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The case for behavioral health integration into primary care
In a typical primary care practice, detecting and managing mental health problems competes with other priorities such as treating acute physical illness, monitoring chronic disease, providing preventive health services, and assessing compliance with standards of care.1 These competing demands for a primary care provider’s time, paired with limited mental health resources in the community, may result in suboptimal behavioral health care.1-3 Even when referrals are made to
Approximately 30% of adults with physical disorders also have one or more behavioral health conditions, such as anxiety, panic, mood, or substance use disorders.6 Although physical and behavioral health conditions are inextricably linked, their assessment and treatment get separated into different silos.7 Given that fewer than 20% of depressed patients are seen by a psychiatrist or psychologist,8 the responsibility of providing mental health care often falls on the primary care physician.8,9
Efforts to improve the treatment of common mental disorders in primary care have traditionally focused on screening for these disorders, educating primary care providers, developing treatment guidelines, and referring patients to mental health specialty care.10 However, behavioral health integration offers another way forward.
WHAT IS BEHAVIORAL HEALTH INTEGRATION?
Behavioral health integration (BHI) in primary care refers to primary care physicians and behavioral health clinicians working in concert with patients to address their primary care and behavioral health needs.11
Numerous overlapping terms have been used to describe BHI, and this has caused some confusion. In 2013, the Agency for Healthcare Research and Quality (AHRQ) issued a lexicon standardizing the terminology used in BHI.11 The commonly used terms are
COORDINATED CARE AND THE COLLABORATIVE CARE MODEL
BHI at the level of coordinated care has almost exclusively been studied and practiced along the lines of the collaborative care model (CCM).14-16 This model represents an advanced level of coordinated care in the BHI continuum. The most substantial evidence for CCM lies in the management of depression and anxiety.14-16
Usual care involves the primary care physician and the patient. CCM adds 2 vital roles—a behavioral health care manager and a psychiatric consultant. A behavioral health care manager is typically a counselor, clinical social worker, psychologist, or psychiatric nurse who performs all care-management tasks including offering psychotherapy when that is part of the treatment plan.
Continue to: The care manager's functions include...
The care manager’s functions include systematic follow-up with structured monitoring of symptoms and treatment adherence, coordination and communication among care providers, patient education, and self-management support, including the use of motivational interviewing. The behavioral health care manager performs this systematic follow up by maintaining a patient “registry”—case-management software used in conjunction with, or embedded in, the practice electronic health record to track patients’ data and clinical outcomes, as well as to facilitate decision-making.
The care manager communicates with the psychiatrist, who offers suggestions for drug therapy, which is prescribed by the primary care physician. The care manager also regularly evaluates the patient’s status using a standardized scale, communicates these scores to the psychiatrist, and transmits any recommendations to the primary care physician (FIGURE 2).17
EVIDENCE FOR CCM
Collaborative and routine care were compared in a 2012 Cochrane review that included 79 randomized controlled trials (RCTs) involving 24,308 patients worldwide.16 Seventy-two of the 79 RCTs focused on patients with depression or depression with anxiety, while 6 studies included participants with only anxiety disorders.16 One additional study focused on mental health quality of life. (To learn about CCM and severe mental illness and substance use disorder, see “Less well studied: CCM and severe mental illness, alcohol dependence.”18-20)
SIDEBAR
Less well studied: CCM and severe mental illness, alcohol dependence
Evidence for collaborative care in severe mental illness (SMI) is very limited. SMI is defined as schizophrenia or other schizophrenia-like psychoses (eg, schizophreniform and schizoaffective disorders), bipolar affective disorder, or other psychosis.
A 2013 Cochrane review identified only 1 RCT involving 306 veterans with bipolar disease.18 The review concluded that there was low-quality evidence that collaborative care led to a relative risk reduction of 25% for psychiatric admissions at Year 2 compared with standard care (RR = 0.75; 95% CI, 0.57-0.99).18
One 2017 RCT involving 245 veterans that looked at a collaborative care model for patients with severe mental illness found a modest benefit for physical health-related quality of life, but did not find any benefit in mental health outcomes.19
Alcohol dependence. There is very limited, but high-quality, evidence for the utility of CCM in alcohol dependence. In one RCT, 163 veterans were assigned to either CCM or referral to standard treatment in a specialty outpatient addiction treatment program. The CCM group had a significantly higher proportion of participants engaged in treatment over the study’s 26 weeks (odds ratio [OR] = 5.36; 95% CI, 2.99-9.59). The percentage of heavy drinking days was significantly lower in the CCM group (OR = 2.16; 95% CI, 1.27-3.66), while overall abstinence did not differ between groups.20
For adults with depression treated with the CCM, significantly greater improvement in depression outcome measures was seen in the short-term (standardized mean difference [SMD] = -0.34; 95% confidence interval [CI], -0.41 to -0.27; risk ratio [RR] = 1.32; 95% CI, 1.22-1.43), in the medium term (SMD = -0.28; 95% CI, -0.41 to -0.15; RR = 1.31; 95% CI, 1.17–1.48), and in the long term (SMD = -0.35; 95% CI, -0.46 to -0.24; RR = 1.29; 95% CI, 1.18–1.41).16
Comparisons of mental health quality of life over the short term (0-6 months), medium term (7-12 months), and long term (13-24 months) did not show any significant difference between CCM and routine care.16 Comparisons of physical health quality of life over the short term and medium term did not show any significant difference between CCM and routine care.16
Continue to: Significantly greater improvement...
Significantly greater improvement in anxiety outcomes was seen for adults treated with CCM in the short term (SMD = -0.30; 95% CI, -0.44 to -0.17; RR = 1.50; 95% CI, 1.21–1.87), in the medium term (SMD = -0.33; 95% CI, -0.47 to -0.19; RR = 1.41; 95% CI, 1.18-1.69), and in the long term (SMD = -0.20; 95% CI, -0.34 to -0.06; RR = 1.26; 95% CI, 1.11–1.42).16
A 2016 systematic review of 94 RCTs involving more than 25,000 patients also provided high-quality evidence that collaborative care yields small-to-moderate improvements in symptoms from mood disorders and mental health-related quality of life.15 A 2006 meta-analysis of 37 RCTs comprising 12,355 patients showed that collaborative care involving a case manager is more effective than standard care in improving depression outcomes at 6 months (SMD = 0.25; 95% CI, 0.18-0.32) and up to 5 years (SMD = 0.15; 95% CI, 0.001-0.31).21
Better care of mental health disorders also improves medical outcomes
Several trials have focused on jointly managing depression and a chronic physical condition such as chronic pain, diabetes, and coronary heart disease,22 demonstrating improved outcomes for both depression and the comanaged conditions.
- Chronic pain. When compared with usual care, collaborative care resulted in moderate reductions in both pain severity and associated disability (41.5% vs 17.3%; RR = 2.4; 95% CI, 1.6-3.2).23
- Diabetes. Patients managed collaboratively were more likely to have a decrease of ≥ 1% in the glycated hemoglobin level from baseline (36% vs 19%; P = .006).24
- Cardiovascular disease. Significant real-world risk reduction was achieved by improving blood pressure control (58% achieved blood pressure control compared with a projected target of 20%).22
IS THERE A COMMON THREAD AMONG SUCCESSFUL CCMs?
Attempts to identify commonalities between the many iterations of successful CCMs have produced varying results due to differing selections of relevant RCTs.25-29 However, a few common features have been identified:
- care managers assess symptoms at baseline and at follow-up using a standardized measure such as the Patient Health Questionnaire (PHQ-9);
- care managers monitor treatment adherence;
- follow-up is active for at least 16 weeks;
- primary care and mental health providers actively engage in patient management; and
- mental health specialists regularly supervise care managers.
The one feature that is consistent with improved outcomes is the presence of the care manager.25-29
Continue to: The improvement associated...
The improvement associated with collaborative care is clinically meaningful to patients and physicians. In one RCT, collaborative care doubled response rates of depression treatment compared with usual care.3 Quality improvement data from real-world implementation of collaborative care programs suggests that similar outcomes can be achieved in a variety of settings.30
COST BENEFITS OF CCM
Collaborative care for depression is associated with lower health care costs.29,31
A meta-analysis of 57 RCTs in 2012 showed that CCM improves depression outcomes across populations, settings, and outcome domains, and that these results are achieved at little to no increase in treatment costs compared with usual care (Cohen’s d = 0.05; 95% CI, –0.02–0.12).26
When collaborative care was compared with routine care in an RCT involving 1801 primary care patients ≥ 60 years who were suffering from depression, a cost saving of $3363 per patient over 4 years was demonstrated in the intervention arm.31
A technical analysis of 94 RCTs in 2015 concluded that CCM is cost effective compared with usual care, with a range of $15,000 to $80,000 per quality-adjusted life year gained. These studies also indicated that organizations’ costs to implement CCM increase in the short term. Based on this analysis, organizations would need to invest between $3 to $22 per patient per month to implement and sustain CCMs, depending on the prevalence of depression in the population.29
Continue to: OTHER MODELS OF BHI
OTHER MODELS OF BHI
Higher levels of BHI such as co-location and integration do not have the same quality of evidence as CCM.
A 2009 Cochrane review of 42 studies involving 3880 patients found that mental health workers delivering psychological therapy and psychosocial interventions in primary care settings brought about significant reductions in primary care physician consultations (SMD = ‐0.17; 95% CI, ‐0.30 to ‐0.05); a relative risk reduction of 23% in psychotropic prescribing (RR = 0.67; 95% CI, 0.56–0.79); a decrease in prescribing costs (SMD = ‐0.22; 95% CI, ‐0.38 to ‐0.07); and a relative risk reduction in mental health referral of 87% (RR = 0.13; 95% CI, 0.09–0.20) for the patients they were seeing.32 The authors concluded the changes were modest in magnitude and inconsistent across different studies.32
Embedding medical providers in behavior health centers—ie, the reverse co-location model—also has very limited evidence. An RCT involving 120 veterans found that patients enrolled in a reverse co-location clinic did significantly better than controls seen in a general care clinic in terms of continuity of care and preventive care such as screening for hypertension (84.7% vs 65.6%; X 2 = 5.9, P = .01), diabetes (71.2% vs 45.9%; X 2 = 7.9, P < .005), hepatitis (39% vs 14.8%; X 2 = 9, P = .003), and cholesterol (79.7% vs 57.4%; X 2 = 6.9, P = .009).33
HOW TO IMPLEMENT A SUCCESSFUL BHI PROGRAM
A demonstration and evaluation project involving 11 diverse practices in Colorado explored ways to integrate behavioral health in primary care. Five main themes emerged34,35:
- Frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care.
- Define relationships and protocols up front, understanding that they will evolve.
- Build inclusive, empowered teams to provide the foundation for integration.
- Develop a change management strategy of continuous evaluation and course correction.
- Use targeted data collection pertinent to integrated care to drive improvement and impart accountability.
The Institute for Clinical and Economic Review has organized an extensive list of resources36 for implementing BHI models, a sampling of which is shown in TABLE 2.
Continue to: TAKE-AWAY POINTS
TAKE-AWAY POINTS
There is high quality evidence that collaborative care works for the management of depression and anxiety disorder in primary care, and this is associated with significant cost savings.
CORRESPONDENCE
Rajesh (FNU) Rajesh, MD, Main Campus Family Medicine Clinic, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109; frajesh@metrohealth.org
1. Rost K, Nutting P, Smith J, et al. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150-154.
2. Rush A, Trivedi M, Carmody T, et al. One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies. Biol Psychiatry. 2004;56:46-53.
3. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting. JAMA. 2002;288:2836-2845.
4. Department of Veterans Affairs. Bradford DW, Slubicki MN, McDuffie J, et al. Effects of care models to improve general medical outcomes for individuals with serious mental illness. 2011. https://www.hsrd.research.va.gov/publications/esp/smi-REPORT.pdf. Accessed August 22, 2018.
5. Druss BG, von Esenwein S. Improving general medical care for persons with mental and addictive disorders: systematic review. Gen Hosp Psychiatry. 2006;28:145-153.
6. Druss BG, Walker ER. Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation; February 2011.
7. Reed SJ, Shore KK, Tice JA. Effectiveness and value of integrating behavioral health into primary care. JAMA Intern Med. 2016;176:691-692.
8. Young AS, Klap R, Sherbourne CD, et al. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61.
9. Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK38632/. Accessed March 2, 2019.
10. Unützer J, Schoenbaum M, Druss B, et al. Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatr Serv. 2006;57:37-47. doi: 10.1176/appi.ps.57.1.37.
11. Peek CJ; the National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus. AHRQ. https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Published April 2013. Accessed May 29, 2019.
12. Heath B, Wise Romero P, Reynolds K. A standard framework for levels of integrated healthcare and update throughout the document. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf. Published March 2013. Accessed May 29, 2019.
13. Integrating physical and behavioral health care: promising Medicaid models. The Henry J. Kaiser Family Foundation. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf. Published February 2014. Accessed May 29, 2019.
14. Vanderlip ER, Rundell J, Avery M, et al. Dissemination of integrated care within adult primary care settings: the collaborative care model. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf. Published 2016. Accessed May 29, 2019.
15. Gerrity M. Evolving models of behavioral health integration: evidence update 2010-2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf. Published May 2016. Accessed May 29, 2019.
16. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10.1002/14651858.cd006525.pub2.
17. Team Structure. University of Washington AIMs Center. https://aims.uw.edu/collaborative-care/team-structure. Published 2017.Accessed May 29, 2019.
18. Reilly S, Planner C, Gask L, et al. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev. 2013;(11):CD009531.
19. Kilbourne AM, Barbaresso MM, Lai Z, et al. Improving physical health in patients with chronic mental disorders. J Clin Psychiatry. 2017;78:129-137.
20. Oslin DW, Lynch KG, Maisto HSA, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Intern Med. 2013;29:162-168.
21. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.
22. Rossom RC, Solberg LI, Magnan S, et al. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2017;15:77-85.
23. Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2009-2110.
24. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
25. Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions. Med Care. 2013;51:922-930.
26. Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry. 2012;11:790-804.
27. U.S. Department of Veterans Affairs. Rubenstein LV, Williams JW Jr, Danz M, et al. Determining key features of effective depression interventions. 2009. http://www.hsrd.research.va.gov/publications/esp/depinter.cfm. Accessed August 22, 2018.
28. Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One. 2014;9:e108114.
29. Institute for Clinical and Economic Review. Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf. Accessed August 27, 2018.
30. Rubenstein LV, Chaney EF, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91-113.
31. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
32. Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev. 2009;(1):CD000532.
33. Druss BG, Rohrbaugh RM, Levinson CM, et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen Psychiatry. 2001;58:861-868.
34. Davis M, Balasubramanian BA, Waller E, et al. Integrating behavioral and physical health care in the real world: early lessons from advancing care together. J Am Board Fam Med. 2013;26:588-602.
35. Gold SB, Green LA, Peek CJ. From our practices to yours: key messages for the journey to integrated behavioral health. J Am Board Fam Med. 2017;30:25-34.
36. Institute for Clinical and Economic Review. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/02/CTAF_BHI_Action_Guide_060215.pdf. Accessed April 25, 2019.
In a typical primary care practice, detecting and managing mental health problems competes with other priorities such as treating acute physical illness, monitoring chronic disease, providing preventive health services, and assessing compliance with standards of care.1 These competing demands for a primary care provider’s time, paired with limited mental health resources in the community, may result in suboptimal behavioral health care.1-3 Even when referrals are made to
Approximately 30% of adults with physical disorders also have one or more behavioral health conditions, such as anxiety, panic, mood, or substance use disorders.6 Although physical and behavioral health conditions are inextricably linked, their assessment and treatment get separated into different silos.7 Given that fewer than 20% of depressed patients are seen by a psychiatrist or psychologist,8 the responsibility of providing mental health care often falls on the primary care physician.8,9
Efforts to improve the treatment of common mental disorders in primary care have traditionally focused on screening for these disorders, educating primary care providers, developing treatment guidelines, and referring patients to mental health specialty care.10 However, behavioral health integration offers another way forward.
WHAT IS BEHAVIORAL HEALTH INTEGRATION?
Behavioral health integration (BHI) in primary care refers to primary care physicians and behavioral health clinicians working in concert with patients to address their primary care and behavioral health needs.11
Numerous overlapping terms have been used to describe BHI, and this has caused some confusion. In 2013, the Agency for Healthcare Research and Quality (AHRQ) issued a lexicon standardizing the terminology used in BHI.11 The commonly used terms are
COORDINATED CARE AND THE COLLABORATIVE CARE MODEL
BHI at the level of coordinated care has almost exclusively been studied and practiced along the lines of the collaborative care model (CCM).14-16 This model represents an advanced level of coordinated care in the BHI continuum. The most substantial evidence for CCM lies in the management of depression and anxiety.14-16
Usual care involves the primary care physician and the patient. CCM adds 2 vital roles—a behavioral health care manager and a psychiatric consultant. A behavioral health care manager is typically a counselor, clinical social worker, psychologist, or psychiatric nurse who performs all care-management tasks including offering psychotherapy when that is part of the treatment plan.
Continue to: The care manager's functions include...
The care manager’s functions include systematic follow-up with structured monitoring of symptoms and treatment adherence, coordination and communication among care providers, patient education, and self-management support, including the use of motivational interviewing. The behavioral health care manager performs this systematic follow up by maintaining a patient “registry”—case-management software used in conjunction with, or embedded in, the practice electronic health record to track patients’ data and clinical outcomes, as well as to facilitate decision-making.
The care manager communicates with the psychiatrist, who offers suggestions for drug therapy, which is prescribed by the primary care physician. The care manager also regularly evaluates the patient’s status using a standardized scale, communicates these scores to the psychiatrist, and transmits any recommendations to the primary care physician (FIGURE 2).17
EVIDENCE FOR CCM
Collaborative and routine care were compared in a 2012 Cochrane review that included 79 randomized controlled trials (RCTs) involving 24,308 patients worldwide.16 Seventy-two of the 79 RCTs focused on patients with depression or depression with anxiety, while 6 studies included participants with only anxiety disorders.16 One additional study focused on mental health quality of life. (To learn about CCM and severe mental illness and substance use disorder, see “Less well studied: CCM and severe mental illness, alcohol dependence.”18-20)
SIDEBAR
Less well studied: CCM and severe mental illness, alcohol dependence
Evidence for collaborative care in severe mental illness (SMI) is very limited. SMI is defined as schizophrenia or other schizophrenia-like psychoses (eg, schizophreniform and schizoaffective disorders), bipolar affective disorder, or other psychosis.
A 2013 Cochrane review identified only 1 RCT involving 306 veterans with bipolar disease.18 The review concluded that there was low-quality evidence that collaborative care led to a relative risk reduction of 25% for psychiatric admissions at Year 2 compared with standard care (RR = 0.75; 95% CI, 0.57-0.99).18
One 2017 RCT involving 245 veterans that looked at a collaborative care model for patients with severe mental illness found a modest benefit for physical health-related quality of life, but did not find any benefit in mental health outcomes.19
Alcohol dependence. There is very limited, but high-quality, evidence for the utility of CCM in alcohol dependence. In one RCT, 163 veterans were assigned to either CCM or referral to standard treatment in a specialty outpatient addiction treatment program. The CCM group had a significantly higher proportion of participants engaged in treatment over the study’s 26 weeks (odds ratio [OR] = 5.36; 95% CI, 2.99-9.59). The percentage of heavy drinking days was significantly lower in the CCM group (OR = 2.16; 95% CI, 1.27-3.66), while overall abstinence did not differ between groups.20
For adults with depression treated with the CCM, significantly greater improvement in depression outcome measures was seen in the short-term (standardized mean difference [SMD] = -0.34; 95% confidence interval [CI], -0.41 to -0.27; risk ratio [RR] = 1.32; 95% CI, 1.22-1.43), in the medium term (SMD = -0.28; 95% CI, -0.41 to -0.15; RR = 1.31; 95% CI, 1.17–1.48), and in the long term (SMD = -0.35; 95% CI, -0.46 to -0.24; RR = 1.29; 95% CI, 1.18–1.41).16
Comparisons of mental health quality of life over the short term (0-6 months), medium term (7-12 months), and long term (13-24 months) did not show any significant difference between CCM and routine care.16 Comparisons of physical health quality of life over the short term and medium term did not show any significant difference between CCM and routine care.16
Continue to: Significantly greater improvement...
Significantly greater improvement in anxiety outcomes was seen for adults treated with CCM in the short term (SMD = -0.30; 95% CI, -0.44 to -0.17; RR = 1.50; 95% CI, 1.21–1.87), in the medium term (SMD = -0.33; 95% CI, -0.47 to -0.19; RR = 1.41; 95% CI, 1.18-1.69), and in the long term (SMD = -0.20; 95% CI, -0.34 to -0.06; RR = 1.26; 95% CI, 1.11–1.42).16
A 2016 systematic review of 94 RCTs involving more than 25,000 patients also provided high-quality evidence that collaborative care yields small-to-moderate improvements in symptoms from mood disorders and mental health-related quality of life.15 A 2006 meta-analysis of 37 RCTs comprising 12,355 patients showed that collaborative care involving a case manager is more effective than standard care in improving depression outcomes at 6 months (SMD = 0.25; 95% CI, 0.18-0.32) and up to 5 years (SMD = 0.15; 95% CI, 0.001-0.31).21
Better care of mental health disorders also improves medical outcomes
Several trials have focused on jointly managing depression and a chronic physical condition such as chronic pain, diabetes, and coronary heart disease,22 demonstrating improved outcomes for both depression and the comanaged conditions.
- Chronic pain. When compared with usual care, collaborative care resulted in moderate reductions in both pain severity and associated disability (41.5% vs 17.3%; RR = 2.4; 95% CI, 1.6-3.2).23
- Diabetes. Patients managed collaboratively were more likely to have a decrease of ≥ 1% in the glycated hemoglobin level from baseline (36% vs 19%; P = .006).24
- Cardiovascular disease. Significant real-world risk reduction was achieved by improving blood pressure control (58% achieved blood pressure control compared with a projected target of 20%).22
IS THERE A COMMON THREAD AMONG SUCCESSFUL CCMs?
Attempts to identify commonalities between the many iterations of successful CCMs have produced varying results due to differing selections of relevant RCTs.25-29 However, a few common features have been identified:
- care managers assess symptoms at baseline and at follow-up using a standardized measure such as the Patient Health Questionnaire (PHQ-9);
- care managers monitor treatment adherence;
- follow-up is active for at least 16 weeks;
- primary care and mental health providers actively engage in patient management; and
- mental health specialists regularly supervise care managers.
The one feature that is consistent with improved outcomes is the presence of the care manager.25-29
Continue to: The improvement associated...
The improvement associated with collaborative care is clinically meaningful to patients and physicians. In one RCT, collaborative care doubled response rates of depression treatment compared with usual care.3 Quality improvement data from real-world implementation of collaborative care programs suggests that similar outcomes can be achieved in a variety of settings.30
COST BENEFITS OF CCM
Collaborative care for depression is associated with lower health care costs.29,31
A meta-analysis of 57 RCTs in 2012 showed that CCM improves depression outcomes across populations, settings, and outcome domains, and that these results are achieved at little to no increase in treatment costs compared with usual care (Cohen’s d = 0.05; 95% CI, –0.02–0.12).26
When collaborative care was compared with routine care in an RCT involving 1801 primary care patients ≥ 60 years who were suffering from depression, a cost saving of $3363 per patient over 4 years was demonstrated in the intervention arm.31
A technical analysis of 94 RCTs in 2015 concluded that CCM is cost effective compared with usual care, with a range of $15,000 to $80,000 per quality-adjusted life year gained. These studies also indicated that organizations’ costs to implement CCM increase in the short term. Based on this analysis, organizations would need to invest between $3 to $22 per patient per month to implement and sustain CCMs, depending on the prevalence of depression in the population.29
Continue to: OTHER MODELS OF BHI
OTHER MODELS OF BHI
Higher levels of BHI such as co-location and integration do not have the same quality of evidence as CCM.
A 2009 Cochrane review of 42 studies involving 3880 patients found that mental health workers delivering psychological therapy and psychosocial interventions in primary care settings brought about significant reductions in primary care physician consultations (SMD = ‐0.17; 95% CI, ‐0.30 to ‐0.05); a relative risk reduction of 23% in psychotropic prescribing (RR = 0.67; 95% CI, 0.56–0.79); a decrease in prescribing costs (SMD = ‐0.22; 95% CI, ‐0.38 to ‐0.07); and a relative risk reduction in mental health referral of 87% (RR = 0.13; 95% CI, 0.09–0.20) for the patients they were seeing.32 The authors concluded the changes were modest in magnitude and inconsistent across different studies.32
Embedding medical providers in behavior health centers—ie, the reverse co-location model—also has very limited evidence. An RCT involving 120 veterans found that patients enrolled in a reverse co-location clinic did significantly better than controls seen in a general care clinic in terms of continuity of care and preventive care such as screening for hypertension (84.7% vs 65.6%; X 2 = 5.9, P = .01), diabetes (71.2% vs 45.9%; X 2 = 7.9, P < .005), hepatitis (39% vs 14.8%; X 2 = 9, P = .003), and cholesterol (79.7% vs 57.4%; X 2 = 6.9, P = .009).33
HOW TO IMPLEMENT A SUCCESSFUL BHI PROGRAM
A demonstration and evaluation project involving 11 diverse practices in Colorado explored ways to integrate behavioral health in primary care. Five main themes emerged34,35:
- Frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care.
- Define relationships and protocols up front, understanding that they will evolve.
- Build inclusive, empowered teams to provide the foundation for integration.
- Develop a change management strategy of continuous evaluation and course correction.
- Use targeted data collection pertinent to integrated care to drive improvement and impart accountability.
The Institute for Clinical and Economic Review has organized an extensive list of resources36 for implementing BHI models, a sampling of which is shown in TABLE 2.
Continue to: TAKE-AWAY POINTS
TAKE-AWAY POINTS
There is high quality evidence that collaborative care works for the management of depression and anxiety disorder in primary care, and this is associated with significant cost savings.
CORRESPONDENCE
Rajesh (FNU) Rajesh, MD, Main Campus Family Medicine Clinic, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109; frajesh@metrohealth.org
In a typical primary care practice, detecting and managing mental health problems competes with other priorities such as treating acute physical illness, monitoring chronic disease, providing preventive health services, and assessing compliance with standards of care.1 These competing demands for a primary care provider’s time, paired with limited mental health resources in the community, may result in suboptimal behavioral health care.1-3 Even when referrals are made to
Approximately 30% of adults with physical disorders also have one or more behavioral health conditions, such as anxiety, panic, mood, or substance use disorders.6 Although physical and behavioral health conditions are inextricably linked, their assessment and treatment get separated into different silos.7 Given that fewer than 20% of depressed patients are seen by a psychiatrist or psychologist,8 the responsibility of providing mental health care often falls on the primary care physician.8,9
Efforts to improve the treatment of common mental disorders in primary care have traditionally focused on screening for these disorders, educating primary care providers, developing treatment guidelines, and referring patients to mental health specialty care.10 However, behavioral health integration offers another way forward.
WHAT IS BEHAVIORAL HEALTH INTEGRATION?
Behavioral health integration (BHI) in primary care refers to primary care physicians and behavioral health clinicians working in concert with patients to address their primary care and behavioral health needs.11
Numerous overlapping terms have been used to describe BHI, and this has caused some confusion. In 2013, the Agency for Healthcare Research and Quality (AHRQ) issued a lexicon standardizing the terminology used in BHI.11 The commonly used terms are
COORDINATED CARE AND THE COLLABORATIVE CARE MODEL
BHI at the level of coordinated care has almost exclusively been studied and practiced along the lines of the collaborative care model (CCM).14-16 This model represents an advanced level of coordinated care in the BHI continuum. The most substantial evidence for CCM lies in the management of depression and anxiety.14-16
Usual care involves the primary care physician and the patient. CCM adds 2 vital roles—a behavioral health care manager and a psychiatric consultant. A behavioral health care manager is typically a counselor, clinical social worker, psychologist, or psychiatric nurse who performs all care-management tasks including offering psychotherapy when that is part of the treatment plan.
Continue to: The care manager's functions include...
The care manager’s functions include systematic follow-up with structured monitoring of symptoms and treatment adherence, coordination and communication among care providers, patient education, and self-management support, including the use of motivational interviewing. The behavioral health care manager performs this systematic follow up by maintaining a patient “registry”—case-management software used in conjunction with, or embedded in, the practice electronic health record to track patients’ data and clinical outcomes, as well as to facilitate decision-making.
The care manager communicates with the psychiatrist, who offers suggestions for drug therapy, which is prescribed by the primary care physician. The care manager also regularly evaluates the patient’s status using a standardized scale, communicates these scores to the psychiatrist, and transmits any recommendations to the primary care physician (FIGURE 2).17
EVIDENCE FOR CCM
Collaborative and routine care were compared in a 2012 Cochrane review that included 79 randomized controlled trials (RCTs) involving 24,308 patients worldwide.16 Seventy-two of the 79 RCTs focused on patients with depression or depression with anxiety, while 6 studies included participants with only anxiety disorders.16 One additional study focused on mental health quality of life. (To learn about CCM and severe mental illness and substance use disorder, see “Less well studied: CCM and severe mental illness, alcohol dependence.”18-20)
SIDEBAR
Less well studied: CCM and severe mental illness, alcohol dependence
Evidence for collaborative care in severe mental illness (SMI) is very limited. SMI is defined as schizophrenia or other schizophrenia-like psychoses (eg, schizophreniform and schizoaffective disorders), bipolar affective disorder, or other psychosis.
A 2013 Cochrane review identified only 1 RCT involving 306 veterans with bipolar disease.18 The review concluded that there was low-quality evidence that collaborative care led to a relative risk reduction of 25% for psychiatric admissions at Year 2 compared with standard care (RR = 0.75; 95% CI, 0.57-0.99).18
One 2017 RCT involving 245 veterans that looked at a collaborative care model for patients with severe mental illness found a modest benefit for physical health-related quality of life, but did not find any benefit in mental health outcomes.19
Alcohol dependence. There is very limited, but high-quality, evidence for the utility of CCM in alcohol dependence. In one RCT, 163 veterans were assigned to either CCM or referral to standard treatment in a specialty outpatient addiction treatment program. The CCM group had a significantly higher proportion of participants engaged in treatment over the study’s 26 weeks (odds ratio [OR] = 5.36; 95% CI, 2.99-9.59). The percentage of heavy drinking days was significantly lower in the CCM group (OR = 2.16; 95% CI, 1.27-3.66), while overall abstinence did not differ between groups.20
For adults with depression treated with the CCM, significantly greater improvement in depression outcome measures was seen in the short-term (standardized mean difference [SMD] = -0.34; 95% confidence interval [CI], -0.41 to -0.27; risk ratio [RR] = 1.32; 95% CI, 1.22-1.43), in the medium term (SMD = -0.28; 95% CI, -0.41 to -0.15; RR = 1.31; 95% CI, 1.17–1.48), and in the long term (SMD = -0.35; 95% CI, -0.46 to -0.24; RR = 1.29; 95% CI, 1.18–1.41).16
Comparisons of mental health quality of life over the short term (0-6 months), medium term (7-12 months), and long term (13-24 months) did not show any significant difference between CCM and routine care.16 Comparisons of physical health quality of life over the short term and medium term did not show any significant difference between CCM and routine care.16
Continue to: Significantly greater improvement...
Significantly greater improvement in anxiety outcomes was seen for adults treated with CCM in the short term (SMD = -0.30; 95% CI, -0.44 to -0.17; RR = 1.50; 95% CI, 1.21–1.87), in the medium term (SMD = -0.33; 95% CI, -0.47 to -0.19; RR = 1.41; 95% CI, 1.18-1.69), and in the long term (SMD = -0.20; 95% CI, -0.34 to -0.06; RR = 1.26; 95% CI, 1.11–1.42).16
A 2016 systematic review of 94 RCTs involving more than 25,000 patients also provided high-quality evidence that collaborative care yields small-to-moderate improvements in symptoms from mood disorders and mental health-related quality of life.15 A 2006 meta-analysis of 37 RCTs comprising 12,355 patients showed that collaborative care involving a case manager is more effective than standard care in improving depression outcomes at 6 months (SMD = 0.25; 95% CI, 0.18-0.32) and up to 5 years (SMD = 0.15; 95% CI, 0.001-0.31).21
Better care of mental health disorders also improves medical outcomes
Several trials have focused on jointly managing depression and a chronic physical condition such as chronic pain, diabetes, and coronary heart disease,22 demonstrating improved outcomes for both depression and the comanaged conditions.
- Chronic pain. When compared with usual care, collaborative care resulted in moderate reductions in both pain severity and associated disability (41.5% vs 17.3%; RR = 2.4; 95% CI, 1.6-3.2).23
- Diabetes. Patients managed collaboratively were more likely to have a decrease of ≥ 1% in the glycated hemoglobin level from baseline (36% vs 19%; P = .006).24
- Cardiovascular disease. Significant real-world risk reduction was achieved by improving blood pressure control (58% achieved blood pressure control compared with a projected target of 20%).22
IS THERE A COMMON THREAD AMONG SUCCESSFUL CCMs?
Attempts to identify commonalities between the many iterations of successful CCMs have produced varying results due to differing selections of relevant RCTs.25-29 However, a few common features have been identified:
- care managers assess symptoms at baseline and at follow-up using a standardized measure such as the Patient Health Questionnaire (PHQ-9);
- care managers monitor treatment adherence;
- follow-up is active for at least 16 weeks;
- primary care and mental health providers actively engage in patient management; and
- mental health specialists regularly supervise care managers.
The one feature that is consistent with improved outcomes is the presence of the care manager.25-29
Continue to: The improvement associated...
The improvement associated with collaborative care is clinically meaningful to patients and physicians. In one RCT, collaborative care doubled response rates of depression treatment compared with usual care.3 Quality improvement data from real-world implementation of collaborative care programs suggests that similar outcomes can be achieved in a variety of settings.30
COST BENEFITS OF CCM
Collaborative care for depression is associated with lower health care costs.29,31
A meta-analysis of 57 RCTs in 2012 showed that CCM improves depression outcomes across populations, settings, and outcome domains, and that these results are achieved at little to no increase in treatment costs compared with usual care (Cohen’s d = 0.05; 95% CI, –0.02–0.12).26
When collaborative care was compared with routine care in an RCT involving 1801 primary care patients ≥ 60 years who were suffering from depression, a cost saving of $3363 per patient over 4 years was demonstrated in the intervention arm.31
A technical analysis of 94 RCTs in 2015 concluded that CCM is cost effective compared with usual care, with a range of $15,000 to $80,000 per quality-adjusted life year gained. These studies also indicated that organizations’ costs to implement CCM increase in the short term. Based on this analysis, organizations would need to invest between $3 to $22 per patient per month to implement and sustain CCMs, depending on the prevalence of depression in the population.29
Continue to: OTHER MODELS OF BHI
OTHER MODELS OF BHI
Higher levels of BHI such as co-location and integration do not have the same quality of evidence as CCM.
A 2009 Cochrane review of 42 studies involving 3880 patients found that mental health workers delivering psychological therapy and psychosocial interventions in primary care settings brought about significant reductions in primary care physician consultations (SMD = ‐0.17; 95% CI, ‐0.30 to ‐0.05); a relative risk reduction of 23% in psychotropic prescribing (RR = 0.67; 95% CI, 0.56–0.79); a decrease in prescribing costs (SMD = ‐0.22; 95% CI, ‐0.38 to ‐0.07); and a relative risk reduction in mental health referral of 87% (RR = 0.13; 95% CI, 0.09–0.20) for the patients they were seeing.32 The authors concluded the changes were modest in magnitude and inconsistent across different studies.32
Embedding medical providers in behavior health centers—ie, the reverse co-location model—also has very limited evidence. An RCT involving 120 veterans found that patients enrolled in a reverse co-location clinic did significantly better than controls seen in a general care clinic in terms of continuity of care and preventive care such as screening for hypertension (84.7% vs 65.6%; X 2 = 5.9, P = .01), diabetes (71.2% vs 45.9%; X 2 = 7.9, P < .005), hepatitis (39% vs 14.8%; X 2 = 9, P = .003), and cholesterol (79.7% vs 57.4%; X 2 = 6.9, P = .009).33
HOW TO IMPLEMENT A SUCCESSFUL BHI PROGRAM
A demonstration and evaluation project involving 11 diverse practices in Colorado explored ways to integrate behavioral health in primary care. Five main themes emerged34,35:
- Frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care.
- Define relationships and protocols up front, understanding that they will evolve.
- Build inclusive, empowered teams to provide the foundation for integration.
- Develop a change management strategy of continuous evaluation and course correction.
- Use targeted data collection pertinent to integrated care to drive improvement and impart accountability.
The Institute for Clinical and Economic Review has organized an extensive list of resources36 for implementing BHI models, a sampling of which is shown in TABLE 2.
Continue to: TAKE-AWAY POINTS
TAKE-AWAY POINTS
There is high quality evidence that collaborative care works for the management of depression and anxiety disorder in primary care, and this is associated with significant cost savings.
CORRESPONDENCE
Rajesh (FNU) Rajesh, MD, Main Campus Family Medicine Clinic, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109; frajesh@metrohealth.org
1. Rost K, Nutting P, Smith J, et al. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150-154.
2. Rush A, Trivedi M, Carmody T, et al. One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies. Biol Psychiatry. 2004;56:46-53.
3. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting. JAMA. 2002;288:2836-2845.
4. Department of Veterans Affairs. Bradford DW, Slubicki MN, McDuffie J, et al. Effects of care models to improve general medical outcomes for individuals with serious mental illness. 2011. https://www.hsrd.research.va.gov/publications/esp/smi-REPORT.pdf. Accessed August 22, 2018.
5. Druss BG, von Esenwein S. Improving general medical care for persons with mental and addictive disorders: systematic review. Gen Hosp Psychiatry. 2006;28:145-153.
6. Druss BG, Walker ER. Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation; February 2011.
7. Reed SJ, Shore KK, Tice JA. Effectiveness and value of integrating behavioral health into primary care. JAMA Intern Med. 2016;176:691-692.
8. Young AS, Klap R, Sherbourne CD, et al. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61.
9. Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK38632/. Accessed March 2, 2019.
10. Unützer J, Schoenbaum M, Druss B, et al. Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatr Serv. 2006;57:37-47. doi: 10.1176/appi.ps.57.1.37.
11. Peek CJ; the National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus. AHRQ. https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Published April 2013. Accessed May 29, 2019.
12. Heath B, Wise Romero P, Reynolds K. A standard framework for levels of integrated healthcare and update throughout the document. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf. Published March 2013. Accessed May 29, 2019.
13. Integrating physical and behavioral health care: promising Medicaid models. The Henry J. Kaiser Family Foundation. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf. Published February 2014. Accessed May 29, 2019.
14. Vanderlip ER, Rundell J, Avery M, et al. Dissemination of integrated care within adult primary care settings: the collaborative care model. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf. Published 2016. Accessed May 29, 2019.
15. Gerrity M. Evolving models of behavioral health integration: evidence update 2010-2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf. Published May 2016. Accessed May 29, 2019.
16. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10.1002/14651858.cd006525.pub2.
17. Team Structure. University of Washington AIMs Center. https://aims.uw.edu/collaborative-care/team-structure. Published 2017.Accessed May 29, 2019.
18. Reilly S, Planner C, Gask L, et al. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev. 2013;(11):CD009531.
19. Kilbourne AM, Barbaresso MM, Lai Z, et al. Improving physical health in patients with chronic mental disorders. J Clin Psychiatry. 2017;78:129-137.
20. Oslin DW, Lynch KG, Maisto HSA, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Intern Med. 2013;29:162-168.
21. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.
22. Rossom RC, Solberg LI, Magnan S, et al. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2017;15:77-85.
23. Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2009-2110.
24. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
25. Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions. Med Care. 2013;51:922-930.
26. Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry. 2012;11:790-804.
27. U.S. Department of Veterans Affairs. Rubenstein LV, Williams JW Jr, Danz M, et al. Determining key features of effective depression interventions. 2009. http://www.hsrd.research.va.gov/publications/esp/depinter.cfm. Accessed August 22, 2018.
28. Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One. 2014;9:e108114.
29. Institute for Clinical and Economic Review. Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf. Accessed August 27, 2018.
30. Rubenstein LV, Chaney EF, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91-113.
31. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
32. Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev. 2009;(1):CD000532.
33. Druss BG, Rohrbaugh RM, Levinson CM, et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen Psychiatry. 2001;58:861-868.
34. Davis M, Balasubramanian BA, Waller E, et al. Integrating behavioral and physical health care in the real world: early lessons from advancing care together. J Am Board Fam Med. 2013;26:588-602.
35. Gold SB, Green LA, Peek CJ. From our practices to yours: key messages for the journey to integrated behavioral health. J Am Board Fam Med. 2017;30:25-34.
36. Institute for Clinical and Economic Review. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/02/CTAF_BHI_Action_Guide_060215.pdf. Accessed April 25, 2019.
1. Rost K, Nutting P, Smith J, et al. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150-154.
2. Rush A, Trivedi M, Carmody T, et al. One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies. Biol Psychiatry. 2004;56:46-53.
3. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting. JAMA. 2002;288:2836-2845.
4. Department of Veterans Affairs. Bradford DW, Slubicki MN, McDuffie J, et al. Effects of care models to improve general medical outcomes for individuals with serious mental illness. 2011. https://www.hsrd.research.va.gov/publications/esp/smi-REPORT.pdf. Accessed August 22, 2018.
5. Druss BG, von Esenwein S. Improving general medical care for persons with mental and addictive disorders: systematic review. Gen Hosp Psychiatry. 2006;28:145-153.
6. Druss BG, Walker ER. Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation; February 2011.
7. Reed SJ, Shore KK, Tice JA. Effectiveness and value of integrating behavioral health into primary care. JAMA Intern Med. 2016;176:691-692.
8. Young AS, Klap R, Sherbourne CD, et al. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61.
9. Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK38632/. Accessed March 2, 2019.
10. Unützer J, Schoenbaum M, Druss B, et al. Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatr Serv. 2006;57:37-47. doi: 10.1176/appi.ps.57.1.37.
11. Peek CJ; the National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus. AHRQ. https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Published April 2013. Accessed May 29, 2019.
12. Heath B, Wise Romero P, Reynolds K. A standard framework for levels of integrated healthcare and update throughout the document. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf. Published March 2013. Accessed May 29, 2019.
13. Integrating physical and behavioral health care: promising Medicaid models. The Henry J. Kaiser Family Foundation. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf. Published February 2014. Accessed May 29, 2019.
14. Vanderlip ER, Rundell J, Avery M, et al. Dissemination of integrated care within adult primary care settings: the collaborative care model. SAMHSA-HRSA. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf. Published 2016. Accessed May 29, 2019.
15. Gerrity M. Evolving models of behavioral health integration: evidence update 2010-2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf. Published May 2016. Accessed May 29, 2019.
16. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10.1002/14651858.cd006525.pub2.
17. Team Structure. University of Washington AIMs Center. https://aims.uw.edu/collaborative-care/team-structure. Published 2017.Accessed May 29, 2019.
18. Reilly S, Planner C, Gask L, et al. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev. 2013;(11):CD009531.
19. Kilbourne AM, Barbaresso MM, Lai Z, et al. Improving physical health in patients with chronic mental disorders. J Clin Psychiatry. 2017;78:129-137.
20. Oslin DW, Lynch KG, Maisto HSA, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Intern Med. 2013;29:162-168.
21. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.
22. Rossom RC, Solberg LI, Magnan S, et al. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2017;15:77-85.
23. Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2009-2110.
24. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
25. Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions. Med Care. 2013;51:922-930.
26. Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry. 2012;11:790-804.
27. U.S. Department of Veterans Affairs. Rubenstein LV, Williams JW Jr, Danz M, et al. Determining key features of effective depression interventions. 2009. http://www.hsrd.research.va.gov/publications/esp/depinter.cfm. Accessed August 22, 2018.
28. Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One. 2014;9:e108114.
29. Institute for Clinical and Economic Review. Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf. Accessed August 27, 2018.
30. Rubenstein LV, Chaney EF, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91-113.
31. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
32. Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev. 2009;(1):CD000532.
33. Druss BG, Rohrbaugh RM, Levinson CM, et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen Psychiatry. 2001;58:861-868.
34. Davis M, Balasubramanian BA, Waller E, et al. Integrating behavioral and physical health care in the real world: early lessons from advancing care together. J Am Board Fam Med. 2013;26:588-602.
35. Gold SB, Green LA, Peek CJ. From our practices to yours: key messages for the journey to integrated behavioral health. J Am Board Fam Med. 2017;30:25-34.
36. Institute for Clinical and Economic Review. Integrating behavioral health into primary care. 2015. https://icer-review.org/wp-content/uploads/2016/02/CTAF_BHI_Action_Guide_060215.pdf. Accessed April 25, 2019.
