Addressing Common Behavioral
Health Problems in Primary Care
Module 7
James J. Werner, PhD, MSSA
Case Western Reserve University
Learning Objectives
• Understand the magnitude, prevalence, and health effects of:
• Behaviorally-related health problems
• Unhealthy lifestyle behaviors
• Common behavioral disorders
• Learn a direct practice framework for addressing common health
problems, unhealthy lifestyle behaviors, and behavioral disorders
in primary care
• Learn methods used by primary care behavioral healthcare
providers to effectively address depression and diabetes
Most Common Reasons for Primary
Care Visits4
Top 10 reasons why patients obtained
primary care in 2009
diabetes knee pain
hypertension back pain
stomach pain fever
cough vision problems
throat symptoms headache
• These accounted for ~1/3 of all U.S. primary care visits
These appear to be purely physical
health problems, but…5
• Clinicians can identify a biological cause for only 16%
of most common physical complaints
• The majority of patients coming to primary care have
no discoverable organic disease
Behavioral Factors are Highly Relevant
in Primary Care5
• Behaviorally-related physical complaints
• Up to 70% of primary care visits are related to behavioral
health needs
• Behavioral health disorders
• 1 in 5 Americans are affected by behavioral health disorders
during any given year
• 50% of all behavioral disorders are treated in primary care
• Health behavior issues
• On average, 97% of Americans need to change one or more
health behaviors to maintain or regain health
Discussion
1) Why is it that only a small proportion of patients seeing
primary care providers have clear biological causes for
their illnesses?
2) What other factors may be causing patients to
experience illness symptoms?
3) What types of personnel are needed in primary care to
most effectively meet the majority of patients’ needs?
What skills should they have?
Behavioral Health Provider (BHP)
Services in Primary Care
Collaborate with primary care providers to assist patients
experiencing:
A need to improve health self-management skills
A need to change unhealthy lifestyle behaviors
Somatic symptoms of known or unknown origin
A wide range of mental health problems including depression,
anxiety, substance abuse, and psychosocial stressors
Adjustment problems following loss of function
Distress over a diagnosis or progression of disease
Many other types of health issues
5 A’s Model
A Flexible & Patient Centered Approach to
Assessment and Intervention
• Integrated approach to assessment and intervention
• Well-established & evidence-based
• Familiar to PC clinicians & PC teams
• Can be applied to any patient with any problem
• Highly adaptable to the preferences of patients
5 A’s Model
1) Assess
Risk factors, behaviors,
symptoms, attitudes, preferences
5) Arrange 2) Advise
Specify plans for follow- Specify options for treatment,
up (visits, phone calls, e- how symptoms can be decreased,
mail reminders) & how functioning & quality of life
Personal Action Plan can be improved
1. List goals in behavioral terms.
2. List strategies to change health
behaviors.
3. Specify follow-up plan.
4. Share the plan with the healthcare team.
4) Assist 3) Agree
Provide information, teach skills, Collaboratively select goals
and help problem-solve barriers based on patient interest
to reach goals and motivation to change
5 A’s: Assess
• Objectives
• Determine what is associated with patient’s problem
• Determine what could change in order to decrease symptoms
or improve functioning
• Assess patient’s motivation for change
• Actions
• Gather information on symptoms, thoughts, emotions,
behaviors, family, friends, & environment
5 A’s: Advise
• Objective
• Describe to the patient the range of potential interventions and
expected outcomes
• Actions
• Using information from the ‘Assess’ step, describe to the
patient the various options for intervention
• Discuss the implications of each intervention for the target
outcomes specified by the patient
• Use Motivational Interviewing with patients not ready to take
action
5 A’s: Agree
• Objective
• Enable the patient to decide on best course of action on basis
of options discussed in the ‘Advise’ stage.
• Actions
• Engage and support the patient in the process of considering
options for intervention
• Allow patient to suggest new options not previously discussed
• Give patient time and space to consider options and discuss
them with significant others
5 A’s: Assist
• Objective
• Help the patient implement the agreed-upon intervention
• Develop new skills, solve problems, overcome barriers,
implement behavior changes
• Actions
• Support the patient’s efforts to implement the intervention
5 A’s: Arrange
• Objective
• Specify the patient’s plan for follow-up with the BHC, PCP,
specialty mental health provider, or other provider
• Actions
• Advise and assist the patient in arranging follow-up
appointments
• Communicate the patient’s follow-up plan to others on the
healthcare team
• If follow-up is with BHC, discuss the focus of the next
appointment
Discussion (Cont’d)
1) How does the 5 A’s model’s ‘Assess’ step compare to
the assessment procedures you currently use at your
field placement/internship site?
2) The 5 A’s model is a clinical framework for addressing
a wide range of health conditions. Can you apply the
model to one of your current clients at your internship?
3) What issues should be considered when using the 5
A’s model with patients of different cultures?
5 A’s Model for Initial Consultation
Visit 1
• Introduce
• Assess
behavioral health consultation service (1-2 min.)
• Identify/clarify consultation problem (1 min.)
• Conduct functional assessment (12-15 minutes)
• Advise
• Summarize understanding of the problem (1-2 min.)
• List possible change-plan options (1-2 min.) or begin Motivational Interviewing
• Agree
• Engage the patient in determining a course of action, if any
• Assist
• Start a change plan (10 min.)
• Arrange
• Determine and discuss next steps; communicate plan to healthcare team
Total time: 30 minutes
Applying the 5 A’s to Two Common
Primary Care Problems
• Depression
• Diabetes
Depression1
• 10%-30% of PC patients have depression
• Frequently unrecognized by PCPs
• Time-limited psychotherapies often effective when
combined with antidepressant treatment
• Patients with mild to moderate depression can be
effectively treated in PC
• Referral may be needed for patients with higher levels of
severity
Depression1 (Cont’d - 2)
Assess:
• Introduce, identify, clarify
• Assess the patient’s goals and motivation
• What does the patient want to change?
• What are the patient’s levels of motivation and confidence?
• Conduct symptom assessment
• Tools: PHQ-2, PHQ-9, MDQ, ‘SIGECAPS’
• Conduct functional assessment
• Onset, duration, intensity, frequency, effects on functioning
• Potential biological causes: thyroid disorders, nutritional deficits, neurological
damage (eg, head trauma, stroke), substance use
• Suicidal ideation: history, precipitants, frequency, method, impulsivity
• Assess medication adherence if antidepressant has been prescribed
Depression1 (Cont’d)
Advise
• Use handout to explain the typical downward spiral of depression
• Identify the patient’s solutions:
• Inquire about what has helped patient with depression previously, and what they
were doing differently then vs. now (ie, Solution-Focused ‘exceptions &
‘differences’ questions)
• Discuss options
• Consider antidepressant prescription, watchful waiting, referral to specialty MH, &
options suggested by the patient
• Develop a plan
• Present evidence-based options for depression: behavioral activation, cognitive
disputation, problem-solving, patient’s own method
• Describe what each option involves and how it may help
• Begin motivational interviewing with patients not ready to take action
Depression1 (Cont’d - 3)
Agree
• Engage the patient in discussing the options put forth in the
‘Advise’ step
• Allow the patient to suggest new options of her own
• Give the patient the opportunity to discuss options with family
or friends if they wish
• A follow-up appointment may be necessary to discuss the
options further
Depression1 (Cont’d - 4)
Assist
• Implement one or more interventions chosen by the
patient
• Selected Intervention: Behavioral activation
• Help the patient set specific and realistic goals to increase
enjoyable and meaningful activities
• Explain why and how the patient should monitor her mood
daily
• Handout tool is available
Depression1 (Cont’d - 5)
Assist (continued)
• Selected intervention: Cognitive disputation
• Ask patient to identify her own unhelpful thoughts
• Teach patient how to question the accuracy of these thoughts
• Teach patient to challenge distorted thoughts, and to choose to think
and respond differently
• If this method fails to achieve the patient’s objectives, use a stepped
care approach to intensify treatment
• Employ more comprehensive cognitive therapy (or refer the patient if this
method exceeds the BHC’s available time)
• Teach: the 8 common types of cognitive distortions; tracking and
categorizing thoughts; tracking emotions and behaviors
Depression1 (Cont’d - 6)
Assist (continued)
• Selected intervention: Problem Solving
a) Help the patient identify and define the problem
b) Brainstorm solutions with patient
c) Assist patient in evaluating possible solutions
d) Assist patient in selecting a solution to try
e) Assist patient in developing methods for assessing outcomes
f) Ask patient to describe how she plans to implement the method
g) Assess outcomes with patient in a follow-up visit
h) If outcomes are not favorable, return to step d
Depression1 (Cont’d - 7)
Arrange
• The number of necessary follow-up visits can vary
greatly between individuals
• If patient is not having success after 2 or 3 visits and
barriers are difficult to overcome, consider referral to
specialty mental health
• Communicate with PCP about patient’s preferred
approach
• Keep PCP apprised of patient’s progress
Activity
1. How might a BHP and a PCP effectively collaborate to
provide higher quality care to a depressed patient than
either one could alone?
2. How could the PCP and BHP reduce stigma for a
patient who is uncertain about being referred for the
first time to a BHP?
Diabetes2
Prevalence of diabetes in U.S. (2010)
• 25.8 million people have diabetes in the U.S.
• 8.3% of the total population
• 11.3% of Americans age 20 and over
• Up from 8.7% in 2002
• 26.9% of Americans age 65 and over
• Up from 18.3% in 2002
Prevalence of pre-diabetes in U.S. (2010)
• 79 million adults in U.S.
Diabetes2 (Cont’d - 2)
• Type II: begins as insulin resistance. As the need for insulin rises,
the pancreas gradually loses its ability to produce it.
• 90-95% of all diagnosed cases
• Type 1: develops when the body's immune system destroys
pancreatic beta cells, the only cells in the body that make the
hormone insulin that regulates blood glucose.
• ~5% of all diagnosed cases of diabetes.
• Gestational: Hormones during pregnancy contribute to insulin
resistance. Diabetes results if the pancreas cannot produce
enough insulin due to beta cell dysfunction.
• ~7% of pregnancies
Diabetes2 (Cont’d)
Risk factors
• Obesity / high body mass index (BMI)
• Sedentary lifestyle
• Unhealthy eating habits: diet high in fat and sugar, low in fiber
• High blood pressure & high cholesterol
• History of gestational diabetes
• Family history
• Ethnicity: Hispanic/Latino Americans, African Americans, Native
Americans, Asian Americans, Pacific Islanders, Alaska Natives
• Polycystic ovary syndrome
• Increased age
Diabetes2 (Cont’d - 3)
Complications Management
• Heart disease • Monitor & maintain healthy blood
• Stroke glucose levels
• High blood pressure • Monitor & maintain a healthy weight
• Blindness • Maintain a diet high in nutrients and
• Nerve damage fiber, low in fats and carbohydrates
• Kidney failure • Be physically active
• Amputations • Adhere closely to medication regimen
(85% are prescribed medication)
• Dental disease
• Depression
• Others…
Diabetes2 (Cont’d - 4)
Diabetes is one of the most challenging chronic diseases to self-
manage due to:
• Need to monitor dietary intake and test blood glucose
• Need to monitor feet, eyes, & renal function
• Many patients must adhere to complex medication regimens, including
self-administration of insulin
• Increased risk of depressive symptoms
• Keep in mind that there is significant variability among patients in the level
of effort required to manage diabetes
• Depending on disease severity, psychosocial factors, cognitive variables, other
& factors
Diabetes1
Objectives for BHC
• Collaborate with patient and PCP to improve
management of physiological aspects of disease
• Help patient reduce emotional distress
• Support patient in maintaining healthy lifestyle
behaviors
Diabetes1 (Cont’d - 5)
Assess
• Introduce BHC service, identify the problem, clarify the patient’s needs
• Assess the patient’s goals and motivation
• What does the patient want to change and why?
• What are the patient’s levels of motivation and confidence? (MI ruler)
• Assess relevant psychosocial/spiritual factors (instruments: Diabetes
Distress Scale, PHQ-9)
• Depression
• Anxiety
• Stress
• Anger
• Loneliness
• Social/family/spiritual support
Diabetes1 (Cont’d - 6)
Assess (continued)
• Assess modifiable risk factors (sources: check medical record, ask patient
directly)
• High blood pressure
• Obesity/BMI/dietary habits
• HbA1c levels
• Level of regular physical activity
• Frequency of blood sugar monitoring and level of control
• Medication adherence
• Summarize your understanding of the problem for the patient and check
for agreement
• Ask the PCP about her goals for the patient and incorporate into next step
Diabetes1 (Cont’d - 7)
Advise
• Identify patient’s solutions: Inquire about what has helped patient
manage diabetes in the past, and what they were doing differently then
vs. now (ie, Solution-Focused ‘exceptions & ‘differences’ questions)
• Discuss options eg., improving medication adherence, make dietary
changes, increasing physical activity, options suggested by the patient
• Discuss options that interest the patient most
• Develop a plan
• Recommend methods for achieving goals, eg., increase frequency of
blood sugar checks to 2 times/day, walk for 15 minutes twice each
day, use pill organizers, patient’s previously successful methods
• Describe what each option involves and how it can help the patient
achieve her goals
Diabetes1 (Cont’d - 8)
Agree
• Engage the patient in discussing the options put forth in the
‘Advise’ step
• Allow the patient to suggest and discuss options of her own
• Give the patient the opportunity to discuss the options with
significant others
• A follow-up appointment may be necessary to further discuss
options and agree on a plan of action
Diabetes1 (Cont’d - 9)
Assist
• The patient will implement one or more interventions they have
selected, for example:
• Maintain a daily self-monitoring log of blood sugar readings
• Implement a plan to immediately remediate out of range blood sugar levels
• Walk a targeted number of steps/day to increase physical activity
• Replace commonly eaten foods that spike blood sugar levels with more
healthy choices
• Take specific actions to decrease depression and emotional distress
• Increase social engagement with friends and family to improve coping capacity
Diabetes1 (Cont’d - 10)
Arrange
• Complex patients are likely to require greater numbers of follow-
up visits
• If patient is not having success after 2 or 3 visits with the BHC:
• Obtain input from PCP and healthcare team about potential next steps
• Meet with the patient again to discuss options
• Consider arranging access to additional resources, eg., diabetes educator,
nutritionist, psychiatry referral, diabetes group visits
• Develop ongoing criteria that specify when the patient should
revisit the BHC, for example:
• If patient gains10 pounds or more
• Patient’s HbA1c goes above 7
Discussion (Cont’d)
1) The risk of developing diabetes increases with age.
What might be some of the biggest challenges faced
by an elderly patient who is newly diagnosed with Type
II diabetes?
How can a BHC effectively support an elderly patient
in meeting those challenges?
2) What other types of programs or services could be
helpful to patients when a primary care practice serves
a population with high rates of Type II diabetes?
References
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2. National Diabetes Fact Sheet. (2011). Centers for Disease Control and Prevention. Atlanta, GA.
3. Kroenke, K. & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation,
therapy and outcome. American Journal of Medicine, 86, 262-266.
4. National Ambulatory Medical Care Survey. (2009). Summary Tables. National Center for Health Statistics.
Centers for Disease Control and Prevention, Atlanta, GA.
5. Mental Health: A Report of the Surgeon General. (1999). United States Public Health Service. Center for Mental
Health Services. National Institute of Mental Health, Washington, DC.
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mortality and disability for diseases, injuries, and risk factors in 1990 and projected to 2020: Vol. 1 of Global
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