity was also found, including that more barriers were related to future drinking among all participants and less mental health and addictions treatment visits among participants in one treatment condition. Conclusions/ Importance: Our results provide initial support for the utility of the TBS-14 among primary care patients with Alcohol Use Disorder. Use of the TBS-14 could enable healthcare providers to better understand patient-specific treatment barriers, provide corrective information on treatment misconceptions, and inform individualized treatment plans that increase patient engagement in addiction services.
- [Show abstract] [Hide abstract] ABSTRACT: The Veterans Health Administration’s MOVE! Program is the largest health care-delivered weight loss intervention in the United States. As a referring clinician’s perceptions and knowledge of health programs may impact implementation, examining perceptions of MOVE! may inform improvements to this and other programs. This study investigated primary care clinician perceptions of MOVE! (n = 754, 50% nurses). Perceived effectiveness ratings were highest for groups with 11 to 25 group members (p < 0.01) and for a combined lecture and support group format (p = 0.026), though session length and several other aspects of delivery were not associated with perceptions of effectiveness. MOVE! staff also rated the program as more effective than did other clinicians (p < 0.01). Many respondents lacked knowledge about program specifics, especially those not involved with MOVE! delivery (vs. those directly involved; p < 0.01). These findings indicate that variety in group size and format is related to perceptions of MOVE! effectiveness,. Also, clinicians not involved with MOVE! may lack knowledge about the program and underestimate its effectiveness, which could negatively affect referral likelihood or enthusiasm expressed to referred patients. Findings highlight opportunities for clarifying perceptions of a weight control program among clinicians in a large health care system. © Association of Military Surgeons of the U.S. All rights reserved.
- [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.
- [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.
- [Show abstract] [Hide abstract] ABSTRACT: This study aimed to determine whether mental health factors predict Veterans' willingness to hear about research participation opportunities. A sample of 954 Veterans completed measures to assess psychological functioning and were asked about interest in clinical research opportunities and willingness to share de-identified personal data with researchers. Of these Veterans, 75.8% were willing to listen to research opportunities at their local VA, and 100% agreed to share de-identified information. Poorer mental health correlated with a greater willingness to listen to research opportunities implying that Veterans who are experiencing a greater degree of mental health impairment may be overrepresented in clinical studies. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.
- [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. Participants/methods: 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. Results: 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. Conclusions: 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.
- [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.
- [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.
- [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.
- [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).
- [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.
- [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.
- [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).
- [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.
- [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.
Integrated Healthcare AssociationOakland, California, United States
University of RochesterRochester, New York, United States
Syracuse, New York, United States
- Department of Psychology