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CFHA Abstract Summaries, Vol 3, Summer 2017



Rhee, T.G., Capistrant, B.D., Schommer, J.C. Hadsall, R.S., & Uden, D.L. (2017, April 14). Effects of depression screening on diagnosing and treating mood disorder among older adults in office-based primary care outpatient settings: An instrumental variable analysis. Preventative Medicine, 100, 101-111. doi: 10.1016/j.ypmed.2017.04.015  OBJECTIVE: The objective of this study is to determine the efficacy of using depression screening assessments within a primary care setting for diagnosing and treating mood disorders among the elderly population.  METHODS: An instrumental variable design method is used to control for selection bias.. Data was analyzed using information from the 2010-2012 National Ambulatory Medical Care Survey. The sample size was n=9,313 unweighted. Injury prevention and stress management were the variables used.  RESULTS: The study showed mixed findings. Based on depression screening alone, a negative correlation to potentially inappropriate antidepressant prescriptions was seen and no significant correlation to diagnosing of mood disorders in relation to overall prescriptions.  CONCLUSION: PCPs and care-team members should actively utilize depression assessments as a screening tool to minimize inappropriate dispensing of unnecessary antidepressant prescriptions in the elderly population. Newby, J. M., Mewton, L., & Andrews, G. (2017). Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care. Journal of anxiety disorders, 46, 25-34.doi: 10.1016/j.janxdis.2016.06.002  OBJECTIVE: To compare effectiveness of disorder-specific versus transdiagnostic internet cognitive behavior therapy (iCBT) for anxiety and depression in primary care settings.  METHODS: Patient characteristics, adherence and effectiveness of Transdiagnostic iCBT (n=1005) were compared to disorder-specific programs for generalized anxiety disorder (GAD) (n=738) and depression (n=366) in a naturalistic non-randomised comparison study. Patients completed their iCBT program in primary care. The PHQ-9 (depression), GAD-7 (generalized anxiety), K-10 (distress), and the WHODAS-II (disability) were measured at pre- and post-treatment.  RESULTS: Patients in the Transdiagnostic program had higher comorbidity rates and baseline distress. All programs were associated with medium to large within-group effect sizes for improving anxiety, depression and distress between pre- and post-treatment (d's=0.64-1.39). Controlling for baseline group differences in severity, we found small effect sizes favoring the Transdiagnostic program over the GAD program in reducing PHQ-9 (d=0.44, 95%CI: 0.34-0.53), K-10 (d=0.21, 95%CI: 0.16-0.35) and WHODAS scores (d=0.20, 95%CI: 0.10-0.29), and small effect sizes favoring the Transdiagnostic program over the Depression program in reducing GAD-7 scores (d=0.48, 95%CI: 0.36-0.60). A smaller proportion of patients completed the Transdiagnostic program (44.9%) compared to the depression (51.6%) and GAD (49.2%) programs, which was attributable to baseline differences in age and symptom severity.  CONCLUSIONS: Both Transdiagnostic iCBT and disorder-specific iCBT programs are 2 effective in primary care, but there appears to be small effects favoring Transdiagnostic iCBT. Methods to increase adherence are needed to optimize the benefits to patients, and these findings await replication in a RCT. Cano-Garcia, F.J., Gonzalez-Ortega, M.D., Sanduvete-Chaves, S. Chacon-Moscoso, S., & Moreno-Borrego, R. (2017, March 23). Evaluation of a psychological intervention for patients with chronic pain in primary care. Front Pschol., 8: 435. doi: 10.3389/fpsyg.2017.00435  OBJECTIVE: To evaluate the use of psychological interventions with patients being treated for chronic pain in a primary care setting.  METHODS: The sample pool consisted of 40 patients who were being treated for chronic pain, not related to cancer, in a primary care setting in Seville, Spain. Criteria included: they were an adult, the patient was not currently in an employment dispute, they were not diagnosed with a psychopathology, and not currently receiving psychological treatment. Patients participated in 10 group sessions which were held once per week. Groups were limited to no more than 14 participants. Sessions covered psychoeducation addressing self-management practices and coping strategies such as: breathing and relaxation, attention management, cognitive restructuring, problem solving, dealing with emotions, social and adaptive skills training and life-coaching and goal setting. A functional assessment was completed upon initial interview and at the 6-month follow-up meeting.  RESULTS: Based on the results of the study, although initial analysis showed the intervention to be successful, improvement declined with follow-up.  CONCLUSION: The results were analyzed statistically and clinically using IMMPACT standards. Data was collected using a high degree of standardization and specificity. Based on the detailed design of the intervention assessment, using psychological interventions in a primary care setting to treat chronic pain patients appears to be an effective strategy. Erickson, Z. D., Kwan, C. L., Gelberg, H. A., Arnold, I. Y., Chamberlin, V., Rosen, J. A., ... & Kunkel, C. F. (2017). A randomized, controlled multisite study of behavioral interventions for Veterans with mental illness and antipsychotic medication-associated obesity. Journal of General Internal Medicine, 32(1), 32-39. doi: 10.1007/s11606-016-3960-3  OBJECTIVE: Due to weight gain and other metabolic sequelae of antipsychotic medications which impact patient health and quality of life, researchers investigated efficacy of a behavioral weight management intervention for veterans with mental illness who were taking antipsychotic medications across four medical centers within the Veterans Affairs (VA) Healthcare System.  METHODS: Overweight veterans (and some non-veteran women) diagnosed with mental illness that required ongoing antipsychotic therapy (n = 121) were randomized into either a more intensive “Lifestyle Balance” intervention group (LB, n = 62) or the less intensive “Usual Care” group (UC, n = 59). Study participation lasted for 12 months. LB was modified from the Diabetes Prevention Program and consisted of classes and individual nutritional counseling with a dietitian. UC consisted of weight monitoring and provision of self-help skills. Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.  RESULTS: Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB 3 participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001).  CONCLUSIONS: Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach. Acosta, M. C., Possemato, K., Maisto, S. A., Marsch, L. A., Barrie, K., Lantinga, L., ... & Rosenblum, A. (2017). Web-delivered CBT reduces heavy drinking in OEF-OIF veterans in primary care with symptomatic substance use and PTSD. Behavior Therapy, 48(2), 262-276. doi: 10.1016/j.beth.2016.09.001  OBJECTIVE: In order to increase access to behavioral health treatment for veterans, researchers sought to evaluate a novel web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care.  METHODS: Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined.  RESULTS: Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future.  CONCLUSION: These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns. Mavandadi, S., Wright, E. M., Graydon, M. M., Oslin, D. W., & Wray, L. O. (2017). A randomized pilot trial of a telephone-based collaborative care management program for caregivers of individuals with dementia. Psychological Services, 14(1), 102-111. doi: 10.1037/ser0000118.  OBJECTIVE: To assess the effectiveness of an accessible, telephone-based, patient- and caregiver(CG)-centered, collaborative care management program that involves CG education and psychosocial support in improving CG and patient outcomes.  METHODS: CBs (n = 75) of older veterans with dementia receiving care from Veterans Affairs (VA) Medical Center primary care practices were randomized to receive either dementia care management or usual care (UC). Of interest in this study were the frequency and severity of patients’ dementia-related symptoms, CG distress related to patients’ behavioral and neuropsychiatric symptoms (primary outcomes), and CG coping and mastery (secondary outcomes).  RESULTS: Adjusted, intention-to-treat longitudinal models suggest that CGs receiving care management reported significantly greater reductions in distress due to patients’ dementia-related (p = .05) and neuropsychiatric (p = .01) symptoms compared with CGs in UC. Additionally, CGs in the intervention reported significantly larger improvements in their ability to cope (p = .03) and caregiving mastery (p = .03). No significant group differences were found in CG burden or patients’ dementia-related symptom frequency or severity over time.  CONCLUSION: Findings suggest that CGs of veterans with dementia may benefit from a telephone-delivered care management program in improving CG-related outcomes. They highlight the potential for such programs as adjuncts to dementia care offered in primary care practices. 4 van Orden, M., Leone, S., Haffmans, J., Spinhoven, P., & Hoencamp, E. (2017). Predication of mental health services use one year after regular referral to specialized care versus referral to stepped collaborative care. Community Men. Health J., 53(3): 316-323. doi: 10.1007/s10597-016-0046-y  OBJECTIVE: To determine the referring patients with common mental health disorders to the collaborative mental health care-team within primary care setting as opposed direct referral to specialized practitioners would lower enabling factors identified as service use and treatment delay.  METHODS: A post-hoc analysis of baseline characteristics was used to evaluate treatment intensity (number of visits) during 1-year follow-up. Multilevel multivariate regression analyses of baseline data were taken into consideration and this data counted as potential predicators of visit counts.  RESULTS: Showed the enabling factors service concept and referral delay for treatment had a significant correlation to mental health visit counts, particularly when the results were dichotomized over five or more visits. By including outcome variables as a count variable affirmed the predictive value of the enabling factors (service concept and referral delay) and added marital status as a significant predicator.  CONCLUSION: Enabling factors appear to be key predicators of mental health services use. Kelly, E., Duan, L., Cohen, H., Kiger, H., Pancake, L., & Brekke, J. (2017, April). Integrating behavioral healthcare for individuals with serious mental illness: A randomized controlled trial of a peer health navigator intervention. Schizophr Res., 182: 135-141. doi: 10.1016/j.schres.2016.10.031  OBJECTIVE: To determine if populations dually diagnosed with a mental-physical health condition would be better served through interventions which improve health and health-care self-management skills.  METHODS: For this study, 151 consumers diagnosed with serious mental illnesses randomly received either standard mental healthcare plus the Bridge intervention (n=76) or standard mental healthcare while on a 6-month waitlist (n=75). Those on a waitlist received services post-waitlist period.  RESULTS: A comparison of the results for the two groups showed those receiving immediate treatment (the non-waitlist group) had greater improvement in access and use of needed healthcare services, better patient-practitioner relationships, less propensity towards emergency or urgent care use, and improved self-management practices.  CONCLUSION: Based on the study results, using manualized treatment plans to address general medical care of individuals who have serious mental illnesses improved outcomes. Hiratsuka, V. Y., Moore, L., Dillard, D. A., Avey, J. P., Dirks, L. G., Beach, B., & Novins, D. (2017). Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska native health systems. The Journal of Behavioral Health Services & Research, 44(2), 224-241. doi:10.1007/s11414-016-9519-6  OBJECTIVE: To review key points and considerations as made by patients, health care-team members, and tribal leaders with regards to factors which need to be included in the assessment and intervention process when treating adult trauma patients referred to two large American Indian/Alaska native (AI/AN) primary care systems.  METHODS: Data was collected and analyzed using a qualitative and iterative method using a community based participatory approach directed by a cross-site steering committee. A total of 24 leaders and providers each participated in the interview process. Thirteen patients participated in four focus groups. 5  RESULTS: Based on the data collected and using a thematic approach, a preliminary trauma screening assessment, intervention guidelines and materials were developed for use when treating patients from the AI/AN community.  CONCLUSION: Although the preliminary study proved to be productive in developing a screening tool and brief intervention process, it was determined that based on the nature of the traumas experienced by this population further research would need to be conducted in these health systems to determine efficacy. Mendoza, K., Ulloa, A., Saaveda, N., Galvan, J., & Berenson, S. (2016). Predicting womens utilization of primary care mental health services in Mexico City. Journal of Primary Care & Community Health. doi: 10.1177/2150131916678497  OBJECTIVE: To see if by analyzing social-cultural factors associated with Mexican women seeking primary care mental health services (PCMHS), a hypothesis could be postulated to increase PCMHS utilization.  METHODS: A questionnaire was administered to 456 female patients in a Mexico City primary care clinic. A chi-square analysis was conducted using social-cultural variables which included demographics, perceptions of and experiences with PCMHS. Based on the results and subsequent literature review a logistic regression model was created.  RESULTS: Based on the study results, women who had good coping skills and were not intimidated by talking to a mental health practitioner (MHP), those who did not identify loneliness as a concern, and followed the doctor’s treatment plan, were more likely to pursue PCMHS.  CONCLUSION: It was determined in this population PCP’s play a vital role in a women’s decision to seek mental health services. Consequently, it is important to consider socio-cultural dynamics and proper referrals to PCMHS. Lagomasino, I. T., Dwight-Johnson, M., Green, J. M., Tang, L., Zhang, L., Duan, N., & Miranda, J. (2017). Effectiveness of collaborative care for depression in public-sector primary care clinics serving Latinos. Psychiatric Services, 68(4), 353-359. doi:10.1176/  OBJECTIVE: To determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients in public-sector clinics.  METHODS: 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N = 196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N = 204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks.  RESULTS: Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001).  CONCLUSIONS: Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.




The PCBH model has the potential to impact various aspects of health care. For instance, the PCBH model can assist primary care practices in the achievement of the Quadruple Aim (improving population health, increasing patient satisfaction, reducing per-capita costs, improving provider satisfaction). The PCBH model has also helped many practices achieve the goals of Patient Centered Medical Homes (PCMH) which aim to provide more efficient, population-based team care within primary care. With an emphasis on managing co-morbid conditions, such as diabetes, the PCBH model can also be an innovative approach to achieving improved health behavior outcomes in a practice. And as medical homes and value-based outcomes continue to drive the direction of the service delivery, the PCBH model can help a practice achieve positive changes for the patient, primary care provider, and health care delivery system. To make this happen on a larger scale changes in funding, policy and regulations, workforce development and research and evaluation have to be adopted. The PCBH Special Interest Group (SIG) is where we work to make this happen.









The purpose of the Primary Care Behavioral Health Special Interest Group is to: To grow interest and enthusiasm, provide learning experiences, and promote actionable dissemination activities among CFHA members regarding PCBH Service Model delivery.  Discussion topics will include:  funding, policy and procedures, advocacy, skill acquisition, training models, and research and evaluation. The SIG will also promote and support CFHA conference workshops and presentations focusing on PCBH Service Model delivery.







Behavioral health issues account for 20% to 40% of all concerns raised in a primary care visit; “PCBH” is a model of behavioral healthcare that focuses on addressing behavioral health concerns impacting a patient’s overall health, within a primary care office. PCBH utilizes Behavioral Health Consultants (BHCs) trained in empirically-supported, brief interventions to treat mild to moderate concerns that commonly present in primary care offices, such as anxiety, depression, and the management of chronic health conditions such as obesity, chronic pain, and diabetes. BHC’s work alongside primary care providers, nurses, administrators and other healthcare providers to deliver services in exam rooms through warm hand-offs (unscheduled, impromptu visits) or scheduled visits. The PCBH model uses a population-based approach to improve the general public’s access to appropriate and effective behavioral health services, that might be otherwise lost through the referral process. The PCBH model also offers an opportunity for providers to engage in bidirectional learning, collaborate care, and opportunities to coordinate care, improving the overall functioning of a shared patient.



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