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Department of Pediatrics, University of Washington, Seattle, WashingtonCenter for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
Department of Pediatrics, University of Washington, Seattle, WashingtonCenter for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaChildren's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Despite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings. This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement. Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups. Integration of behavioral health into primary care settings has the potential to address these barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.
Although behavioral health conditions are common sources of morbidity among adolescents and young adults, research in these populations lags behind research in older age groups. This article specifically examines integrated care research in this age group and suggests important directions to move the field forward.
Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement.
Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents.
]. Despite the recognition of the significant short- and long-term impacts of behavioral health disorders on development and the availability of effective treatments, only about one-third of adolescents with a diagnosable behavioral disorder receive appropriate care [
]. Of particular concern, only half of adolescents who meet criteria for “severe” impairment from a mental health disorder report having received care [
]. On average, 10 years pass from the initial onset of a mental health disorder and seeking treatment, with younger age at onset associated with longer delays in treatment [
One approach to reducing delay in treatment and improving treatment delivery is the development of models aimed at improving recognition and treatment for behavioral health disorders in primary care settings through the integration of behavioral health services into medical settings [
]. Several studies have also shown high rates of mental health comorbidity among individuals with chronic medical illnesses commonly seen in primary care [
]. A recent meta-analysis of integrated behavioral health trials across pediatric age groups found that they had a small-to-moderate effect improving the outcomes of mental health and substance use disorders (d = 042; 95% confidence interval, .29–.55; p < .001) [
]. Thus, the integration of care has the potential to improve outcomes for both behavioral and physical health. In this article, we aim to specifically review research regarding models of integrated behavioral health in primary care settings among adolescent and young adult populations with the aim of describing needed areas of research.
Review of the Literature
To assess the current state of the literature, we conducted a systematic review of the literature using MEDLINE and PsycINFO to identify research studies examining integrated behavioral health interventions for the treatment of mental health and substance use disorders among adolescent and young adult populations in primary care settings. Literature searches contained four categories of search terms, all of which were joined by “and” conditions:
(1)
Age group designation: “adolescent,” “young adult,” or “college”
(2)
Variations of integration and/or setting: “primary care,” “school,” “collaborative care,” “integrated care,” or “coordinated care”
(3)
Variations of “mental health care,” “psychotherapy,” “behavioral health,” or “mental health”
(4)
Variations of diagnosis: “depression,” “anxiety,” “disruptive behavior,” “eating disorder,” or “substance”
To be included, studies had to be focused on older adolescents and/or young adults (study population predominantly within the age range of 13–25 years), examine patient outcomes, have a comparison group, offer an integrated or health care provider-led intervention for a behavioral health condition in primary care, be published in English, and be conducted in 2004 or later. Studies of adult populations that did not specifically examine young adults separate from the older adult population were not included. For the purposes of this review, we considered school-based health clinics and college health clinics to be primary care settings. We excluded studies that recruited from the primary care setting but did not have evidence of collaboration or care delivered in that setting, as well as those conducted in the broader school setting such as classroom or campus-wide interventions. We only included those focused on treatment or secondary prevention in at-risk individuals. As the intent was to look at alcohol and illicit drug misuse, tobacco use interventions were not included.
In total, when duplicates were excluded, the systematic searches identified 1,086 potential articles of which 1,032 did not meet inclusion criteria based on review of the title or abstract (Figure 1). We conducted full-text article reviews for the remaining 54 articles plus an additional 3 articles identified via bibliographies of identified literature for a total of 57. Of these 57, 36 articles were excluded. The reasons for exclusion included the following: pilot or feasibility trial with no comparison group (19 studies), repeat use of a study sample without the presentation of new patient outcomes (8 studies), intervention not in a primary care setting (7 studies), not intervention trial (2), and no behavioral outcomes provided (1). Based on full-text review, 21 trials were identified for inclusion. As detailed in Table 1, studies meeting inclusion criteria were conducted in multiple countries including the United States (N = 10), Australia (N = 3), New Zealand (N = 3), South Africa (N = 1), and multiple countries (N = 2, United States and Canada, and United States and Czech Republic). All included studies were reviewed for quality by two independent reviewers using the US Preventive Services Task Force Quality Rating Criteria for Randomized Controlled Trials and Cohort Study Criteria (accessed in Appendix C by Goy et al. [
Primary care provider training in mental health communication skills in order to use skills at child wellness or other visits
Usual care
6 months
Intervention associated with greater reductions in impairment among minority but not white youth. No changes noted in youth symptoms, but intervention was associated with a decrease in parent symptoms.
Comparison between three arms, no no-treatment cohort
1 month
Groups receiving consultation reported increased rates of physical activity, nutrition, and sleep as well as reductions in drinking and driving behaviors.
Screening with physician feedback. Optional telephone-based parenting program delivered by parent-educator
Usual care
9 months
Intervention associated with reductions in aggressive and delinquent behaviors and attention problems. Parents also reported less child bullying and physical fighting.
Computerized brief intervention based on motivational interviewing with or without therapist facilitation
Usual care plus informational brochure and Web sites
3, 6, and 12 months
Intervention associated with reduced cannabis-related problems and reduced other drug use (3 and 6 months) but not with reductions in cannabis or alcohol use.
Web-based assessment and personalized feedback on alcohol use
Information pamphlet
6 weeks and 6 months
Intervention associated with reduced total alcohol consumption at 6 weeks but not 6 months, as well as reduced personal problems and academic problems (6 months only)
Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: A randomized clinical trial.
Brief motivational interviewing—two 15-minute sessions with a physician and two follow-up calls
Booklet on general health issues
12 months
Intervention associated with reduced 28-day alcohol use and alcohol problem index. No reduction in binge drinking, health care utilization, injuries, drunk driving, depression, or tobacco use.
Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
A mobile phone application for the assessment and management of youth mental health problems in primary care: Health service outcomes from a randomised controlled trial of mobiletype.
Use of a phone app to collect data on mood, stress, coping, activities, eating, sleeping, exercise, and substance use for physician review during follow-up
Attention control
6 weeks and 6 months
Intervention associated with increased provider understanding of mental health and patient emotional self-awareness and decreased overall mental health symptoms. No significant reductions in depressive or other mental health disorders.
The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial.
Integrative internet-based depression prevention for adolescents: A randomized clinical trial in primary care for vulnerability and protective factors.
J Can Acad Child Adolesc Psychiatry.2008; 17: 184-196
Secondary depression prevention among adolescents with subthreshold symptoms
Brief motivational interviewing with provider followed by participation in an Internet preventive intervention (14 modules)
Brief advice (2–3 minutes) + Internet preventive intervention (14 modules)
4–8, 12 weeks
Both groups experienced declines in depressive symptoms, increases in social support by peers, and reductions in depression-related impairment at school. The motivational interviewing group was significantly less likely to experience a depressive episode or report hopelessness by 12 weeks.
Modified cognitive behavioral therapy self-help manual guided by brief sessions with a specialist or nonspecialist health professional.
Delayed treatment control
6 months
Intervention associated with significant improvements in psychological and bulimic symptom scales, reduced frequency of mean binge eating episodes, and greater remission of eating disordered behaviors.
Fluoxetine alone, Fluoxetine plus guided cognitive behavioral therapy self-help book, or placebo plus guided cognitive behavioral therapy self-help book
Placebo alone
3–4 months
Participants receiving fluoxetine had reduced binge eating and vomiting episodes and a greater improvement in psychological symptoms. There was no benefit noted from self-help book. High rate of treatment drop out in both arms.
Quality improvement intervention including depression care management, patient and provider choice of meds, cognitive behavioral therapy, or both
Enhanced usual care
6 months
Intervention associated with significantly improved receipt of treatment, depressive symptoms, mental health–related quality of life, and satisfaction with care.
Collaborative care intervention delivered by depression care management, patient and family choice of meds, cognitive behavioral therapy or both; stepped care algorithms and psychiatric supervision
Enhanced usual care
6 and 12 months
Intervention associated with significantly improved receipt of treatment, depressive symptoms, and functional status as well as higher rates of depression remission.
To promote accurate comparison, studies identified in our review were organized into three groups with increasing levels of integration. Groups were determined a priori based on the framework outlined in the 2010 report on Evolving Models of Behavioral Health Integration in Primary Care: “coordinated care,” “co-located care,” and “integrated care” (briefly described below and as outlined in Table 2) [
]. In “coordinated care models,” primary care providers work with community-based behavioral health specialists to provide care. The behavioral health specialist may serve as an advisor to the primary care provider without seeing the patient or can provide direct care with a coordinated exchange of information. Educational interventions that aim to enhance primary care provider skills with support and oversight by mental health providers also fit into this category. In “co-located care models,” primary care and behavioral health providers are located in the same setting to simplify the referral process, enhance communication between providers, and remove patient barriers to care. “Integrated care” refers to models of care with a shared treatment plan between providers with both behavioral and health elements. These models often involve a multidisciplinary team working together using a predefined protocol and a “population-based approach” to tracking outcomes in order to assure improvement for the entire patient panel.
Table 2Collaborative care categorization overview
Coordinated
Co-located
Integrated
•
Routine behavioral health screening in primary care setting
•
Referral relationships developed between primary care and behavioral health
•
Methods established for routine exchange of information between treatment settings
•
Primary care provider may deliver brief behavioral health interventions depending on severity
•
Medical and behavioral health services located in the same setting
•
Referral process developed to delineate cases to be seen by behavioral health
•
Proximity promotes enhanced informal communication and bidirectional consultation
•
Needs of the clinic population may influence the type of behavioral health services offered
•
Medical and behavioral services can be located in the either the same or separate facilities
•
Shared treatment plan between providers with both behavioral and medical elements
•
Multidisciplinary team works together to deliver care using a prearranged protocol
•
Use of a database to track the care of patients who screen positive
•
Protocols and improvement goals target the whole population in the database
Our review identified a total of 21 randomized controlled trials with behavioral health outcome measurement among adolescents and young adults: 17 in the category of “coordinated care,” 0 in the category of “co-located care,” and 4 in the category of “integrated care.” Results are discussed by category below, and details of specific studies within each category are provided in Table 1.
“Coordinated Care” Research
Our review identified 17 studies meeting the criteria for “coordinated care.” Eight studies described interventions in which enhanced behavioral health care was provided by the primary care provider [
Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: A randomized clinical trial.
Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
]. One study examined provider communication skills training aimed at increasing patient and family engagement in behavioral health care and found improvements in parent-reported child functioning for minority, but not white, youth [
]. Five studies examined the effectiveness of provider training in screening, brief motivational interviewing, and referral for substance misuse among adolescent [
Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: A randomized clinical trial.
Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
] and found the use of these methods to be effective in reducing alcohol or other substance misuse, increasing patient's readiness to change substance misuse behaviors, and/or decreasing consequences of substance misuse. One additional study found that training providers to implement a behavioral health contract paired with consultation among college students reduced the frequency of drinking and driving but not overall substance misuse [
]. A final study found that screening coupled with access to a telephone-based parenting intervention was associated with reductions in child aggressive and delinquent behaviors and attention problems [
Integrative internet-based depression prevention for adolescents: A randomized clinical trial in primary care for vulnerability and protective factors.
J Can Acad Child Adolesc Psychiatry.2008; 17: 184-196
A mobile phone application for the assessment and management of youth mental health problems in primary care: Health service outcomes from a randomised controlled trial of mobiletype.
The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial.
] brief advice from the primary care provider and found such strategies to be effective in reducing substance misuse. In one of these studies, even a single dose of computer-facilitated motivational interviewing showed sustained effects for a year [
]. The remaining three studies used technological interventions to improve outcomes for depression. One study examined the use of mobile health symptom-tracking technology for adolescent and young adult depression and found significant improvements in provider-reported skills and patient-reported emotional self-awareness but not in mental health outcomes or treatment engagement [
A mobile phone application for the assessment and management of youth mental health problems in primary care: Health service outcomes from a randomised controlled trial of mobiletype.
]. The second study found a cognitive behavioral therapy-informed computer game to have comparable effectiveness to in-person counseling in reducing depressive symptoms among adolescents [
The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial.
]. The third study found that adolescents with depressive symptoms who received motivational interviewing from their providers were more likely to participate in a web-based cognitive behavioral therapy program designed to prevent worsening of symptoms than those who received only brief advice [
Integrative internet-based depression prevention for adolescents: A randomized clinical trial in primary care for vulnerability and protective factors.
J Can Acad Child Adolesc Psychiatry.2008; 17: 184-196
Finally, there were two studies employing the integration of self-administered manualized cognitive behavioral therapy into primary care management of bulimia nervosa among predominantly young adult women [
]. The second study did not find any reductions in bulimic behaviors associated with the manualized treatment but did find reductions in bulimic behaviors among individuals in medication treatment arms [
Our search did not identify any randomized trials examining outcomes for “co-located care” models. We found only two studies that examined behavioral outcomes for youth receiving “co-located care,” both used technological solutions to create virtual co-location and are included here for reference. One retrospective study of a convenience sample of youth who had received a telehealth behavioral consultation found improved behavioral outcomes at 3 months postconsultation [
]. Additionally, a large cohort study of the provision of telephone access to mental health specialists in primary care found high rates of completion of recommended mental health consultation and reduced symptoms over time for referred youth [
We identified four studies meeting the criteria of “integrated care” in the adolescent and young adult age group all of which focused on adolescent depression [
]. Two studies examined adaptations of adult collaborative care models and involved depression care managers in primary care practices who helped primary care providers with depression assessment, symptom tracking, evidence-based treatment delivery, and advancement of treatment based on prespecified algorithms and with input from psychiatric consultants. Both found that the collaborative care was associated with increased treatment engagement and significantly improved outcomes for depression among adolescents compared to usual care [
]. A third study examined the addition of a brief psychotherapy protocol for antidepressant-treated adolescents in primary care and found that psychotherapy was associated with only mild nonsignificant reductions in depressive symptoms [
]. The authors noted that youth in the intervention arm were more likely to choose to prematurely discontinue antidepressants than those receiving usual care and hypothesized that this discontinuation may have attenuated the effects of the intervention. The final study examined the integration of interpersonal therapy delivered by trained therapists for teens with depression seen in the school-based health clinic setting. They found benefit of interpersonal psychotherapy over treatment as usual particularly in youth with high levels of conflict with mothers and social dysfunction with friends [
While behavioral health disorders have a significant impact on the functioning and impairment of adolescents and young adults, our literature review revealed a relatively small number of research studies testing behavioral health integration in this population. This limited body of literature is particularly surprising in light of the extensive array of collaborative care studies addressing these conditions in adult populations [
] and points to the need for further development and testing of interventions among the adolescent and young adult populations. Our review also identified several gaps in the literature in which research would be beneficial in moving the field forward.
First, more high-quality research is needed in the implementation of integrated care models for the behavioral health conditions that most commonly occur among adolescents and young adults. A recent Cochrane review identified 79 randomized controlled trials of integrated care models for depression and anxiety among adult populations with overwhelming evidence for effectiveness in reducing depression and anxiety symptoms [
]. In contrast, our search revealed only three randomized controlled trial studies of integrated care models among adolescents, all of which focused on depression. We did not identify any randomized controlled trials addressing behavioral health integration for anxiety, the most prevalent disorder during adolescence, nor eating disorders among adolescents which are often medically managed in primary care. Similarly, although integrated care models have been tested among younger children with attention deficit disorder [
], studies have not included adolescents above age 13 years or young adults. Additional opportunities for new research areas include the following: examining effectiveness of brief interventions developed for primary care administration in adult settings among adolescent and young adult populations, evaluation of technological strategies to increase access to psychotherapy in primary care, and improved models for the primary care integration of web-based psychotherapy methods that have been shown to be effective for depression and anxiety in adolescent and young adult populations [
Our review also suggested the need for more research addressing how developmental stage affects the types of needed supports and interventions. Prior research suggests that developmental factors can influence the presentation of mental health symptoms, the ability to be independent in care, the impact of stigma, and the efficacy of particular types of interventions [
]. The studies in our review differed in the range of included ages, and none were designed with adequate numbers to explore if the intervention was similarly effective across developmental stage. Future studies should address this gap and examine if there are consistent patterns to the types of components (e.g., parental engagement, behavioral skills) required at different ages. One notable area of absence of developmental information was in the young adult population. While most adult studies include individuals who are 18 years and older, our search identified relatively few studies in which integrated behavioral health care was specifically examined in young adults, most of which were focused on substance use in college health settings [
Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: A randomized clinical trial.
]. More research is needed to determine if existing adult collaborative care models are reaching and meeting the needs of this population.
Additionally, more research is needed to identify key strategies to facilitate the dissemination of behavioral health integration models that have been found to be effective in randomized trials into actual primary care practice in the United States. There is good evidence for the effectiveness of integrated care for depression [
] (especially when combined with what is known in the adult literature), but significant work still exists in adopting these programs into practice under the current funding system. While our review did identify descriptive papers of large-scale implementation projects [
], they did not include rigorous patient-level outcome assessments or comparison groups. In the US health care system, the funding of activities related to care management and psychiatric supervision has been a particular challenge that will require creative solutions and might benefit from more research. In a recent survey, clinicians identified lack of resources as a key barrier to implementing integrated care plans in Medical Homes [
]. Finally, integrated care practice requires specific skills among providers including shared management plans, group case supervision by psychiatrists, and training for depression care managers. Further investigation is needed on how to train providers for these skills possibly taking an earlier approach to multidisciplinary training between behavioral health and medical trainees.
The field of adolescent and young adult health care is rapidly shifting in ways that may create new opportunities for improving behavioral health outcomes for this population. The Affordable Care Act opens new opportunities to serve young adults through expansion of health insurance coverage [
]. The Patient-Centered Medical Home model aims to reduce the cost of health care and improve patient experience and population health through the integration of needed services, such as behavioral health, into a single setting [
]. School-based health clinics and college health clinics may provide new opportunities to test models that integrate educational and other social supports [
]. By expanding our research in integrated care among adolescents and young adults, we will be positioned well to maximize these new opportunities and to improve key behavioral health outcomes.
Acknowledgments
The authors would like to acknowledge Peter Scal MD, MPH, for his contribution to the conceptualization of this paper, Garret Zieve for his assistance in critical review of the literature, and Elizabeth Ozer, PhD, and Robin Harwood, PhD, for providing input on the overall content of the paper and critically reviewing the final manuscript. This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UA6MC27378 for $960,000. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.
References
Merikangas K.R.
He J.P.
Burstein M.
et al.
Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
J Am Acad Child Adolesc Psychiatry.2010; 49: 980-989
Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement.
Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents.
Integrative internet-based depression prevention for adolescents: A randomized clinical trial in primary care for vulnerability and protective factors.
J Can Acad Child Adolesc Psychiatry.2008; 17: 184-196
Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: A randomized clinical trial.
Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
A mobile phone application for the assessment and management of youth mental health problems in primary care: Health service outcomes from a randomised controlled trial of mobiletype.
The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial.
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