Evidence-Based Behavioral Interventions in Primary Care
Although there is growing sentiment that strengthening behavioral health care services in primary care is critically needed, the majority of existing behavioral interventions were developed for settings very different from the fast paced environment of primary care.
Current strategies require extensive clinical training and an unrealistic time commitment from both the patient and the provider. Although many psychotherapies require six to twelve sessions to be effective, in reality, most people only go to one or two. Less than 10% of primary care patients with depression receive a minimally adequate level of evidence-based psychotherapy, in part because many of the psychotherapies being used were developed for weekly, one-hour visits with a specialty mental health provider.
“As integrated care becomes commonplace, the challenge is to transform effective behavioral interventions to meet the competing demands and limited resources of primary care clinics,” explains Pat Areán, director of the University of Washington’s new Targeted Treatment Development Program and affiliate faculty investigator at the AIMS Center. “Most patients prefer behavioral interventions like psychotherapy, counseling, or cognitive training to medication. The lack of evidence-based behavioral interventions that are tailored to primary care poses a major barrier to their treatment.”
Integrated care provides patients with on-site mental health care to prevent fragmented treatment and decrease the number of patients who slip through the cracks. Effective integrated care models such as Collaborative Care use medications, behavioral interventions, or both, changing the treatment plan as necessary until the patient gets better. To be effective in primary care, a behavioral intervention should:
• Include a patient engagement component. Skipping right to treatment doesn’t work.
• Be time efficient, running no more than 20-30 minutes a visit.
• Follow a structure-based approach. A modularized treatment with clear steps keeps the provider and patient on track despite the distractions in primary care.
• Minimize required clinical training. The treatment should be able to be administered by non-specialists who work in a health care team.
• Be relevant and applicable to the diverse patient populations found in primary care.
• Have a substantial research evidence-base.
Of the multiple behavioral interventions in existence, only a few have been proven to work in primary care including Problem Solving Therapy-Primary Care, Cognitive Behavioral Therapy, Interpersonal Counseling, and Behavioral Activation.
Problem Solving Therapy-Primary Care (PST-PC) is the most widely-used intervention to treat depression and anxiety in the primary care environment. PST-PC is a brief therapy that uses six to ten, 30-minute sessions to help patients solve the “here and now” problems contributing to their depression. PST-PC has been found to significantly improve mental health treatment in a wide range of settings, including diverse provider and patient populations.
An adaptation of Cognitive Behavioral Therapy (CBT) has also been found to be beneficial for both depression and anxiety in primary care. CBT uses short-term, goal-oriented therapy to interrupt patterns of thinking that prevent patients from feeling better. Brief Cognitive Therapy makes the intervention more accessible in primary care by using shorter and fewer sessions.
Interpersonal Counseling (IPC), an outgrowth of Interpersonal Therapy, may further reduce the time required to treat depression in primary care. The model was found to be more effective than normal care after six or fewer, 30-minute sessions with some patients improving markedly after only one or two. Designed to be implemented by nurse practitioners in primary care, IPC focuses on current functioning, recent life changes, sources of stress and difficulties in interpersonal relationships.
A fourth behavioral intervention proven to work in primary care is Behavioral Activation (BA), an evidence-based psychotherapy that identifies work, social, health, or family activities patients have stopped engaging in because of their mood. BA takes concrete steps to re-introduce these activities into the patient’s life and decrease avoidance behaviors and any other behaviors that contribute to a depressed mood. The patient and provider create an action plan, including any obstacles, triggers, and consequences.
While the above behavioral interventions have been proven to work in primary care, they all have constraints that make them difficult to implement, such as the amount of training and on-going supervision clinicians need, not to mention the time demands needed from patients.
“We need to create new interventions from the ground up,” said Areán. “We need interventions that are personalized, easy to learn and easy to deliver in the settings they are needed most.”
The UW’s Targeted Treatment Development Program is currently focused on developing behavioral interventions in low-income, ethnic minority, and older populations implemented in non-specialty settings such as primary care, assisted living, senior services, and day treatment. These new interventions will be based on advances in cognitive neuroscience, using input from patients and clinicians to inform the design of the intervention.
“Primary care has the potential to significantly reduce the global burden of mental health conditions if we can create nimble, adaptable, innovative solutions that any clinician can provide and that are acceptable to a broad array of patients,” said Areán.