Behavioral Health

The case for behavioral health integration into primary care

J Fam Pract. 2019 June;68(5):278-284

References

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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.

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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.

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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

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