Friday, March 17, 2017

Understanding the Issues Regarding Misuse of the Term "Behavioral Health"

by Anne Donahue
IBH-PC Stakeholder Advisory Group

What is the accurate definition of “behavioral health”?

“The chronic diseases that drive the majority of mortality, morbidity and cost in America and around the globe are largely behavioral in origin or management. Tobacco, diet, physical inactivity, alcohol, substance abuse, non-adherence to treatment, insomnia, anxiety, depression, and stress are major causes of morbidity, mortality and expense, especially when chronic medical problems such as heart disease, lung disease, diabetes, or kidney disease are also present. Behavioral problems can often be effectively managed with improved outcomes for patients, their families and the health care system, but the current health care system is often unable to provide such care. Behavioral health includes mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors.” (From the study protocol for Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems)
In other words, “behavioral health care” is about health behavior, whether in relation to medical or psychological issues that are barriers to health. Behavioral health care that addresses change in behavior includes examples such as motivation to quit smoking, to exercise, to follow a diet, or to follow physical therapy routines; learning new ways to respond to stress; or addressing how to cope with past trauma. 
  • Mental health and substance abuse conditions are often addressed through health behavior change, and thus many MH/SA conditions come within behavioral health care, just as many other health conditions do. 
  • On the other hand, many mental health and substance abuse conditions have significant medical components and some may be mostly medical in nature, just as many other health conditions are mostly medical in nature. 

Thus behavioral health is an umbrella that includes MH/SA, but is not only MH/SA. The opposite is also true: biological and genetic health factors are an umbrella that also include MH/SA. If we recognized all of health as a holistic spectrum, we would recognize that most illnesses have biopsychosocial components, and treatment needs to align with each of those aspects, in relationship to the role each is playing in the specific person’s condition. It’s not an all or none, in any category. 

What are the problems when the terms behavioral health is (mis)used as synonymous with or as an alternative term for MH/SA?  

  • Inaccuracy: The problem is not with recognizing the benefits of behavioral intervention for MH/SA; it is about failing to recognize the need for behavioral intervention for a person with heart disease. Likewise, both MH and heart disease may benefit from pharmacological or other medical interventions. In the one, if we focus only on treating the behavior we may miss an underlying illness; in the other, if we fail to address behavioral health, we might preclude medical recovery. It is a barrier to understanding the inter-relationship between behavior and all of health, and thus a barrier to fully integrated, holistic health care.
  • Stigma: It is stigmatizing and hurtful to people with MH/SA conditions because the message is that the cause of the condition is a behavior (e.g., you drink too much; you are lazy; you are weak; thus you are to blame) OR that it is being called “behavioral” because the symptoms take the form of behavior that you are failing to control (e.g., you act out; you are violent; in other words, you are the problem.) It exacerbates the false separation between “mental” and “physical” health by re-categorizing them into “behavioral-fault” and “medical-not-your-fault.” 

It is a product of the inherent marginalization of persons within a stigmatized minority that the plea to avoid this hurtful language is so broadly ignored. 

Why is addressing stigma so important? 

The consequence of this historic stigma and discrimination in public attitudes is loss of successful health intervention, because:
  1. It diminishes the perceived importance of access to MH/SA health care (parity)
  2. It remains the single largest barrier to people seeking and accepting care

As long as people believe that if they seek help or acknowledge having an emotional crisis, they will be labelled and stigmatized in this way, we will face deep challenges in supporting individuals with these health conditions.

Wednesday, March 15, 2017

New Report: Behavioral Health Integration in Pediatric Primary Care

Thanks to Stakeholder Advisory Group member Jim Hester for bringing this to our attention:

New Report  

Behavioral Health Integration in Pediatric Primary Care: 

Considerations and Opportunities for Policymakers, Planners, and Providers
Much of the research on behavioral health integration (BHI) has focused on adults. But children are affected by mental disorders too. Estimates consistently indicate that 13% to 20% of US children have been diagnosed with a mental disorder. Yet not a single state in the country has an adequate supply of child psychiatrists, and 43 states are considered to have a severe shortage.

Models exist, however, for treating many of these children effectively in primary care settings that offer integrated, family-centered care. In this Milbank-sponsored report, Elizabeth Tobin Tyler, JD, MA, of Brown University, and Rachel L. Hulkower, JD, MSPH, and Jennifer W. Kaminski, PhD, of the Centers for Disease Control and Prevention, explore the prevalence of childhood behavioral health problems; describe the need for, barriers to, and models of BHI in pediatrics; and offer BHI policy and implementation considerations for policymakers, planners, and providers.

The report aims to help policymakers and providers who are looking for research-supported models of care that will improve the health of children with mental disorders. 

Sunday, March 12, 2017

Does ACT mean we don't need IBH-PC?

A recent article by IBH-PC consultants Deborah CohenFrank DeGruy and others reports a study of integration with many of the same goals as ours. It is based on a sub-analysis of the ACT study from Colorado. The key findings were improvement in depression (measured by interviews and by PHQ-9 depression score). These results are more good news for the idea of Integrating Behavioral Health and Primary Care.

Does this study (and other results of ACT) mean that the IBH-PC study is not needed? No - important as ACT is, there are a lot of limitations and unanswered questions that we will address in IBH-PC.

This analysis did not have a control group. IBH-PC has randomized concurrent controls.

Because it studied only patients with high scores on the PHQ-9 at baseline, it is subject to regression to the mean. IBH-PC will not select for high scores at baseline.

It had 475 patients from five practices, all in one state. IBH-PC will enroll 3,000 patients from 40 practices all over the country.

It addressed only depression.  IBH-PC will study a broad range of overlapping medical and behavioral conditions.

All of these issues weaken the conclusions that can be drawn and limit the ability of policy- and decision-makers to get fully behind integration. So, we soldier on!

Thanks

- Ben Littenberg

Outcomes of Integrated Behavioral Health with Primary Care
Bijal A. Balasubramanian, Deborah J. Cohen, Katelyn K. Jetelina, L. Miriam Dickinson, Melinda Davis, Rose Gunn, Kris Gowen, Frank V. deGruy III, Benjamin F. Miller, and Larry A. Green
J Am Board Fam Med March-April 2017; 30:130-139; doi:10.3122/jabfm.2017.02.160234

Abstract
Background: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care.
Methods: This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices.
Results: Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.
Conclusions: Integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care. Integration is a worthwhile investment; clinical leaders, policymakers, and payers should support integration in their communities.