Johanna Klaus

The Behavioral Health Laboratory: building a stronger foundation for the patient-centered medical home.

The Veterans Health Affairs is in the process of implementing a new model for the delivery of primary care: The Patient-Centered Medical Home (PCMH). One critical challenge of any PCMH model will be the integration of basic mental health treatment into primary care. Such a mental health integration program must be flexible enough to incorporate new evidence-based treatments as patient demographics and health care needs evolve over time. This paper summarizes the Behavioral Health Laboratory (BHL) care management model, a program already in place in more than 20 Veterans Affairs facilities along with private sector insurance providers, as ideally suited to fill this role in the PCMH. The BHL uses a platform of standardized, software-aided mental health assessments and clinical care managers to deliver evidence-based treatments for depression, anxiety, and substance abuse in primary care settings. The authors review this comprehensive program of screening, assessment, treatment, and referral to specialty care when needed. The BHL program is consistent with the guiding principles of the Patient-Centered Medical Home: applying chronic illness disease management principles to provide more continuous, coordinated, and efficient primary care services to patients with diverse needs. Just as importantly, the authors review how this standardized platform for delivering integrated mental health services provides the flexibility to incorporate novel interventions for a changing population.

Missed Opportunities: Fewer Service Referrals After Positive Alcohol Misuse Screens in VA Primary Care

OBJECTIVE The primary purpose of this study was to compare referral to additional clinical services after primary care clinicians screened for and found a positive screen for alcohol misuse, depression, or posttraumatic stress disorder (PTSD). METHODS Results from the Alcohol Use Disorders Identification Test, Patient Health Questionnaire 2, and Primary Care PTSD screens performed over two years at the Philadelphia Veterans Affairs (VA) Medical Center and affiliated VA community sites were analyzed by mixed-effects logistic regression. A total of 9,052 veterans with positive screens were eligible for additional clinical services. RESULTS Odds of referral to additional clinical services for positive depression or PTSD screens were significantly higher than for positive screens for alcohol misuse (odds ratio=10.60 and 19.49, respectively). CONCLUSION Primary care-based screening for alcohol misuse is managed differently than for depression or PTSD.

Mental health symptom severity in cannabis using and non-using Veterans with probable PTSD

BACKGROUND Posttraumatic Stress Disorder (PTSD) is a disabling illness suffered by many Veterans returning from war. Some Veterans believe that cannabis may be therapeutic for PTSD. The purpose of this study was to better understand the association between cannabis use and PTSD symptoms. METHODS The study was a matched case-control cross-sectional evaluation of the psychiatric and sociocultural associations of cannabis use in Veterans with probable PTSD. Patient self-report measures were examined comparing cannabis users (cases) to non-users (controls) who were case-matched on age and gender. RESULTS Results indicated that there were no significant differences between cases and controls in mean PTSD Checklist-Civilian version (PCL-C) scores (59.2 and 59.1, respectively). There was also no association between PTSD scores and frequency of cannabis use. It was also observed that cases were more likely to be non-Caucasian, financially challenged, and unmarried. LIMITATIONS The sample is a convenience sample of Veterans being referred for a clinical assessment and therefore, sampling biases may limit the generalizability of the results to other populations including Veterans not seeking health care in the Veterans Affairs (VA) system. CONCLUSIONS The results do not support the theory that cannabis use would be associated with less severe PTSD symptoms. Results do suggest important sociocultural differences in cannabis users compared to controls.

Age Group Differences Among Veterans Enrolled in a Clinical Service for Behavioral Health Issues in Primary Care

OBJECTIVES : To examine age group differences in the identification, engagement, clinical outcomes, and monitoring of older, relative to middle aged and younger, veterans with behavioral health needs enrolled in an integrated care management program DESIGN : Cross-sectional and longitudinal SETTING : Primary care clinics affiliated with two Veterans Affairs Medical Centers PARTICIPANTS : A total of 9,087 veterans were referred to the Behavioral Health Laboratory (BHL) for a behavioral health assessment and 7,251 completed an initial assessment MEASUREMENTS : Data on consult source and reason for the referral, clinical assessment outcomes, and engagement were collected during a 3-year period. Variations in process and patient-level factors were examined as a function of age group. RESULTS : Although all age groups evidenced high rates of engagement in clinical assessment calls, older adults were slightly more likely to complete the assessments than young/middle-aged veterans. Clinical assessment outcomes revealed that although older adults were less likely to meet criteria for more complex, severe conditions, rates of disorder remained clinically significant, and comorbidity was common. Finally, older veterans receiving treatment monitoring for a newly prescribed antide- pressant consistently reported high rates of antidepressant adherence during the course of the monitoring calls and showed significant reductions in depressive symptomatology during the course of monitoring. CONCLUSIONS : Results indicate age-related variability in processes and outcomes among veterans referred to the BHL and suggest that older veterans are just as likely to benefit from a program designed to facilitate the identification, engagement, monitoring, and care management of primary care patients experiencing behavioral health issues.

Treating Heavy Drinking in Primary Care Practices: Evaluation of a Telephone-based Intervention Program

Objective:Alcohol misuse is prevalent and has been linked to a number of adverse mental and physical health outcomes and disability. Brief interventions may be effective in helping patients to engage in nonharmful drinking. The objective of the current study was to test the implementation of a telephone-based brief intervention (telephone care management; TCM) with heavy drinkers in primary care. The addition of TCM to primary care provider standard care (screening and brief advice) was compared with standard care alone. It was hypothesized that delivery of TCM would be feasible and that patients assigned to TCM would show better drinking outcomes than those in standard care. Methods:Heavy drinkers (N=146) at the Philadelphia Veterans Affairs primary care clinics were enrolled and randomly assigned to treatment condition. Participants in the TCM condition received a motivation-based treatment focused on helping patients to reduce their alcohol use. Results:Although both groups significantly decreased their drinking over time, with 40% of participants no longer engaging in heavy drinking at follow-up, the outcomes did not differ between groups at follow-up. Both groups decreased the number of drinking days and the average number of drinks/day over the follow-up period. Conclusions:Implementation of the program in primary care proved feasible. Participants reported a decrease in alcohol use frequency and alcohol-related problems. However, contrary to hypotheses, the addition of TCM was not associated with greater improvement in drinking outcomes.

Message Framing and Engagement in Specialty Mental Health Care

OBJECTIVE Engagement rates in specialty mental health care for depression are suboptimal. This study examined the extent to which framing-by gain, by loss, or neutral- of health messages promotes appointment attendance among patients referred to specialty mental health care. METHODS The study employed a randomized, prospective, experimental design. Patients meeting criteria for major depression and referred to specialty mental health care at the Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center were randomly assigned (N=360) to receive a patient reminder letter routinely mailed prior to scheduled specialty care appointments (neutral) or one of two messages (gain framed versus loss framed) that were added to the routine letter. Appointment and attendance data were extracted from the computerized system. Logistic regression was used to determine the association between message frame condition and initial appointment attendance. RESULTS The sample (mean±SD age=51.5±13.5) was primarily male (85%) and nonwhite (62%), and the mean depressive symptom score indicated moderately severe depression. Participants who received the gain-framed message after being referred to specialty mental health care were significantly more likely to attend their appointment than those who received a neutral letter (p=.04). No statistically significant differences were noted among those receiving a loss-framed message compared with the other two arms. CONCLUSIONS Findings suggest that highlighting the benefits of attending an initial specialty mental health care appointment, even if in writing, can affect engagement rates. If replicated, results have the potential to improve mental health treatment initiation rates in a timely, efficient, and cost-effective manner.

Gender Differences in Social Relationships and Mental Health Among Veterans Affairs Patients

ABSTRACT This study explored gender differences in social relationships and associated symptoms of depression and post-traumatic stress disorder (PTSD) among 6,449 Veterans Affairs (VA) primary care patients referred for a behavioral health assessment. Patients provided demographic information, information on social relationships, and mental health symptoms. Multiple regression analyses were conducted to examine associations between gender, social relationships, and symptoms, and to test moderation by gender. Women reported more social interaction and negative social exchanges than men. No gender differences were obtained in perceived social support. Social functioning difficulties were associated with greater symptom severity. Gender did not moderate the strength of these associations. Findings highlight gender differences in experiences of social relationships.