How do integrated behavioral health providers treat anxiety in routine clinical practice? Robyn L....
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Transcript of How do integrated behavioral health providers treat anxiety in routine clinical practice? Robyn L....
How do integrated behavioral health providers treat anxiety in
routine clinical practice?Robyn L. Shepardson, Ph.D., Clinical Research PsychologistJennifer S. Funderburk, Ph.D., Clinical Research Psychologist
VA Center for Integrated Healthcare
Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.
Session # H1aFriday, October 16, 2015
Faculty Disclosure
The presenters of this session• have NOT had any relevant financial
relationships during the past 12 months.
Research Funding:This research was supported by the 2014 Research and Evaluation Fellowship from CFHA and a VA VISN 2 Center for Integrated Healthcare pilot grant.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• List the intervention techniques most commonly used by integrated behavioral health providers to treat anxiety symptoms
• Identify the most common comorbid symptoms among primary care patients referred for anxiety symptoms
• Discuss different approaches to handling presentations of comorbid anxiety and depression
Bibliography / Reference
1. Auxier, A., Runyan, C., Mullin, D., Mendenhalll, T., Young, J. & Kessler, R. (2012). Behavioral health referrals and treatment initiation rates in integrated primary care: A Collaborative Care Research Network study. Translational Behavioral Medicine, 2, 337-344.
2. Combs, H., & Markman, J. (2014). Anxiety disorders in primary care. Medical Clinics of North America, 98, 1007-1023. doi:10.1016/j.mcna.2014.06.003
3. Funderburk, J. S., Dobmeyer, A. C., Hunter, C. L., Walsh, C. O., & Maisto, S. A. (2013). Provider practices in the primary care behavioral health (PCBH) model: An initial examination in the Veterans Health Administration and United States Air Force. Families, Systems, & Health, 31, 341-353.
4. Funderburk, J. S., Sugarman, D. E., Maisto, S. A., Ouimette, P., Schohn, M., Lantinga, L., … Strutynski, K. (2010). The description and evaluation of the implementation of an integrated healthcare model. Families, Systems, & Health, 28, 146-160.
5. Funderburk, J. S., Sugarman, D. E., Labbe, A. K., Rodrigues, A., Maisto, S. A., & Nelson, B. (2011). Behavioral health interventions being implemented in a VA primary care system. Journal of Clinical Psychology in Medical Settings, 18, 22-29.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
VETERANS HEALTH ADMINISTRATION
Overview
• Anxiety in primary care
• Approach to treating anxiety within PCBH
• Study methods
• Study results
• Group discussion
6
VETERANS HEALTH ADMINISTRATION
Anxiety in Primary Care
• Prevalence of 15-20% for any anxiety disorder
• Subthreshold anxiety is also common
• High comorbidity with depression and other symptoms/problems
7(Ansseau et al., 2004; Kaufman & Charney, 2000; Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007; Niesenson, Pepper, Schwenk, & Coyne, 1998; Rodriguez et al. 2004; Rucci et al., 2003)
VETERANS HEALTH ADMINISTRATION
Anxiety in Primary Care
• Impairment
– Decreased quality of life
– Worse psychosocial functioning
– High burden of disability
– Over and above comorbid MDD
– Even subthreshold symptoms
8(Batelaan et al., 2007; Beard, Weisberg, & Keller, 2010; Kessler et al., 2005; Mendlowicz & Stein, 2000; Olatuni, Cisler, & Tolin, 2007; Sherbourne et al., 2010; Stein et al., 2005)
VETERANS HEALTH ADMINISTRATION
Anxiety in Primary Care
• Recent growth of integrated care, including the Primary Care Behavioral Health (PCBH) model
• Integrated behavioral health providers (BHPs) in primary care to provide brief treatment
• Anxiety is 2nd most common reason for referral to BHPs
9
(Auxier et al., 2012; Bryan, Morrow, & Appolonio, 2009; Cigrang et al. 2006; Funderburk et al., 2010, 2011)
VETERANS HEALTH ADMINISTRATION
Anxiety in Primary Care
• Strong need for effective brief interventions for anxiety
• But little available for 1-6 30-minute session format
• BHPs likely adapting interventions designed for specialty mental health
• But how?
10
VETERANS HEALTH ADMINISTRATION
Anxiety in Primary Care
• How exactly are BHPs treating anxiety in clinical practice?
• Chart review study (N = 180 Veterans)• Most common interventions for patients with anxiety
– 23% patient education– 20% behavioral activation– 20% supportive therapy– 14% cognitive techniques– 12% relaxation training
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(Bryan et al. 2012; Funderburk et al., 2011)
VETERANS HEALTH ADMINISTRATION
Primary Aim
• Examine how BHPs treat patients with anxiety in integrated primary care settings
• What types of interventions are used?
12
VETERANS HEALTH ADMINISTRATION
Secondary Aims
• Assess the type and prevalence of comorbid mental and behavioral health symptoms among patients presenting with anxiety
• Examine how BHPs approach treatment of comorbid anxiety and depression
13
VETERANS HEALTH ADMINISTRATION
Methods
• National web-based survey of integrated BHPs
• Focused on PCBH model of integrated care
• Recruited from 6 relevant email list servs
• Participants completed eligibility screener, provided informed consent, then completed 15-minute survey
• Compensation: handout on free clinical resources helpful with treating anxiety in IPC
14
VETERANS HEALTH ADMINISTRATION
Eligibility Criteria
Inclusion criteria: • has worked in IPC setting for at least 6 months
• currently practicing integrated BHP (at least 1 day/week over last month)
• working in PCBH model of integrated care
• has at least Master’s degree or equivalent graduate training (≥2 years) in a relevant field (e.g., psychology, social work, MFT, counseling)
• has Internet access and working email address
Exclusion criteria:• psychiatric prescriber
15
VETERANS HEALTH ADMINISTRATION
Survey
• Participant demographics
• Patient and session characteristics
• Patient symptoms/problems
• Interventions used in last session
• General approach to handling comorbid anxiety and depression
16
VETERANS HEALTH ADMINISTRATION
Definition of AnxietyWe are interested in how integrated behavioral health providers (BHPs) assess and treat patients who have a primary presenting complaint of non-PTSD anxiety.
By non-PTSD anxiety we mean symptoms of: • generalized anxiety disorder• panic disorder• agoraphobia• social anxiety disorder• specific phobia• anxiety not otherwise specified / unspecified or other specified anxiety disorder• adjustment disorder with anxiety or with mixed anxiety and depressed mood
Symptoms can be: • subthreshold – not reaching the threshold for a clinical diagnosis based on DSM-
IV/DSM-5 or • threshold – reaching the level of a clinical diagnosis
17
VETERANS HEALTH ADMINISTRATION
Sample Size
• 329 providers accessed survey– 8% did not meet eligibility criteria– 92% were eligible
• Of those eligible, 96% participated
• N = 291 participants
18
VETERANS HEALTH ADMINISTRATION
Participant Demographics
• Age M = 40.2 years (SD = 10.9), range: 26-72
• 76% Female
• 9% Hispanic or Latino
• 88% White
19
VETERANS HEALTH ADMINISTRATION
Participant Characteristics
20
Psychologist Social worker Master's level counselor
RN or other nurse
Other0%
25%
50%
75%
100%
59%
26%
11%1% 2%
Type of Provider
other: 4 MFTs, 3 other
VETERANS HEALTH ADMINISTRATION
Participant Characteristics
21
Cogni
tive-
beha
viora
l
Eclecti
c or i
nteg
rativ
e
Accep
tanc
e & C
omm
itmen
t The
rapy
Behav
iora
l
Family
syste
ms
Psych
odyn
amic/
psy
choa
nalyt
ic
Human
istic/
exis
tent
ial
Insig
ht-o
rient
ed
Inte
rper
sona
l
Other
0%
25%
50%
75%
100%
52%
21%9% 6% 3% 3% 2% 1% 1% 2%
Theoretical Orientation
VETERANS HEALTH ADMINISTRATION
Participant Characteristics
22
VA FQHC Outpatient clinic or hospital
CMHC DOD Other0%
25%
50%
75%
100%
41%
21% 25%
3% 1%10%
Primary Work Setting
other: 6% primary care practice, 1% academic medical center, 3% other
VETERANS HEALTH ADMINISTRATION
Patient Demographics
• Age M = 41 years (SD = 16), range: 7-99
– 6% (n = 16) under age 18
• 44% Female
• 12% Hispanic or Latino
• 74% White, 12% Black
• 46% on medication for anxiety
23
VETERANS HEALTH ADMINISTRATION
Session Characteristics
• 95% individual
• 97% face-to-face
• M = 38 minutes (SD = 12), median = 35, range: 10-73
24
VETERANS HEALTH ADMINISTRATION
Anxiety
• Severity of anxiety symptoms– 20% subthreshold/mild– 65% moderate– 16% severe
• DSM-5 anxiety diagnoses– 96% met criteria for dx– 18% had >1 dx– Most common were 32% GAD, 26% Anxiety NOS, 20% Panic
disorder, 16% Adjustment disorder with anxiety
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VETERANS HEALTH ADMINISTRATION
Comorbid Symptoms/Problems
26
Sleep
Depress
ion
Stress
/adju
stm
ent
Chronic
pain
Medica
l pro
blem
s
Obesit
y
Tobacco u
se
Alcohol m
isuse
Oth
er
Substance
misu
se
Med a
dherence
None
Suicidality
PTSD
Mania
/hyp
omania
Psych
osis
Dementia
0%
10%
20%
30%
40%
50%
60%
70%
61% 59%56%
23%19%
16%12% 11%
7% 7% 6% 5% 5% 4% 2% 2% 1%
95% at least 1 other symptom besides anxietyM = 2.9 (SD = 1.5), median = 3, range: 0-8
VETERANS HEALTH ADMINISTRATION
Depression
• Severity of depression symptoms– 14% not applicable– 52% subthreshold/mild– 29% moderate– 5% severe
• DSM-5 depression diagnoses– 53% met criteria for dx– 16% Depression NOS, 16% Adjustment disorder with
depressed mood, 12% MDD
27
VETERANS HEALTH ADMINISTRATION
Most Common Interventions
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Technique Prevalence Mean (SD) # of minutes
(among users)
Psycho-education about anxiety 85% 9.2 (7.3)
CBT education 80% 9.2 (6.2)
Relaxation training 66% 7.8 (5.2)
Supportive therapy 66% 10.3 (10.7)
Cognitive therapy 47% 8.4 (6.2)
Behavioral activation 44% 5.0 (3.0)
Stress management 41% 4.9 (3.8)
Self-monitoring 33% 5.5 (3.4)
VETERANS HEALTH ADMINISTRATION
Less Common Interventions
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Technique Prevalence Mean (SD) # of minutes
(among users)
Mindfulness/meditation training 32% 6.3 (4.4)
Motivational interviewing 28% 8.4 (10.4)
Medication information 28% 3.5 (2.4)
Problem-solving training 24% 6.2 (4.5)
Crisis/risk assessment 24% 3.8 (2.9)
Exposure 24% 9.1 (7.8)
Sleep interventions 17% 5.1 (2.4)
ACT-based interventions 16% 7.2 (6.2)
Other 17% 6.0 (6.6)
VETERANS HEALTH ADMINISTRATION
Interventions
• Total number of interventions used – Mean = 6.6 (SD = 2.1), median = 6, range: 1-14
30
1 2 3 4 5 6 7 8 9 10 11 12 13 140
10
20
30
40
50
60
Total Number of Interventions Used
Nu
mb
er
of
Pro
vid
ers
VETERANS HEALTH ADMINISTRATION
Approach to Handling Comorbid Anxiety & Depression
• General approach– 87% I typically target both at the same time– 13% I typically target one at a time
• How?– 50% I explain the inter-relationship between anxiety and depression– 36% I offer one intervention that can target both conditions– 12% I offer one intervention for anxiety and one intervention for
depression– 1% Other
31
VETERANS HEALTH ADMINISTRATION
Approach to Handling Comorbid Anxiety & Depression
• General approach– 87% I typically target both at the same time– 13% I typically target one at a time
• Assuming suicidality is not a concern, which first?– 55% Whichever condition the patient prefers to target first– 29% Whichever condition causes more functional impairment based
on my clinical opinion– 6% Depressive symptoms– 6% Anxiety symptoms– 3% Other
32
VETERANS HEALTH ADMINISTRATION
Discussion: Patient Presentation
• Complex patients– 80% had moderate to severe anxiety– 95% also had (~3) other symptoms/problems– Insomnia, depression, stress/adjustment– Problems related to chronic medical conditions
• Challenges for BHPs? PCPs?
• Implications of comorbidity & complexity for development and implementation of anxiety treatments?
33
VETERANS HEALTH ADMINISTRATION
Discussion: Interventions• BHPs are using many interventions
– Mean = 6.6 techniques– 50% used 6 or more techniques– Little time (3-10 minutes) spent on any 1 technique
• Most BHPs (87%) try to target anxiety and depression at the same time
• Implications of this brevity for quality / fidelity?• Pros and cons of using so many different techniques?• Implications for research – how to identify key ingredients?
34
VETERANS HEALTH ADMINISTRATION
Discussion: Interventions• Types of interventions
– Psycho-education about anxiety & CBT, supportive therapy, relaxation training used by 2/3
– Exposure, cognitive therapy, mindfulness/meditation less common
• Training deficits vs. deliberate adjustments?
• How does evidence-based treatment fit in the real-world PCBH context?
• How can PCPs and medical providers use this information?
35
VETERANS HEALTH ADMINISTRATION
Questions
VA Center for Integrated Healthcare
visit us at
http://www.mirecc.va.gov/cih-visn2/
36
Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!
VETERANS HEALTH ADMINISTRATION
Relaxation & Mindfulness/Meditation
38
Relaxation exercise Prevalence Mindfulness/ meditation exercise
Prevalence
Deep breathing 79% Mindful breathing 55%
Progressive muscle relaxation
28% Meditation 25%
Guided imagery 27% Other mindfulness technique
39%
Autogenic relaxation 4% Other 14%
Other 9%