One Center

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Behavioral Health Consultation

• One Centers Journey Into Primary Care Mental
  Health
• Kirsten Ging, Psy.d
• Jacaranda Palmateer, Psy.D
• Chris Wera, CPA
• SCOTT CYPERS, Ph.D

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Introduction

• DU 11,500 Students (Spring 2011)
• 5,250 Undergraduate
• 4,600 Traditional Graduates
• 1,650 Non-Traditional Students
• 1000 International Students
• Health and Counseling Center (2010-11 Academic)
• 12,659 Primary Care Medical Visits
• 2,800 Nurse Visits
• 6,000 Mental Health Visits

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Organization
4
Why

• Suicide Prevention
• In 2007, there were 34,598 documented suicides in
  the United States, the 11th highest cause of
  death (CDC Annual Report)
• Over 4000 in the 15-24 age range die by suicide
  each year
• Suicide is the second leading cause of death in
  college students
• Only 20 of suicide victims had contact with a
  mental health provider in the month prior to
  their suicide compared to 45 had contact with a
  medical provider (Luoma et al, 2002)
• Only 15 of college aged people have seen a
  mental health provider in the last month, and
  only 24 in the past year 77 of people who
  commit suicide have seen a medical provider in
  the last year (Luoma et al, 2002)

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Why

• Access and early intervention issues
• Access issues are said to be the most significant
  reason why someone seeks a medical versus mental
  health appointment for psychological issues
  (Pomerantz, et al, 2004)
• The window of opportunity of effective treatment
  may be missed if treatment is delayed
• Only 1/3 of people with diagnosable mental health
  disorders EVER meet with a mental health
  professional (Gunn Blount, 2009)
• Approximately 32 of undiagnosed adults with
  mental health issues report that they would first
  seek assistance from a primary care medical
  professional only 4 stated that they would seek
  treatment with a psychologist (National Mental
  Health Association, 2000)
• Decreased wait time for specialty care in one VA
  study, wait time for a mental health appointment
  decreased from 3-6 weeks to 19 minutes
  (Pomerantz, et al, 2004)

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Why

• Integration
• The HCC has shared office space for around 8
  years and has been functionally integrated for
  approximately 6 years
• Increased collaboration between mental health and
  medical staff
• Improved crisis support for medical appointments
• Improved understanding of treatment options and
  approaches
• Multidisciplinary meetings and increased
  collaborative care with complicated cases

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What is a Behavioral Health Consultant

• Mental health provider
• Housed with the PC providers
• Performs short-term, solution-focused
  interventions
• Current, primary stress and trigger?
• Patients reaction?
• Patients resources (individual, familial,
  social)?
• Coping strategies ?
• Intervention
• Referral (longer-term counseling or
  hospitalization)?

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Implementation

• Brainstorming
• Selection of screening tool(s)
• How do we ____?

• Training
• Roll out
• Graduate Students Trainees

• Re-evaluation of process
• Added substance use/abuse screening

• Trying to make it permanent
• Future areas of development

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First Stage

• Brainstorming
• Identify the vision/goals
• Development
• Roadblocks and hiccups

• Selection of screening tool(s)
• PHQ-9
• Supplemental suicide screen
• How/when would it be administered
• Interrupt patient visit/cumbersome
• Would students be offended/honest

• How do we . . .?
• Administer the screen(s)
• Address self-harm/suicidal ideation
• Offer versus require consultations for high risk
  patients
• Handle coverage issues

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Patient Health Questionnaire 9 (PHQ-9)

• 10-question survey
• Computer administration/scoring
• Scoring guidelines for severity of depression and
  functional impairment
• Identifies self-harm/suicidal ideation risk
• (Kroenke and Spitzer, 2001)

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sample question
12
score report
13
Daily score summary
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Second Stage Training

• Met as a full staff (medical, counseling,
  administration)
• Discussed how to use the PHQ-9 and scoring
• Established cut-off scores (ranges) for
  referral
• Discussed process for patients with
  self-harm/suicidal ideation risk
• Suggested ways to refer and the warm handoff
• Walked through the process from beginning to end

A Sample Script For How To Refer I noticed
your answers on the survey, and it seems like you
are having a hard time. I have a colleague that
can come, spend some time with you and help you
figure some things out. Would you be willing to
meet with her right now?
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Second Stage Roll Out

• Started with only two providers
• Trouble-shooting
• What happens if scores get missed
• Moved my notes to mental health in EHR
• Decided not to use supplemental survey for SI
• Random answering
• International students/translation difficulties
• Gradually added in the rest of the providers
• Interviewed and selected two Graduate Student
  Trainees (GSTs)

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Third Stage

• Re-evaluation
• Statistical analysis
• Werent seeing the high scores we anticipated
• Use a different screening instrument?
• Added substance use/abuse screening
• Added four questions that were incorporated into
  the survey
• Problems encountered
• Scoring
• Pushback

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Fourth Stage

• Trying to make it permanent
• Ideas for future development
• How can we make it more robust
• Biofeedback
• Translate into different languages
• Continue screening for substance use/abuse

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Interventions

• Motivational interviewing
• Behavioral activation
• Cognitive-Behavioral Therapy
• Third-wave
• How can we suffer better?
• Coping strategies
• Psycho-education

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Cultural Considerations

• International students 1000
• Translation of PHQ-9
• Common for international students to misinterpret
  questions
• Guess at what the question asked
• High scores
• However, the BHC reached international students
  who might not otherwise come in

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Case Presentation

• Jane is a 27-year-old female graduate student
• Presented for a womens annual exam
• PHQ-9 score 13

• More than half the days
• Little interest/pleasure
• Feeling down, depressed, or hopeless
• Having little energy
• Feeling bad about yourself
• Troubles concentrating

• Several days
• Troubles falling asleep
• Poor appetite
• Feeling fidgety and restless

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Case Presentation

• Referral information
• Had been stressed out since beginning graduate
  school
• Experienced low libido

• Additional information
• Spent almost all of her time focusing on school
• Felt like she was neglecting her relationships
• About to graduate and worried about
  post-graduation plans
• Described herself as high strung,
  perfectionistic, and always anxious

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Case Presentation

• First Meeting
• Collaboratively established what to target
• Self-care and behavioral activation (BA)
• Boyfriend
• talk without distractions
• go for a walk holding hands
• sensate focus
• Rewarding experiences
• Museums
• cooking/baking
• bike riding
• Diet and exercise
• eat healthier
• yoga
• Made specific goals (how often, how long)

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Case Presentation

• Second Meeting
• Reviewed what helped
• Discussed tendency to ruminate
• Cognitive distortions
• Rules vs consequences
• Mindfulness/grounding/breathing

• First Meeting
• Collaboratively established what to target
• BA and self-care
• Boyfriend
• Rewarding experiences
• Diet and exercise
• Made specific goals (how often, how long)

• Third Meeting
• Reviewed what helped
• Discussed new stressors
• Fears of post-graduation plans
• On-going family issues
• Explored benefits of therapy for deeper issues

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• Handouts
• Anxiety
• Panic Attacks
• Depression
• Sleep hygiene
• Nutrition
• Fatigue
• Cognitive distortions
• Counseling FAQs
• Diaphragmatic breathing
• Reduced risk drinking

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Medical Provider Her perspective

• Advantages
• Same day, same time
• Avoids future scheduling issues
• Helps to identify somatizing
• Reduces, Oh, by the way
• Reduces chances of missing mental health issues
• Handles patients in acute crisis

• Drawbacks
• Irritation with repeated surveying
• Scores can be more indicative of medical illness
  vs mental health
• Difficult for international students which leads
  to inaccurate information
• Havent used survey as a measure of treatment,
  just screening

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Overall Score Analysis

• Fall Quarter

• Winter Quarter

N1752
N1916
Mean SD Normal
1 0.36 0.673 N
2 0.32 0.604 N
3 0.73 0.897 Y
4 0.84 0.851 Y
5 0.43 0.734 M
6 0.23 0.594 N
7 0.35 0.707 N
8 0.12 0.439 N
9 0.03 0.198 N
10 0.39 0.644 N
Total Score 3.79 4.668 N
Mean SD Normal
1 0.33 0.651 N
2 0.28 0.59 N
3 0.69 0.859 Y
4 0.76 0.799 Y
5 0.39 0.668 N
6 0.19 0.518 N
7 0.32 0.672 N
8 0.1 0.367 N
9 0.03 0.214 N
10 0.33 0.564 N
Total Score 3.41 4.273 N
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Overall Score Analysis

• Spring Quarter

• Quarter by Quarter 10-11

N1919
Mean SD Normal
1 0.364 0.67 N
2 0.28 0.66 N
3 0.69 0.86 Y
4 0.76 0.86 Y
5 0.39 0.77 M
6 0.20 0.54 N
7 0.33 0.69 N
8 0.10 0.41 N
9 0.03 0.30 N
10 0.33 0.60 N
Total Score 3.43 4.36 N
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Overall Score Analysis

• Fall Quarter

• Winter Quarter

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Overall Score Analysis

• Fall Quarter

• Winter Quarter

PHQ-9 Score Frequency Valid Percent Cumulative Percent
0 479 27.3 27.3
1 204 11.6 39.0
2 232 13.2 52.2
3 184 10.5 62.7
4 139 7.9 70.7
5 100 5.7 76.4
6 87 5.0 81.3
7 55 3.1 84.5
8 54 3.1 87.6
9 42 2.4 90.0
10 28 1.6 91.6
11 19 1.1 92.6
12 11 .6 93.3
13 23 1.3 94.6
14 10 .6 95.1
15 17 1.0 96.1
16 17 1.0 97.1
17 12 .7 97.8
18 6 .3 98.1
19 7 .4 98.5
20 6 .3 98.9
21 2 .1 99.0
22 3 .2 99.1
23 3 .2 99.3
24 4 .2 99.5
25 2 .1 99.7
26 2 .1 99.8
27 1 .1 99.8
28 2 .1 99.9
30 1 .1 100.0
Total 1752 100.0  
PHQ-9 Score Frequency Valid Percent Cumulative Percent
0 594 31.0 31.0
1 242 12.6 43.6
2 232 12.1 55.7
3 181 9.4 65.2
4 133 6.9 72.1
5 108 5.6 77.8
6 78 4.1 81.8
7 74 3.9 85.7
8 68 3.5 89.2
9 48 2.5 91.8
10 24 1.3 93.0
11 30 1.6 94.6
12 17 .9 95.5
13 18 .9 96.4
14 9 .5 96.9
15 10 .5 97.4
16 14 .7 98.1
17 7 .4 98.5
18 5 .3 98.7
19 3 .2 98.9
20 4 .2 99.1
21 7 .4 99.5
22 2 .1 99.6
23 1 .1 99.6
24 2 .1 99.7
25 1 .1 99.8
26 2 .1 99.9
30 2 .1 100.0
Total 1916 100.0  
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Score Summary

• Non-Acute
• Fall Quarter 90
• Winter Quarter 91.8
• Spring Quarter 93.1
• Intervention by PHQ-9 Score
• Fall Quarter 10
• Winter Quarter 8.2
• Spring Quarter 6.9
• Acute
• Fall Quarter 1.5
• Winter Quarter 1.1
• Spring Quarter 1.1

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Total Visits to Number of BHC Visits

• Total Visits - Fall Spring Quarter
• N5587
• Actual BHC Visits
• N 216
• 3.87
• Expected as much at 10
• About 6 that decline BHC Consult
• BHC Visit Initiation
• 43 from PHQ-9 Score
• 57 with scores 11 and below

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Conclusions Questions

1. Increased medical provider awareness about mental
   health issues
2. Allowed PCPs to briefly address mental health
   issues because they had someone who could follow
   up immediately
3. Provided students with instant access to a mental
   health provider who could briefly intervene or
   facilitate referral
4. Established a more efficient system for handling
   crises on the medical side
5. Aided in our suicide prevention efforts
6. Facilitated collaboration and integration of
   medical and mental health issues, especially for
   complicated cases
7. Reached a larger number of international students
8. Improved the relationship between the medical
   and mental health providers

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References Resources

• Gunn, W. B., Blount, A. (2009). Primary care
  mental health A new frontier for psychology.
  Journal of Clinical Psychology, 65 (3), 235-252.
• James, L. C., ODonohue, W. T. (2009). The
  Primary Care Toolkit Practical Resources for
  the Integrated Behavioral Care Provider. New
  York Springer. 
• Hunter, C. L., Goodie, J. L., Ooordt, M. S.,
  Dobmeye, A. C. (2009) Integrated Behavioral
  Health in Primary Care. Washington, D. C.
  American Psychological Association.
• Kroenke, K., Spitzer, R. L., Williams, J. B.
  (2001). Validity of a brief depression severity
  measure. Journal of General Internal Medicine,
  16 (9), 606-613.
• Luoma, J. B., Martin, C. E., Pearson, J. L.
  (2002). Contact with mental health and primary
  care providers before suicide A review of the
  evidence. The American Journal of Psychiatry,
  159 (6), 909-916. 
• Pomerantz, A., Cole, B. H., Watts, B. V.,
  Weeks, W. B. (2008). Improving efficiency and
  access to mental health care combining
  integrated care and advanced access. General
  Hospital Psychiatry, 30 (6), 546-551.
• Robinson, P. J., Reiter, J. T. (2007).
  Behavioral Consultation and Primary Care A
  Guide to Integrating Services. New York
  Springer.