Download Behavioral Health Integration: Screening and Identification

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