In any area of clinical practice, what drives innovation is research.
The same is true for the new movement toward integrated care. And there has been a history—at the National Institute of Mental Health (NIMH), the Agency for Healthcare Research and Quality, the John A. Hartford Foundation, and the Robert Wood Johnson Foundation—of funding research on best practices for integrating mental health and primary care. The Collaborative Care for Depression Model, as exemplified by the IMPACT program developed by Jürgen Unützer, M.D., M.P.H., and colleagues at the University of Washington, is a prominent example of an innovative model with more than a decade of research behind it (Psychiatric News, August 2, 2013).
In an interview with Psychiatric News, Susan Azrin, Ph.D., of the Division of Services and Intervention Research at NIMH, talked about new NIMH initiatives designed to bring “practice-ready” innovations concerning mental health-primary care integration to primary care settings—and to community mental health centers working to integrate primary medical care for patients with serious mental illness.
“More than 30 million previously uninsured people will enter the U.S. health care system this year as a result of the Affordable Care Act and its expansion of Medicaid,” Azrin said. “About 6 million of these newly insured people will have untreated mental health problems, and many are likely to have multiple chronic medical conditions due to a lack of prior care, and their overall health may be poor. Primary care will be the likely health care entry point for these complex patients, so there is a new urgency in the mental health-primary care interface.”
Because of the unique difficulties of primary care clinicians seeing complex patients amid competing demands, as well as system and reimbursement challenges, bringing research-tested innovations in integrated care to clinicians’ practices has not been without problems.
“Previously, integrated care research at NIMH and elsewhere has tended to follow the traditional linear approach to intervention development,” Azrin said. “The linear approach attempts to translate findings conducted under highly controlled conditions to diverse community settings. But bridging the research-to-practice gap for integrated care has been slow with this approach. Interventions shown effective in clinical trials often have only modest traction in the primary care community.”
She said what’s often been lacking in this research is an early focus on the intervention’s potential for sustainability and uptake. “Primary care practices need flexible mental health care interventions that are relevant to the majority of their patients and compatible with the realities of primary care practice,” Azrin said. “To meet this practice need, the research field should focus on flexible, integrated care models that target multiple psychiatric and medical comorbidities and are compatible with the reality of the primary care setting.”
Specifically, she said, such research should focus on generating knowledge that decision makers need, incorporating practice-based evidence, using efficient methods, and planning for sustainability and broad uptake from the outset.
She described three NIMH-funded efforts that hold promise for delivering practice-ready integrated care solutions to the physician’s office.
Antidepressant Adherence via Interactive Voice Recognition; primary investigator: Gregory Clarke, Ph.D., of Kaiser Permanente.This study is testing a very-low-cost direct-to-patient antidepressant adherence intervention using automated telephone interactive voice recognition. Study participants are identified using electronic medical records, and recruitment is by mailed brochures, which is inexpensive and similar to how patients might access such an intervention in real-world practice. Participant exclusions are minimal, resulting in a highly generalizable sample, and the intent-to-treat design allows Clarke and colleagues to assess both intervention dropouts and completers to better understand who would participate in the intervention. Additionally, Clarke and colleagues will conduct evaluative qualitative interviews with study participants and other key stakeholders to identify barriers and/or facilitators of intervention implementation, as well as keys for future dissemination.
Physician Training to Support Patient Self-Efficacy for Depression Care Behaviors; primary investigator: Anthony Jerant, M.D., of the University of California, Davis. This study will seek to train primary care physicians (PCPs) in the use of self-efficacy enhancing interviewing techniques (SEE IT) with patients who have coexisting depression and diabetes. SEE IT is a low-intensity, low-cost, 15-minute provider-training intervention to increase patients’ ability to effectively manage these co-occurring conditions. Jerant and colleagues are training PCPs at 14 offices to use SEE IT with patients during routine office visits. If effective, Azrin said, SEE IT could easily be used with a broad range of PCP patients to increase self-efficacy for managing many mental and general medical conditions that require self-management strategies.
The Mental Health Research Network (MHRN), led by psychiatrist Gregory Simon, M.D., of Group Health Research Institute. This is a practice-based research network of 11 public-domain research centers based in not-for-profit health care systems. Azrin said the network exemplifies the “health care system as lab approach,” where critical practice problems drive the research questions and the data needed to answer them. MHRN is conducting a surveillance study of depression treatments and evaluating their effectiveness using routinely collected scores on the nine-item Patient Health Questionnaire (PHQ-9). The network is also developing capacity for a trial of population-based suicide prevention programs with 15,000 outpatients who, based on the PHQ-9, are at risk of attempting suicide. “Given the diversity of its primary care practices and patient populations, the MHRN offers an ideal infrastructure for rapid and efficient development of practice-ready integrated care solutions,” Azrin told Psychiatric News.
What about research focused on bridging the gap between primary care and care of people with severe and persistent mental illness in community mental health centers and public mental health settings? Azrin said that NIMH funds a number of research projects—by Benjamin Druss, M.D., of Emory University, Martha Sajatovic, M.D., of University Hospitals, Cleveland, Stephen Bartels, M.D., of Dartmouth Medical School, and Gail Daumit, M.D., of Johns Hopkins University, among others—to address this problem.
For instance, in Daumit’s Randomized Trial of Achieving Health Lifestyles in Psychiatric Rehabilitation (ACHIEVE) nearly 300 people with schizophrenia, bipolar disorder, or major depressive disorder were divided into two groups—half participated in a program focused on improving eating and exercise habits, while the other half received no special training. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight was −7.0 pounds. The results were published in the New England Journal of Medicine (April 25, 2013).
In addition, NIMH recently issued a major funding announcement titled “Improving Health and Reducing Premature Mortality in People With Severe Mental Illness.” Azrin said the initiative supports research to test the effectiveness of service interventions that aim to reduce common modifiable health risk factors that contribute to premature mortality for adults with severe mental illness, as well as for children with serious emotional disturbance.
Azrin said that the Affordable Care Act has introduced powerful momentum toward integrated care, and she described a research agenda that is now intensely focused on generating the evidence that clinicians can use and that health care decision makers need. “The evidence most valued by decision makers answers questions such as: Will the intervention work in my setting? For which patients will it work? What staff can deliver the intervention? How much training will they need? And what will it cost?” ■