Behavioral Health in

Idaho…Opportunities for Pioneering

Alex J. Reed, PsyD, MPHDirector of Behavioral Science, Mental Health and Research

Family Medicine Residency of IdahoClinical Assistant Professor, Department of Family Medicine

Clinical Assistant Professor, Department of Psychiatry and Behavioral ScienceUniversity of Washington School of Medicine

Objectives• Review the behavioral health and

primary care outlook for Idaho • Discuss an innovative model for

behavioral health here in Idaho!

MH In Idaho• In 2010, 36.3% of Idahoans report

poor mental health, compared to 34% of U.S. citizen.

• 54,000-84,000 Idahoans live with serious mental health conditions

Boun

Bonner

Kootenai

BenewahBenewah Shoshone

LatahLatah

ClearwaterClearwater

Nez Perce

Lewis

Idaho

Adams

ValleyValley

Washington

Payette

Canyon

Boise

Ada

OwyheeTwin Falls

Jerome

Blaine

Lincoln

Minidoka

Cassia

Power

OneidaFranklin

Bear Lake

Bannock

Caribou

Bingham

Lemhi

CusterClark Fremont

TetonJefferson Madison

Bonneville

Butte

Gooding

CamasElmore

Gem

Idaho Mental Health Professional Shortage AreaService Areas

Geographic HPSA

State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 4/07 – please contact (208) 334-5993 for updates

Facility

MH Training in Idaho• Idaho has several programs for

training mental health professionals– SW – BSU– Counseling – ISU, NNU– Counseling Ph.D.- ISU– Clinical Ph.D. – none

Mental Illness in Primary Care• Most patients with mental health disorders

initially present to their PCP• Often, the PCP is the first point of contact

for patients who often present with a variety of physical complaints, somatic symptoms, and sub threshold psychiatric symptoms that vary in number, intensity and duration

• 80% of all psychotropic medications are prescribed by nonpsychiatric medical providers

Druss, B. G. (2002). The mental health/primary care interface in the United States: History, structure & context. Gen Hosp Psychiatry, 24: 197-202.Katon, W., Reis, R.K., Kleinman, A. (1984). The prevalence of somatization in primary care. Compr Psychiatry, 25 (2)., 208-215

Mental Health & Primary Care• Primary care is the “def facto”

mental health system for 70% of the population.

• Rates of mental health problems are significantly higher for patients with chronic conditions.

• Public mental health patients die 25 years younger than the national average

Colton, C.W., Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life los, and causes of death among public mental health clients in eight states. Prev Chron Dis. http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed Sept 20, 2012.

.

Chronic Conditions and MHCost w/o Mental Health Condition

Cost w/Mental Health Condition

All Adults $1,913 $3,545

Heart Condition $4,697 $6,919

High Blood Pressure $3,481 $5,492

Asthma $2,908 $4,028

Diabetes $4,172 $5,559

Agency for Healthcare Research and Quality (2003). Medical Expenditure Panel Survey, Rockville, MD.

Idaho Primary Care Health Professional Shortage AreaService Areas

Geographic HPSAPopulation Group HPSA

State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 5/12 – please contact (208) 334-5993 for updates

Bonner

Kootenai

BenewahBenewah Shoshone

LatahClearwater

Idaho

Adams

Washington

Payette

Canyon

Ada

OwyheeTwin Falls

Jerome

Blaine

Lincoln

Minidoka

CassiaBear Lake

CusterClark Fremont

Gooding

CamasElmore

Gem

Bannock

Valley

Lewis

Nez Perce

Lemhi

Power

FranklinOneida

Boise

Butte

Bingham

JeffersonMadison Teton

Caribou

Boundary

Bonneville

Leading Causes of Death in Idaho 2009

Cause % of All Deaths

Malignant Neoplasms 22.1Heart Disease 21.6Chronic Lower Resp Disease 6.5Accidents 6.0Cerebrovascular Disease 5.6Diabetes Mellitus 3.4Alzheimer’s Disease 2.3Suicide 2.7Influenza and Pnuemonia 1.9Nephritis 1.7

Smk/Diet/Etoh

Beh. FactorsDiet/Sed/SmkSmoking

AlcoholDiet/Sed/SmkDiet/Sed/Smk

AlcoholSmokingDiet/Sed from diabetes

Diet/Sed/Smk

Typical Morning in FM Practice

56 y.o. diabetic w/ poor control

19 y.o. smoker for annual exam

33 y.o. w/ multiple somatic issues

7 y.o. with otitis media

67 y.o. with insomnia70 y.o. with sinusitis52 y.o. with HTN28 y.o with chest pain & SOB

AnxiousSmoking Cessation

DepressionEnuresisAlcohol AbuseFamily Violence

Cardiac Risk FactorsPanic Disorder

Gunn, W. B. & Blount, A. (2009). Primary care mental health: A new frotier for psychology. Journal of Clinical Psycholog, 65 (3), 235-252.

Determinants of Health

Schroeder, Steven A., We Can Do Better -- Improving the Health of the American People, N Engl J Med 2007 357: 1221-1228

Effects of Unrecognized Psychiatric Disorders in PC• High medical utilization• Nonadherence to treatment• Physician frustration “heartsink”• Increased risk for tobacco/substance

use

Colton, C.W., Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life los, and causes of death among public mental health clients in eight states. Prev Chron Dis. http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed Sept 20, 2012.

EXTREME INTEGRATED PRIMARY CARE!!!!

Integrated Primary Care• PCP’s are under significant pressure

to diagnose and treat a broad spectrum of biomedical and psychosocial problems.

• Yet they lack time to manage behavioral problems.

• Patient preference for collaboration between physician and MH Provider

Integrated Primary Care• Physician satisfaction in integrated

settings– After collaboration, physician

satisfaction increased from 54% to more than 90%.

• Collaborative care model for treatment of panic disorder more effective than tx by a physician alone.

Unutzer, J, Katon, W, Callahan, CM, Williams, JW, Hunkeler, E, Harpole, L, Hoffing, M, Della Penna, RD, Noel, PH, Lin, EH, Arean, PA, Hegel, MT, Tang, L, Belin, TR, Oishi, S, Langston, C (2002). Collaborative care management of late life depression in the primary care setting: a randomized control trial. JAMA, 288 (22), 2836-45.

Levine, S., Utuzner, J, Yip, JY, Hoffing, M, Leung, M, Fan, MY, Lin, EH, Grypma, L, Katon, W, Harpole, LH, Langston, CA. (2005). Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary care. Gen Hosp Psychiatry, 27 (6), 383-91.

Roy-Byrne, PP, Katon, W., Cowley, DS., Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Arch Gen Psychiatry, 58, 869-876.

Traditional Mental Health

Primary Care

Traditional Mental Health• Patients seek help themselves or are

referred• 45-50 minutes session for 8-10 visits

(short term) or long term (indefinitely)

• 20 sessions/week @ 46 weeks = 920 hours

• 102 patients served in 1 year

Primary Care• 10-15 minute visits • 15-20 visits per day• 15 visits x 4 days = 60 visits per

week• 46 weeks = 2760 patient visits• These are two very different models

Integrated Care• PCP refers behavioral health

consultant (BHC) to patient for behavioral issue

• BHC sees patient for 15-30 minutes, develops behavioral change plan, reviews with PCP

• BHC may implement, monitor, or change intervention in 1-4 focused visits, or refer for extended mental health care.

Integrated Care• 20 hours of 20 minute visits per

week = 60 visits per week• 46 weeks = 2760 visits per year• 4 visits per patient, serve 690

patients per year• Imagine the public health impact of

such a system!

Why Consider a New Model?• Nearly 50% of all patients in

specialty mental health drop out of therapy without consulting their therapist

• 50-60% non-adherence to psychoactive medications within first 4 weeks.

• Only 1 in 4 patients referred to SMH make the first appointment

• Yet primary care patients would complete treatments that were brief and pragmatic.

What issues can the BHC address?• Depression• Anxiety• Insomnia • Tobacco Use• Weight loss• Physical Inactivity• Irritable Bowel Syndrome

• Parenting • COPD• Asthma• CV disease• Chronic Pain• Sexual Dysfunction• Hypochondriasis• Stress Management

Integrated training at FMRI• FM and Psychiatry residents are

trained in integrated model• We are training SW and Counseling

Students in integrated care models. • One of our graduates is the first BHC

in an outpatient primary care clinic here in Idaho!

Training Needs for Idaho: Integrated Care• Increase training opportunities for

Behavioral Health in Primary Care• Certificate Programs• Reduce financial/ insurance barriers

for fellowship training for psychologists in primary care.