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Impact of Behavioral Health Consultant Interventions on Patient Symptoms and Functioning in an Integrated Family Medicine Clinic m

Craig J. Bryan, Chad Morrow, and Kathryn Kanzler Appolonio Wilford Hall Medical Center

Patterns of symptomatic and functional change associated with behavioral health consultant (BHC) intervention in an integrated family medicine clinic were investigated among 338 primary care patients under routine conditions without exclusion. Patients were referred to the BHC by primary care providers (PCPs) and participated in one to four brief, behaviorally oriented appointments in primary care. The Behavioral Health Measure-20 (BHM) was completed at each appointment. Results indicated that higher levels of distress at baseline were associated with more follow-up appointments, and that patients demonstrated simultaneous, clinically meaningful improvement in well-being, symptoms, and functioning in as few as two to three BHC appointments. Patterns of clinical improvement support the effectiveness of BHC interventions, but contradict the phase model of psychotherapy (Howard, Lueger, Maling, & Martinovich, 1993). & 2009 Wiley Periodicals, Inc. J Clin Psychol 65:281–293, 2009. Keywords: primary care; treatment outcomes; phase model; psychotherapy process

Over 70% of people suffering from psychological disorders are treated in a primary care facility by their primary care provider (PCP; Gatchel & Oordt, 2003). Additionally, the United States Department of Health & Human Services (2000) has noted that unhealthy lifestyles are responsible for most of the top 10 causes of mortality and morbidity in the country (Mokdad, Marks, Stroup, & Gerberding, 2004). The added burden of managing psychological and behavioral issues in The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, the Department of the Air Force, or the U.S. Government. Correspondence concerning this article should be addressed to: Craig J. Bryan, Kelly Family Medicine Clinic, 204 Paul Wagner Drive, San Antonio, TX 78241; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 65(3), 281–293 (2009) & 2009 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20539

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addition to physical complaints, often with limited training in such health issues, can potentially contribute to decreased quality of doctor–patient relationships, as well as reducing PCPs’ life and job satisfaction (Robinson & Reiter, 2007). To enhance the assessment and treatment of psychological and behavioral problems in these settings, specially trained mental health professionals are increasingly being placed in primary care clinics to collaborate with PCPs in targeting these health issues (Packard, 2007). Various models of a collaborative approach between mental health and medical providers—often termed integrated primary care—have been proposed and implemented (Blount, 1998; Gatchel & Oordt, 2003; Strosahl, 2001a). The models vary in terms of how the mental health provider interacts with patients and—more importantly—who maintains primary responsibility for treatment decisions. The behavioral health consultant (BHC) model is marked by brief appointments, timelimited contact with patients, and collaborative decision-making with PCPs. In the BHC model, PCPs refer patients to specially trained mental health professionals (called behavioral health consultants, or BHCs), who conduct brief evaluations and interventions with patients, and then provide feedback and recommendations regarding mental and behavioral health concerns to the PCP. Central to the BHC model of integrated primary care is the PCP’s retention of full responsibility for patient care decisions, in sharp contrast to specialty mental health settings, in which the mental health professional exercises autonomy in treatment decisions. The BHC’s role in this model is that of a consultant embedded within the primary care clinic, allowing for true integration of health care through immediate access to a mental health provider. Patient contact with a BHC is brief and problem-focused, with the typical course of care spanning one to four appointments, each lasting 15 to 30 minutes in length. Integrating mental health services within primary care exists on two dimensions: horizontal and vertical integration (Strosahl, 2001b). Horizontal approaches—a core feature of the traditional primary care setting—emphasize volume of care in which the goal is to impact the entire population to shift it in the direction of good health and well-being. Horizontal integration of behavioral health services likewise emphasizes delivering low-intensity interventions for a high volume of patients. Vertical integration, in contrast, involves the provision of targeted, specialized services for a defined subpopulation (e.g. depression). The BHC model places a premium on horizontal integration, guided by the public health philosophy of enhancing the care of a significant proportion of the population through brief, lowintensity intervention and consultation. Patients who do not respond to these initial interventions—or who have developed a condition requiring specialized care—can be referred to traditional mental health settings to receive such services (Strosahl, 1994). In sharp contrast to the BHC model, traditional mental health settings have implemented a specialty care model that provides high-intensity services for a comparatively small percentage of the population. Delivery of mental health services within an integrated primary care model can reduce health care costs (Dickinson et al., 2005). It is also efficacious in rapidly reducing patients’ symptoms of commonly occurring problems such as depression and panic disorder. For example, as compared to patients receiving routine primary care interventions, patients who receive integrated care report more anxiety-free days (Katon, Roy-Byrne, Russo, & Cowley, 2002) and more depression-free days (Simon et al., 2001), and demonstrate greater improvement in depression, anxiety, and disability measures at 3 and 6 months after receiving integrated care (Roy-Byrne, Katon, Cowley, & Russo, 2001). Among adolescent patients, integrated care Journal of Clinical Psychology

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contributes to significantly lower levels of depressive symptoms and higher quality of life when compared to standard primary care (Asarnow et al., 2005). Similar patterns of significantly decreased depression and improved quality of life have also been observed among older adults receiving integrated care as compared to routine care (Unutzer et al., 2002). These studies, which utilize randomized controlled trial (RCT) designs, are critical for establishing the efficacy of collaborative care on mental health symptoms and functioning. However, few studies have investigated the effectiveness of BHC intervention under the conditions of routine primary care practice, which is marked by a diversity of clinical problems beyond depression and anxiety (e.g. insomnia, stress, pain, diffuse physical complaints). Translational research that maximizes external validity by bringing the experimental situation as close to ‘‘real world’’ practice as possible (Goldfried & Wolfe, 1996) improves generalizability to real world clinical practice and is critical for determining the actual effectiveness of the BHC model. There has similarly been a lack of research investigating the impact of BHC intervention on a patient’s daily functioning. One study of routine integrated primary care practice found that BHC interventions contributed to significant decreases in symptomatic distress over the course of BHC visits, and that patients with greater levels of symptomatic distress at the initial appointment required more follow-up visits for recovery (Cigrang, Dobmeyer, Becknell, Roa-Navarette, & Yerian, 2006). Results of this study support the effectiveness of the BHC model in reducing emotional symptomatology across a diversity of clinical presentations and problems, but it did not investigate the impact on patients’ functional capacity—a particularly important clinical outcome variable in primary care (Robinson & Reiter, 2007). Although functional improvements in integrated primary care have not yet been well-researched, mental health outcomes research utilizing a patient-focused approach emphasizing the process or course of treatment (Howard, Kopta, Krause, & Orlinsky, 1986; Kadera, Lambert, & Andrews, 1996) has found that clinical improvements in mental health typically occurs in three discrete phases (termed the phase model of psychotherapy), with functional changes occurring last: subjective improvement (remoralization), then symptom relief (remediation), then functional improvement (rehabilitation; Howard et al., 1993; Kopta, Howard, Lowry, & Beutler, 1994). The final stage of functional improvement has been proposed to be a key facet of treatment because it entails the unlearning of maladaptive behavioral patterns and the establishment of new, more functional behavioral patterns that serve to reduce the likelihood of relapse. Given that functional improvement purportedly occurs later in the process of psychotherapy—after symptomatic improvement—the emphasis on symptom change alone in integrated primary care outcomes studies may therefore provide an insufficient level of treatment intervention. Additional research to further examine the patterns of symptomatic change over the course of BHC interventions provided in routine clinical settings is therefore needed, as well as investigations describing the impact of such interventions on the functional capacity of patients. The primary aim of the present study was to examine the effectiveness of BHC interventions on emotional symptomatology and life functioning of primary care patients referred under routine conditions, without exclusion or selection. We hypothesized that patients would demonstrate clinically meaningful improvements in psychological symptoms, consistent with Cigrang and colleagues’ (2006) earlier findings. A secondary aim of this study was to describe the typical patterns of clinical Journal of Clinical Psychology

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improvement associated with BHC intervention, particularly as related to change in functional capacity. Method Participants Participants were 338 consecutive patients referred during a 6-month period by their PCP to the BHC service, which was integrated and colocated within a large family medicine clinic at an Air Force base in the southwestern United States. The clinic has a base of approximately 60,000 beneficiaries of all ages that includes active duty and retired military personnel and their family members. Primary care physicians referred patients to the BHC for evaluation and treatment recommendations upon identification of psychosocial health issues during a medical appointment. The patient sample was predominantly female (62.7%) ranging in age from 11 to 83 years old (M 5 35.86). Accurate information regarding the racial/ethnic profile of the sample is unavailable due to limitations in the electronic medical records system, which did not contain information regarding race in over half of the patients. Demographic variables are listed in Table 1. Patients were referred to the BHC for a wide range of problems in isolation (e.g. depression alone) or comorbid with other problems (e.g. depression, insomnia, and pain), with the most frequently occurring identified problems in this sample being depression (28.4%), anxiety (27.2%), insomnia (27.2%), pain (21.0%), and stress (13.0%). Additional identified problems occurring in less than 5% of referrals included tobacco cessation, attention-deficit hyperactivity disorder, anger management, weight management, substance use, grief, memory impairment, parenting skills, sexual functioning, and relationship problems. Almost one third (31.4%) of the sample had more than one problem or co-occurring condition identified in the referral, although it is important to note that many comorbid medical conditions (e.g. diabetes, hypertension) were not coded as a variable in this study unless it was specifically identified by the PCP as the primary referral question. In the study setting, PCPs more frequently referred to the BHC to target specific behavioral or psychosocial issues related to medical conditions, but not the medical condition itself. For example, a patient with poorly controlled diabetes is likely to be referred Table 1 Patient Demographics by Group Total number of appointments n (%)

Gender Male Female Status Active duty Retired active duty Dependent Age M7SD

Total sample

1

2

3

4

(N 5 338)

(n 5 225)

(n 5 80)

(n 5 25)

(n 5 8)

126 (37.3) 212 (62.7)

85 (37.8) 140 (62.2)

33 (41.3) 47 (58.8)

7 (28.0) 18 (72.0)

1 (12.5) 7 (87.5)

160 (47.6) 31 (9.2) 145 (43.2) 35.86713.14

107 (48.0) 18 (8.1) 98 (43.9) 35.72713.21

36 (45.0) 11 (13.8) 33 (41.3) 36.56713.75

12 (48.0) 2 (8.0) 11 (44.0) 37.56711.60

5 (62.5) 0 3 (37.5) 27.5076.61

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for interventions for depression or stress that are contributing to treatment nonadherence, but not diabetes per se. Of the 338 patients in this sample, 225 (66.57%) met with the BHC only once, 80 (23.7%) kept two appointments, 25 (7.40%) kept three appointments, and 8 kept four appointments (2.37%). This distribution is consistent with the BHC model of one to four appointments, with fewer appointments occurring with greater frequency (Robinson & Reiter, 2007). Measure The Behavior Health Measure-20 (BHM) is a brief self-report questionnaire that uses Likert rating scales to assess the three domains of mental health treatment, consistent with the phase model of psychotherapy: well-being, psychological symptoms, and life functioning (Kopta & Lowry, 2002). Each item has a 5-point scale ranging from 0 to 4, with higher scores indicating better health. The BHM has four primary subscales: well-being (WB) consists of three items assessing subjective distress and life satisfaction, symptoms (SYM) consists of 13 items assessing common emotional symptoms such as depression and anxiety, life functioning (LF) consists of four items assessing functional problems in several areas of life, and global mental health (GMH) consists of the average score of all 20 items for an index of overall health. The measure has considerable psychometric strength (Kopta & Lowry, 2002), and can be used to distinguish three levels of mental health functioning based on the clinical significance criteria recommended by Jacobson and Truax (1991). Specifically, patients scoring in the healthy range of the BHM are above the clinical significance criterion (i.e. functioning well), those in the at risk range fall between the clinical significance criterion and 75% of the mathematical distance from the criterion to the mean of the dysfunctional population, and those in the distressed range are below this cutoff (Kopta & Lowry, 2002). As such, the BHM is designed to detect clinically meaningful changes in mental health functioning. Patients completed the BHM at each BHC appointment as a part of routine clinical care. Procedures Patients were referred to the BHC by their PCPs when psychosocial health issues were identified during medical appointments. Behavioral health consultants’ appointments generally occurred within 2 business days of the initial PCP appointment, though on rare occasions (typically due to patient scheduling limitations) BHC appointments occurred 3 or more business days after the PCP appointment. Upon check-in for each BHC appointment, patients were given a paper-and-pencil version of the BHM to complete before the appointment—a standard part of the clinic’s BHC service to supplement clinical decision-making and track changes over time. Behavioral health consultants’ appointments typically last no longer than 25 to 30 minutes. The format for an initial BHC appointment is for the BHC to open with an explanation of their role within the primary care clinic. The BHC next conducts a brief (i.e. less than 15 minutes) functional analysis focused on the referral problem, and then concludes the appointment with recommendations and interventions. Interventions typically consist of brief behavioral strategies (e.g. diaphragmatic breathing, sleep hygiene education, behavioral activation) that can be rapidly taught and practiced by the patient. Behavioral health consultants follow-up with the PCP on the same day as the appointment to discuss the case and provide recommendations for ongoing patient care. Follow-up appointments with the BHC are determined Journal of Clinical Psychology

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collaboratively by the patient and the BHC based on current level of functioning, clinical judgment, and patient preference; they typically occur in 2-week intervals. The total number of appointments in this study occurred naturalistically based on the interaction of clinician recommendation and patient preference. The procedures used in this study were that of routine clinical practice in a family medicine clinic. Paper-and-pencil surveys were stored in the secured BHC administrative office located in the primary care clinic. Upon receiving institutional review board approval for exempt research, BHM data were entered into a database, and electronic medical records were reviewed for demographic and clinical variables. The database was checked for accuracy by one of the authors (C.J.B.), and identified errors were corrected. Results Descriptive statistics were first calculated to describe the clinical presentation of the patients at the initial contact with the BHC. At the time of the first BHC appointment, patients reported poor overall mental health functioning (GMH 5 2.74, SD 5 0.69, distressed), mild subjective distress (WB 5 1.96, SD 5 0.89, at risk), few emotional symptoms (SYM 5 3.04, SD 5 0.67, healthy), and significant impairment in daily functioning (LF 5 2.35, SD 5 0.99, distressed). No significant differences were found at baseline by any demographic variable. Patients were divided into subgroups based on the total number of appointments (i.e. one (n 5 225), two (n 5 80), three (n 5 25), or four (n 5 8)) they kept with the BHC; initial BHM scale scores for each group can be found in Table 2. After controlling for the Table 2 Means, Standard Deviations, and Statistical Tests for BHM Scale Scores Across Appointments, Grouped by Patient Group Appointment number BHM Scale

1

2

One appointment (n 5 225) GMH 2.79 (0.71) – WB 2.01 (0.93) – SYM 3.07 (0.69) – LF 2.39 (1.31) – Two appointments (n 5 80) GMH 2.74 (0.64) 3.06 (0.64) WB 1.96 (0.84) 2.48 (0.90) SYM 3.05 (0.61) 3.30 (0.60) LF 2.35 (0.94) 2.77 (0.88) Three appointments (n 5 25) GMH 2.51 (0.60) 2.73 (0.62) WB 1.71 (0.58) 1.97 (0.64) SYM 2.82 (0.57) 3.01 (0.56) LF 2.07 (1.04) 2.36 (0.96) Four appointments (n 5 8) GMH 2.21 (0.95) 2.41 (0.65) WB 1.33 (1.07) 1.79 (0.85) SYM 2.49 (0.83) 2.71 (0.56) LF 1.94 (1.31) 1.85 (1.04)

3

4

– – – –

– – – –

– – – –

– – – –

2.94 2.42 3.14 2.68

(0.60) (0.79) (0.59) (0.80)

– – – –

2.45 1.96 2.71 1.94

(0.57) (0.52) (0.52) (0.98)

2.54 1.83 2.88 1.94

(0.71) (0.89) (0.62) (1.00)

t 6.870 6.734 5.154 5.446 F 8.539 13.333 5.488 7.706 F 0.990 3.057 2.501 0.092

df 79 79 78 77 df 2, 23 2, 23 2, 23 2, 23 df 3, 5 3, 5 3, 5 3, 5

p o0.001 o0.001 o0.001 o0.001 p 0.002 o0.001 0.011 0.003 p 0.468 0.130 0.174 0.961

d 0.50 0.62 0.38 0.51 l 0.574 0.463 0.677 0.599 l 0.627 0.353 0.400 0.948

Z2 0.43 0.54 0.32 0.40 Z2 0.37 0.65 0.60 0.05

Note. BHM 5 Behavioral Health Measure; GMH 5 global mental health scale; WB 5 well-being scale; SYM 5 symptoms scale; LF 5 life functioning scale. Journal of Clinical Psychology

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number of appointments, significant differences in initial scores between those patients attending two or less appointments and those attending more than two were found. Subsequent analyses were therefore conducted separately for each group of patients. Scale score changes for all patient groups are displayed graphically in Figure 1.

Figure 1. Mean Behavioral Health Measure Scale score change across appointments by patient group. GMH 5 Global mental health scale, WB 5 well-being scale, SYM 5 symptoms scale, LF 5 life functioning scale; 1A 5 one-appointment group; 2A 5 two-appointment group; 3A 5 three-appointment group; 4A 5 four-appointment group. Scores below the horizontal line fall within the distressed range, scores above the horizontal double line fall within the healthy range, and scores between the two horizontal lines fall within the at risk range. Journal of Clinical Psychology

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Paired-samples t tests were next used to investigate score changes for the twoappointment (2A) group, which are summarized in Table 2 along with effect sizes. Results indicate that all BHM scales demonstrated statistically significant improvements in scores with medium-sized effects for global mental health, subjective wellbeing, and life functioning, and a small effect for emotional symptoms. Using the BHM clinical cutoff scores (Kopta & Lowry, 2002), these changes indicate clinically significant improvement in global mental health from distressed to healthy, improvement in subjective well-being from at risk to healthy, and improvement in life functioning from distressed to healthy. Because emotional symptoms at baseline fell in the healthy range, no change in clinical status occurred, although a statistically significant improvement was found. Repeated-measures ANOVA were then used to identify clinical changes over time among the three-appointment (3A) and four-appointment (4A) groups, results of which are summarized in Table 2. For the 3A group, statistically significant improvements in global mental health, subjective well-being, emotional distress, and life functioning were noted. Total number of appointments demonstrated a large effect on global mental health, well-being, and life functioning, as well as a small effect on emotional symptoms. These improvements translate into clinically significant improvements from distressed to healthy in global mental health, subjective well-being, and life functioning, as well as improvement from at risk to healthy in emotional symptoms. Score changes for all scales were linear in nature, as confirmed by follow-up polynomial contrasts: global mental health, (F (1, 24) 5 16.910, po0.001, partial Z2 5 0.29), subjective well-being (F (1, 24) 5 27.823, po0.001, partial Z2 5 0.54) emotional symptoms (F (1, 24) 5 9.284, p 5 0.006, partial Z2 5 0.28) and life functioning (F (1, 24) 5 15.703, p 5 0.001, partial Z2 5 0.40). Between-appointment changes in scale mean scores for the 3A group can be found in Table 3. Results indicate that between the first and second appointments, symptoms and functioning significantly improved, but well-being did not. Between the second and third appointments, well-being and functioning significantly improved, but symptoms did not significantly change. For the 4A group, no statistically significant differences in scores were found, although total number of appointments demonstrated large effects on global mental health, subjective well-being, and emotional symptoms (see Table 2). This could indicate that this group’s small size (n 5 8) did not have adequate power to reach statistical significance. Life functioning scores, in contrast to other scale scores, did

Table 3 Between-Appointment Mean Score Changes for the Three-Appointment Group

GMH WB SYM LF

Appts

DM (SD)

95% CI

t (24)

p

d

1–2 2–3 1–2 2–3 1–2 2–3 1–2 2–3

0.22 0.22 0.27 0.45 0.19 0.13 0.29 0.32

0.04–0.40 0.00–0.43 0.01–0.55 0.13–0.76 0.03–0.35 0.08–0.35 0.01–0.57 0.07–0.57

2.576 2.067 1.960 2.955 2.522 1.270 2.105 2.622

0.017 0.050 0.062 0.007 0.019 0.216 0.046 0.015

0.34 0.30 0.32 0.51 0.31 0.18 0.35 0.41

(0.43) (0.53) (0.68) (0.76) (0.38) (0.52) (0.68) (0.61)

Note. GMH 5 Global Mental Health Scale, WB 5 well-being scale, SYM 5 symptoms scale, LF 5 life functioning scale. Journal of Clinical Psychology

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not change in the 4A subgroup, and remained well below the cutoff for the distressed range. For all subgroups, analyses were repeated while controlling for gender, age, and beneficiary status. Observed score changes remained significant in all cases, suggesting no identifiable differential impact of BHC interventions by demographics. Discussion This study investigated clinical outcomes for primary care patients who were seen by a BHC as part of an integrated primary care clinic. In the BHC model of integrated primary care, the PCP refers patients with identified psychosocial health issues to the BHC, who provides brief, problem-focused interventions to the patient and recommendations to the PCP, who retains primary responsibility for the treatment decisions. The current study investigated routine care of primary care patients with a wide range of behavioral health issues, without exclusion. Results indicated that patients ranged in their level of distress at the time of their initial appointment with the BHC. Not surprisingly, patients with higher levels of distress required more appointments to improve. Overall, patients who followed-up with the BHC demonstrated significant and clinically meaningful improvement, with the exception of the 4A subgroup. This pattern of results replicates previous effectiveness research of the BHC model by Cigrang and colleagues (2006), who also found that patients with greater levels of symptomatic distress at the initial appointment required more follow-up, and displayed significant decreases in distress over the course of BHC visits. Results are also consistent with dose-effect research findings that the greatest amount of improvement in psychotherapy occurs during the first few sessions (Howard et al., 1984). This study builds on previous work in primary care settings by including measures of functional capacity independent of subjective well-being and symptomatic distress. As noted within the psychotherapy literature, functional change tends to occur later in the psychotherapy process—after subjective improvement and symptomatic relief—and can be critical for full recovery and prevention of symptomatic relapse (Howard et al., 1993). Contrary to the expectations of this phase model of psychotherapy (Howard et al., 1993; Kopta et al., 1994), patients in this study demonstrated clinically meaningful improvements in life functioning following the first appointment. In contrast to the phase model again, patients’ improvements in well-being, symptomatology, and life functioning occurred simultaneously, i.e. not in a progressive manner from one phase to the next. This suggests that interventions delivered within the BHC model not only contribute to increased hope and symptom relief, but also contribute to changes in skills and behavioral patterns across settings that enhance daily functioning. A notable exception to this pattern, however, was the 4A group, which will be discussed further below. Follow-up research should be conducted to determine the applicability of the phase model of psychotherapy to mental health services delivered in primary care settings. A limitation to this study is that outcomes measurements were not available for two thirds of the patients (i.e. those who visited with the BHC one time), which limits our ability to state whether or not a single appointment resulted in clinical improvement. The 1A group actually consists of two subgroups: those who were not scheduled for a follow-up either due to minimal symptomatic distress or due to referral to specialty mental health care (n 5 134), and those who were scheduled but Journal of Clinical Psychology

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did not keep the appointment (i.e. no-show patients; n 5 80). This 39.2% no-show rate for follow-ups (i.e. 80 no-show patients of 204 scheduled appointments) could be due to attrition over time. It is possible that some patients experienced worsening or no change in symptomatic distress, resulting in demoralization or lack of confidence in the BHC. Alternatively, it is possible that these patients improved and therefore did not believe they needed to follow-up. Several pieces of data lend support to this latter explanation. First, the 1A group did not significantly differ from the 2A group at the initial visit with respect to demographics or symptomatic scores. Secondly, no differences in demographics, reason for referral, or symptom scores could be found among those who followed-up when scheduled versus those who did not show-up. In short, our data suggest that patients who do not follow-up with the BHC—whether planned or not—do not differ substantially from those who do. These conclusions are made with considerable caution, however, and additional outcomes research that includes follow-up data from the 1A group is clearly needed to unequivocally support the possibility of clinically meaningful change following a single appointment. The observed pattern of rapid, simultaneous, clinically significant improvement in all three areas of mental health (i.e. subjective well-being, symptomatic distress, functional capacity) in this study might be accounted for by differences in service delivery between primary care and specialty mental health settings. Traditional outpatient psychotherapy is marked by an initial stage of information gathering and rapport building—accomplished through such tasks as clinical interviewing, assessment, case formulation, and treatment planning—that can span for several sessions and typically precedes the active application of therapeutic interventions and strategies. Howard and colleagues (1993) have noted that subjective improvements in well-being appear to be associated with this initial stage of psychotherapy, whereas symptomatic and functional improvements are associated with active therapeutic intervention targeting life problems and relapse prevention. Within the BHC model, however, these stages are collapsed into a single, brief appointment: functional analysis (i.e. information gathering and rapport building) typically comprises the first 10–15 minutes, and is immediately followed by psychoeducation and skills training (i.e. active intervention and relapse prevention; cf. Gatchel & Oordt, 2003; Robinson & Reiter, 2007). Results of our study raise the possibility that, for many patients, the focused nature of the BHC model might contribute to more rapid improvement in all dimensions of mental health than traditional mental health models. Further research that directly compares change curves from integrated primary care settings to change curves from traditional psychotherapy settings is required to shed further light on this study’s findings. Rapid, clinically significant improvement has been classified elsewhere as ‘‘sudden gains’’ (Tang & DeRubeis, 1999). Although most studies noting sudden gains have occurred in depressed populations (see Hardy et al., 2005), sudden gains have been found in various disorders treated with a range of interventions (e.g. Stiles et al., 2003). Perhaps this phenomenon accounts for the rapid symptomatic and functional improvements observed in the 2A and 3A groups. Indeed, Tang, DeRubeis, Hollon, Amsterdam, and Shelton (2007) found that sudden gains in cognitive therapy for depression were not due to chance, and may reflect lasting change that could reduce the likelihood of relapse. In terms of the phase model of psychotherapy, such lasting change suggests improvements in life functioning (Howard et al., 1993). The BHC interventions are primarily behaviorally focused and emphasize empirically based psychoeducation and homework. Although mechanisms explaining sudden gains Journal of Clinical Psychology

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remain unclear (Hardy et al., 2005), it is possible that functional improvement in our sample is due to specific problems being directly targeted through brief, behaviorally focused interventions that might contribute to cognitive shifts in patients’ beliefs and expectations (Tang et al., 2007). Conclusions are also limited for the 4A group due to small sample size (n 5 8), although a few observations can be made with the intent of directing future research with a larger sample. First, this group demonstrated a magnitude of symptomatic improvement comparable to that of the other groups (as measured by mean score change), but because they reported such an elevated level of distress to begin with, their improvements did not reach the threshold that would indicate clinically meaningful improvement. Of note, despite improvements in subjective well-being and emotional symptoms, this group did not change at all in life functioning. This pattern of improvement—well-being and symptoms preceding functional capacity— is consistent with the temporal ordering of change proposed in the phase model (Howard et al., 1993). Importantly for BHC practice, the higher level of distress observed in the 4A group, in combination with the lack of change in life functioning (in notable contrast to the other patient groups), could point to a subpopulation of patients for whom the brief, behavioral, and problem-focused BHC interventions are insufficient. Such patients might better be served by traditional mental health services. These conclusions should be taken with caution due to the limitations noted above, but these data suggest the possibility of matching patients with the appropriate level of care as early as the first appointment, akin to the patient profiling approaches proposed for traditional outpatient psychotherapy (Leon, Kopta, Howard, & Lutz, 1999). Future research with larger samples is needed to investigate this potential, which could lead to an important advance in mental health treatment; namely, enhanced ability to match patients with the most appropriate and cost-effective level of care. Another important limitation to this study is the absence of a control group that did not receive BHC services, which restricts our ability to definitively determine whether the observed improvements are due to BHC intervention. Additional studies comparing patients receiving BHC services to patients receiving standard primary care without integrated behavioral health services are therefore required to identify any incremental benefit of BHC services on the health and well-being of primary care patients. Overall, the results of this study lend further support for the effectiveness of brief, problem-focused mental health interventions delivered in primary care settings. Although largely descriptive in nature, the observed clinical improvements should be encouraging for primary care behavioral health professionals who work with patients presenting with a wide spectrum of health concerns. Importantly, our results not only demonstrate subjective and symptomatic recovery, but also improvement in life functioning—a critical change variable for more enduring change and reduction of risk for relapse. Future research should build off these findings by investigating long-term outcomes of BHC intervention because this current study does not address persistence of improvement postintervention. Although the observed improvements in life functioning in this study suggest that clinical gains should be maintained over time, our data cannot address this possibility. Such research would be critical for the potential development of patient profiling models, which could identify those patients suited to primary care interventions versus those better suited by traditional mental health care. Subsequent studies should also incorporate measures of physical health to investigate the effectiveness of routine BHC interventions on physical aspects of Journal of Clinical Psychology

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Journal of Clinical Psychology

DOI: 10.1002/jclp