Kathryn E. Kanzler

Suicidal ideation and perceived burdensomeness in patients with chronic pain.

There is a clear relationship between suicide risk and chronic pain conditions. However, the exact nature of this link has been poorly understood, with risk attribution often limited to comorbid depression. Perceived burdensomeness has already been confirmed as a risk factor for suicidal ideation (SI) and suicide attempt in the general population. Self‐perceived burden, studied among medically and terminally ill medical populations, has begun to receive a great deal of attention as a suicide risk factor. However, this risk has not been considered in an outpatient chronic pain population, a group likely to experience perceived burdensomeness as a particular problem. Guidelines recommend routine suicide risk screening in medical settings, but many questionnaires are time‐consuming and do not allow for the assessment of the presence of newly identified risk constructs, such as perceived burdensomeness. This retrospective study examined the relationship between depression, perceived burdensomeness, and SI in a patient sample seeking behavioral treatment for chronic pain management. A logistic regression model was developed, with preliminary results indicating perceived burdensomeness was the sole predictor of SI, even in the presence of other well‐established risk factors such as age, gender, depressive symptoms, and pain severity. Findings highlight the potential utility of a single‐item screening question in routine clinical care as an incrementally superior predictor of SI in a chronic pain population.

Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic.

The primary aim of the current study was to obtain information about the longitudinal clinical functioning of primary care patients who had received care from behavioral health consultants (BHCs) integrated into a large family medicine clinic. Global mental health functioning was measured with the 20-item self-report Behavioral Health Measure (BHM), which was completed by patients at all appointments with the BHC. The BHM was then mailed to 664 patients 1.5 to 3 years after receipt of intervention from BHCs in primary care, of which 70 (10.5%) were completed and returned (62.9% female; mean age 43.1 ± 12.7 years; 48.6% Caucasian, 12.9% African American, 21.4% Hispanic/Latino, 2.9% Asian/Pacific Islander, 10.0% Other, 4.3% no response). Mixed effects modeling revealed that patients improved from their first to last BHC appointment, with gains being maintained an average of 2 years after intervention. Patterns of results remained significant even when accounting for the receipt of additional mental health treatment subsequent to BHC intervention. Findings suggest that clinical gains achieved by this subset of primary care patients that were associated with brief BHC intervention were maintained approximately 2 years after the final appointment.

Therapeutic alliance and treatment outcome in the primary care behavioral health model.

The current study investigated therapeutic alliance and clinical improvement within an integrated primary care behavioral health model. Participants included 542 primary care patients seen in two large family medicine clinics. Mental health symptoms and functioning were assessed using the 20-item Behavioral Health Measure (Kopta & Lowery, 2002) at the beginning of each patient appointment. Therapeutic alliance was measured with the Therapeutic Bond Scale (CelestHealth Solutions, 2008) following an initial appointment with one of 22 behavioral health consultants (BHCs). Primary care patients rated their therapeutic alliance following a first appointment with a BHC as statistically stronger than alliance ratings from a previously reported sample of outpatient psychotherapy patients after the second, third, and fourth psychotherapy sessions (Kopta, Saunders, Lutz, Kadison, & Hirsch, 2009). Results of a bootstrapped linear regression analysis indicated that therapeutic alliance assessed after the first primary care behavioral health appointment was not associated with eventual clinical change in mental health symptoms and functioning. A strong therapeutic alliance was able to be formed in a primary care behavioral health modality. This exceeded the magnitude found in outpatient psychotherapy alliance ratings. Early therapeutic alliance was unrelated to overall clinical improvement in primary care.

Challenges and Considerations for Managing Suicide Risk in Combat Zones

As suicide rates in the military rise, increased attention has been placed on the effective management of high-risk service members. Military mental health professionals deployed to combat zones face a number of challenges and barriers for effective risk management that are unique to the deployed setting. To date, there exists no body of literature identifying areas in which suicide risk management differs between garrison and combat settings to guide mental health professionals in improving clinical decision making with respect to managing suicidal service members in combat zones. On the basis of experience gained during deployments to combat zones, the authors outline several key features of the deployed context that can impact suicide risk and its effective management in combat zones and integrate empirical findings relevant to each issue. Considerations for clinical care and risk management are discussed.

Integration of behavioral health and primary care: current knowledge and future directions

Integrated behavioral health in primary care has spread rapidly over the past three decades, although significant questions remain unanswered regarding best practices in clinical, financial and operational worlds. Two key models have emerged over time: care management and Primary Care Behavioral Health. Research to date has been promising; however, there is a significant need for more sophisticated multi-level scientific methodologies to fill in the gaps in current knowledge of integrated primary care. In this paper, we summarize current scientific knowledge about integrated primary care and critically evaluate the strengths and weaknesses of this knowledge base, focusing on clinical, financial and operational factors. Finally, we recommended priorities for future research, dissemination, real-world implementation, and health policy implications.

A Shortened Version of the Suicide Cognitions Scale for Identifying Chronic Pain Patients at Risk for Suicide

Research in psychiatric outpatient and inpatient populations supports the utility of the Suicide Cognitions Scale (SCS) as an indicator of current and future risk for suicidal thoughts and behaviors. Designed to assess suicide‐specific thoughts and beliefs, the SCS has yet to be evaluated among chronic pain patients, a group with elevated risk for suicide. The purpose of the present study was to develop and test a shortened version of the SCS (the SCS‐S).

From colleague to patient: ethical challenges in integrated primary care.

Ethical codes and guidelines for mental health professionals focus on traditional avenues of practice, leaving considerable gaps for clinicians in unique settings, such as behavioral health providers in integrated primary care. In this article, an ethical scenario is presented, where a behavioral health provider is faced with a colleague physician seeking assistance for emotional distress. The scenario highlights important ethical questions about multiple relationships/conflict of interest, impaired colleagues, informed consent, and confidentiality. We review gaps in ethical guidance pertinent to the scenario and provide an eight-step rubric for ethical clinical decision making in integrated primary care.

Tinnitus, Traumatic Brain Injury, and Posttraumatic Stress Disorder in the Military

PurposeAcoustic trauma is more prevalent in military settings, especially among individuals with combat-related military occupational specialties. Gunfire, improvised explosive devices, and mortar explosions are a few examples that may cause hearing degradation and tinnitus. It is possible that the same events that are associated with auditory problems can cause traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).MethodThis paper reviews the distinct and overlapping symptoms of tinnitus, TBI, and PTSD, and how these disorders interact to synergistically promote negative outcomes.ResultsTinnitus may serve as a significant contributor to symptoms of TBI and PTSD. Therefore, tinnitus subtypes could be identified as physiologically or psychologically based, or both.ConclusionsAdditional research is warranted to determine the common and unique symptoms and associated neurological pathways of tinnitus, TBI, and PTSD. Brief treatment recommendations are provided, including a multidisciplinary approach for the physical and psychological distress associated with tinnitus.

Symptom Discrimination and Habituation: A Case Study of Behavioral Treatment for Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is a multifaceted disorder of the autonomic nervous system that profoundly impacts physical functioning. In addition to physical consequences, many patients develop situational anxiety that causes reduced activity level, which may impede functional recovery from POTS. Despite links with anxiety, to date there have been no reports of psychological intervention for POTS. Here we report a case study of POTS in a 40-year-old female serving on active duty in the US military. Because there are no established guidelines for the psychological treatment of POTS, intervention techniques were adapted for use with the patient. Elements of cognitive behavioral therapy, including in-vivo exposure and symptom discrimination, were used to target avoidance of feared situations. Over the course of treatment, the patient learned to discriminate her POTS symptoms from anxiety and displayed a significant decrease in POTS-related functional impairment. Implications for future care are discussed.

Ethical and effectiveness considerations with primary care behavioral health research in the medical home.

Integrated primary care research in the Patient-Centered Medical Home (PCMH) presents unique challenges not found in other behavioral health or medical care settings. The PCMH service delivery principles and supporting systems are designed to maximize quality and outcomes of care while controlling health care costs. Conducting ethical research in this setting requires following processes and procedures established by federal statutes that threaten to disrupt this delicate balance. In addition, clinical researchers must consider the ethical requirements and guidance from their respective professional organizations to ensure they adhere to guidelines for conducting ethical research and practice. Given the setting, there is a high likelihood researchers from various disciplines who may adhere to different ethical standards will be collaborating. We present a case example of an ethical concern to illustrate the tension between research and clinical care, discuss federal and professional research guidelines, and propose recommendations for balancing ethical and effective research and clinical care in integrated primary care research in the PCMH.