For many mental health providers, the focus on providing evidence-based treatments for deployment-related issues allows us to improve treatment outcomes for the patients in front of us. However, what about the patients who never make it to our door? While we know that many Service Members and Veterans are not likely to seek out specialty mental health care, patients do have regular contact with their primary care providers (PCPs).For many Service Members, the primary care clinic is the only contact with medical care, the place where the rubber meets the road, and all health care gets done.
Not surprisingly, mental health issues can drive these primary care contacts . In fact, 70-85% of primary care visits are attributable to psychosocial and behavioral causes (Gatchel & Oordt, 2003). Many of the issues that appear to drive these primary care visits are also the most common complaints of members returning from deployment and include; adjustment problems, sleep difficulties, and depressed mood. PCPs may or may not be aware of these mental health issues, and patients may or may not agree to a mental health referral, leaving a large portion who do not receive mental health care. Even when PCPs are made aware of these issues, efforts to provide treatment may be limited by lack of training on best practices.
Integrated behavioral healthcare models have been introduced to take mental health providers where the patients are by embedding them in primary care settings. While these providers, often known as Behavioral Health Consultants (BHCs), do not provide therapy, their consultations and coaching have been shown to lead to significant improvement in general distress among Service Members and Veterans (Bryan et al, 2012). Interestingly, follow-up research now shows that these improvements are maintained over time.
In the study “Longitudinal Outcomes After Brief Behavioral Health Intervention in an Integrated Primary Care Clinic” (Ray-Saanerud et al., 2012), we evaluated global mental health function after an average of two years post-consultation with a BHC to assess changes over time. The study specifically focused on patients who were seen via the USAF’s Behavioral Health Optimization Program (BHOP) service, which is an integrated model (based on Robinson & Reiter, 2007) in which BHCs see patients for brief 15-30 minute appointments, typically up to four appointments total. PCPs refer their patients to the BHC, who provides interventions and recommendations to address the PCP’s concerns; PCPs retain responsibility for patient care. The study was conducted at the BHOP service at Lackland AFB, TX, in the Family Medicine Clinic, and patients were either active-duty Service Members, retired Veterans, or their family members.
A total of 70 patients who were seen for an average of 1.6 appointments responded, with the majority of patients having just one appointment (57.1%) with the BHC. Patients completed the Behavioral Health Measure (BHM), a 20-item self-report of mental health function, on a scale of 0 to 4 where 4 is the best possible score. Scores improved to the normal range (from 2.6 on average to 3.01 on average) by patients’ final BHC appointment, and remained normal at follow-up (3.01 on average) two years later. Of note, patients whose initial scores were in the severely distressed range actually continued to improve after their last appointment with the BHC, from an average of 1.6 pre-consultation to an average of 2.1 post-consultation to an average of 2.5 at follow-up. These results held even when accounting for mental health treatment in between the final BHC appointment and follow-up, which 37.1% of the sample received.
The study demonstrated that gains made via intervention by an integrated behavioral health care provider in a primary care setting are not only significant, but are also lasting. Although these interventions were not therapy, the consultations clearly had an impact on patients’ report of distress. This gets me thinking – how many service members and veterans never go to mental health, but would be willing to see a BHC? What if just one visit post-deployment could reduce the likelihood of developing adjustment problems, chronic sleep disturbance, depression, or PTSD or even increase the likelihood that a connection to mental health care would be made if needed? While more research is indicated, it does not seem far-fetched to think that many post-deployers would benefit from this model, whether newly returned or back for a while .
When we consider how many patients may never set foot in a mental health clinic that are treated solely by their PCPs, going to where our patients need us as the DoD and VA have done makes sense. Moreover, I would argue healthcare providers from all backgrounds should start to consider integrated primary care the first line approach to not only Service Members and Veterans, but to the population in general. Let the rubber meet the road!
Dr. Diana Dolan is a Deployment Behavioral Health Psychologist with the CDP at Lackland AFB, TX. Dr. Dolan passes on her prior military experience as a provider in primary care to the psychology and social work interns at Wilford Hall USAF Medical Center.
Bryan, C. J., Corso, M.L., Corso, K.A., Morrow, C.E., Kanzler, K.E., Ray-Sannerud, B. (2012). Severity of mental health impairment and trajectories of improvement in an integrated primary care clinic. Journal of Consulting and Clinical Psychology 80(3): 396-403.
Gatchel, R.J. & Oordt, M.S. (2003). Clinical health psychology and primary care: praxctical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association. Doi:10.1037//10592-000.
Ray-Sannerud, B.N, Dolan, D.C., Morrow, C.E., Corso, K.A., Kanzler, K.E., Corso, M.L., & Bryan, C.J. (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health 30(1): 60-71.
Robinson, P.J., & Reiter, J.T. (2007) Behavioral consultation and primary care: a guide to integrating services. New York, NY: Springer.