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Behavioral Health Integration: Screening and Identification Neil Korsen, MD, MSc Quality Counts April 11, 2012 Outline Identifying patients who may benefit from behavioral health integration: – Screening for common behavioral health problems Depression Anxiety disorders Substance use disorders – Supporting health behavior change for chronic illness care – Evaluation and treatment of common symptoms such as headache, fatigue, other pain syndromes that are often associated with psychosocial factors. Screening for Depression High risk populations People with chronic illnesses or chronic pain People with a disability People with substance abuse problems Kids with school, sleep or behavior problems People with persistent somatic complaints and negative workup PATIENT QUESTIONNAIRE (PHQ-9) Name: Date: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “ ” to indicate your answer) More Nearly Several Not at all than half every days the days day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way. 0 1 2 3 _____ + _____ + _____ 3. Trouble falling/staying asleep, sleeping too much Add Columns: (Healthcare professional: For interpretation of TOTAL, please refer to back of page) TOTAL: _______ If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all _______ Somewhat difficult _______ Very difficult _______ Extremely difficult _______ Patient Health Questionnaire (PHQ) Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc. Scoring the PHQ-9 First 9 questions: add columns vertically, then tally across bottom of page Total score: 0 to 27 10th question is “Function Score”: what degree depression symptoms have made it difficult for the patient to function in their everyday life Degree of functional difficulty can help determine whether to start active treatment in people with mild symptoms. Guideline: Initial Management & Follow-up Score/ Symptom Level 0-4 No depression 5-9 Mild 10-14 Moderate 15-19 Moderately Severe 20-27 Severe Treatment Follow-up PHQ-9 Consider other diagnoses (Annual screen with chronic conditions or depression hx) Consider other diagnoses If diagnosis is depression, watchful waiting is appropriate initial management 12 months Consider watchful waiting If active treatment is needed, medication or psychotherapy is equally effective; consider function score in choosing treatment 3 - 6 months Active treatment with medication or psychotherapy is recommended Medication or psychotherapy is equally effective 1 – 3 months Medication treatment is recommended For many people, psychotherapy is useful as an additional treatment People with severe symptoms often benefit from consultation with a psychiatrist 1 – 3 months What is Watchful Waiting? Est. 1/3 with mild symptoms will recover without treatment. Watchful waiting: – Seeing pt monthly and monitoring PHQ-9 score, but not starting active treatment. – Encourage self-care activities such as exercise or relaxation. If symptoms have not resolved after 2-3 mos, consider active treatment. PHQ-9 as Outcome Measure Can be used to follow response to treatment Validated as a measure of change and can be used to create an algorithm to guide treatment decisions Interpreting Follow Up Scores PHQ-9 - Change from last score, measured monthly Treatment Response Treatment Plan Drop of 5 or more points each month Good Antidepressant &/or Psychotherapy No treatment change needed. Follow-up in 4 weeks. Drop of 2-4 points each month Fair Antidepressant: May warrant an increase in dose. Psychotherapy: Probably no treatment change needed. Share PHQ-9 with psychotherapist. Drop of 1 point, no change or increase each month Poor Antidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy. Psychotherapy: 1. If depression-specific psychotherapy discuss with supervising psychiatrist, consider adding antidepressant. 2. For patients satisfied in other psychotherapy consider adding antidepressant. 3. For patients dissatisfied in other psychotherapy, review treatment options and preferences. Goals of Treatment Remission: score of 0-4 after an initial score >10 Clinical response: score <10 after an initial score >10 Screening for Anxiety Disorders Anxiety Disorders Anxiety disorders often accompany depression. Common anxiety disorders include: Generalized anxiety disorder (GAD) Panic disorder Post–traumatic stress disorder (PTSD) Social phobia Anxiety Disorders Very common 30% lifetime prevalence in women 20% lifetime prevalence in men Often present with physical symptoms to primary care GAD-7 - Scoring GAD-7 Score Symptoms Treatment Recommendations 5-9 Mild Watchful waiting 10-14 Moderate Psychotherapy – first line of treatment >15 Severe Medication and/or psychotherapy NICE Treatment Guidelines Step 1 ID & assessment; education about GAD and tx options; active monitoring Step 2 Low-intensity psychological interventions: nonfacilitated or guided self-help, psycho-ed groups Step 3 High-intensity psychological intervention: CBT/ applied relaxation or drug treatment Step 4 Specialty treatment: drug and/or psychological treatment; input from multi-agency teams, crisis services, day hospitals or inpatient care http://guidance.nice.org.uk/ Screening for Substance Use Disorders Substance use disorders An estimated 17.6 million American adults (8.5%) meet diagnostic criteria for an alcohol use disorder. Approximately 4.2 million (2%) meet criteria for a drug use disorder. Overall, 19.4 million of American adults (9.4%) meet clinical criteria for a substance use disorder either an alcohol or drug use disorder or both. About 20% of persons with a current substance use disorder experience a mood or anxiety disorder at the same time and vice versa. MaineHealth Adult Wellbeing Screener – Substance Abuse During the past year: No Yes 7. Have you had 4 or more drinks (women) / 5 or more drinks (men) in a day? 8. Have you used an illegal drug or used a prescription drug for a nonmedical reason? Question 7 is recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The single-question screen was 81.8% sensitive and 79.3% specific in the detection of unhealthy alcohol use.* Question 8 was found to be 100% sensitive and 74% specific for identifying people with a drug use disorder in a 2007 study. A “yes” answer to either question 7 or 8 is a positive screen for substance abuse.** *Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. J Gen Intern Med 2009 **Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Arch Int Med 2010 Further Assessment after Positive Screen Adults – alcohol AC-OK AUDIT CAGE Adults – other drugs DAST Adolescents CRAFFT SAMHSA list of substance screening and assessment instruments: http://www.ncsacw.samhsa.gov/files/SAFERR_AppendixD.pdf Implementing Screening A script for the person distributing the tools Who will score forms and when? How will assessment follow screening? How will results get documented? Consider a daily huddle: Role of Behavioral Health Clinician with Chronic Medical Conditions Chronic condition management involves self-management Self-management involves behavior change Behavioral health clinicians can play a role in supporting behavior change – Use of health and behavior codes Impact of Integration on Outcomes of Chronic Medical Conditions Improved outcomes for both medical and co-morbid mental health conditions Improved patient experience Cost impact may be neutral or show slight savings – E. Lin, personal communication, 2012 Integration and Common Physical Symptoms Estimates range from 25-75% of people with common symptoms such as headache, other pain syndromes, and fatigue have no ‘medical’ cause found after reasonable evaluation (Kroenke, 2003) Emerging literature that past or present psychosocial stress and/or common behavioral health conditions are commonly associated with these symptoms Screening and Assessment Tools Scoring and Treatment Guidelines Tools and guides to treatment posted: www.mainehealth.org/mentalhealthintegration Located in Links under Clinical Tools References Kroenke K, et al. Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection. Ann Intern Med. 2007;146:317-325. Kroenke K, Patients Presenting with Somatic Complaints. International Journal of Methods in Psychiatric Research. 2003; 12: 34-43. Kroenke, Spitzer, and Williams. The PHQ-9: Validation of a Brief Depression Severity Measure. Journal of General Internal Medicine. 2001; 16:606-613. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary Care Validation of a Single-Question Alcohol Screening Test. J Gen Intern Med 2009; 24:783-788 Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A Single Question Screening Test for Drug Use in Primary Care. Archives of Internal Medicine 2010; 170:1155-1160