Case Study: Integrated Behavioral Health

The following is based on a fictional case study for a 1st generation 36-year-old Polish-American married male who was referred to an imagined IBH Clinician by his primary care physician for risk of depression in the year 2020.

a. Introduction

The agency is a primary care facility. The team of behavioral health, primary care, and other health care personnel collaborate closely in the same facility, participate in regular team meetings, and demonstrate in-depth understanding of roles and culture. We offer patient-centered, team-based care that addresses physical, mental, and behavioral health needs while promoting self-care, self-esteem, and perceptions that illness is manageable. We follow the IMPACT model, which means collaborative care is critical, we use outcome measurements in our assessments, we develop stepped care plans based on individual treatment plans, and as the IBH provider, I provide support to and educate patients about their behavioral health needs over six to eight brief sessions (Unützer et al., 2020).

Additionally, as the IBH clinician, I am tasked with coordinating care within the primary care team and outside our system, have an ecological focus, demonstrate knowledge of the biopsychosocial assessment, and work to overcome barriers in service access (Stanhope, Heyman, Amarante, & Doherty, 2018). I engage with patients and their families, conduct biopsychosocial assessments and other ongoing assessments, offer ongoing evaluation, and actively participate in care planning and coordination. For initial consultation, I utilize the five A’s: assess, advise, agree, assist, and arrange (Hunter, Goodie, Oordt, & Dobmeyer, 2012).

b. Client Information

Ken is 36 years old, a 1st generation Polish American married male who has three children, ages 9, 7, and 4. The patient recently presented to his primary care doctor with a depressed affect (alternately sad and flat). Ken has been in treatment for depression previously; his chart indicates that he experienced his first depression in his mid-20s. Over the past decade, he has suffered numerous relapses of depressive episodes, each lasting six to eight weeks with symptomatology remitting for approximately 18 months between each recurrence of Major Depressive Disorder. He reported that his experiences with long-term psychodynamic-oriented psychotherapy, as well as taking an SSRI anti-depressant, have had little to no effect on his depression.

Additionally, Ken has been on and off various antidepressants over the past decade, most with initial relief and then subsequent remission of Major Depression within 18 months or so. He reported experiencing worsening depressive symptoms coinciding with the onset of the COVID-19 pandemic, school closures, and stay-at-home orders in NYC. It should be noted that his family has a history of depressive symptoms and Ken’s grandfather died by suicide when Ken was an adolescent. In the lead up to each major depressive episode, Ken experienced several months marked by moderate anxiety and increasingly more distressing depressive symptoms. However, he reported that the cancellation of school ‘put him over the edge’.

Moreover, Ken reported no history of medical disorders, substance abuse or developmental delays, although his chart indicates his BMI is in the ‘slightly obese’ range. He did report symptoms that may have been Attention Deficit Hyperactivity Disorder (ADHD), including always struggling with an inability to maintain his concentration that has worsened since the COVID-19 outbreak occurred in NYC. Lastly, he noted concerns about his parents (both over the age of 70) and reported feeling suspicious about the spread of coronavirus notes that he is beginning to believe this is a ‘plot to keep me down.’

The screening tools that I propose using with Ken are the PHQ9 to further assess Ken’s depressive symptoms and a suicide screening tool because of Ken’s report about despairing over ‘‘the purpose’’ of his life. The PHQ9 is not only a valuable tool for detecting depression, but also a valid and reliable screening tool for monitoring the severity of depression symptoms (Kroenke,Sptitzer, & Williams, 2001). As such, Ken’s PHQ9 score will help us determine the severity of his symptoms right now and could help guide our chosen intervention. Based on the evidence that depression is a risk factor for suicide and some of the statements relayed by Ken, it would be pertinent to screen for suicide to best meet his treatment needs, including determining if he would benefit from immediate transfer for inpatient care, as well as safety planning even if he does not need to be hospitalized (Ng, How, & Ng, 2017).

c. Health Care Equity

Ken is a White male in his 30s who is in a heterosexual marriage, none of which place him in a minority category or at risk for discrimination. As such, Ken’s age, race, gender identity, and sexual orientation likely have not negatively affected his experience at this clinic. If anything, white privilege may play a role in affording Ken better, more attentive health services (Hobbs, 2018; Stepanikova & Oates, 2017). However, his status as a 1st generation American descended from Polish Jews could significantly impact his experience if he feels that medical personnel stereotype and discriminate against him based on his cultural, ethnic, and/or religious identities. Perceived discrimination among the Jewish population correlates with physical health declines (Epel, Kaplan, & Moran, 2010).

To increase health care equity for patients in our clinic, I would practice a model of integrated and culturally relevant care and continue to increase my cultural humility so that I can best support each diverse patient we serve (Davis et al, 2015; Tervalon & Murray-Garcia, 1998). I would also advocate that all our personnel be trained in cultural humility and practice culturally relevant care, assuming this practice is not already in place.

d. Functional Assessment Questions

1. What do you experience in your body when you are feeling low?
2. On a scale from 1 to 10, 1 being perfect and restful and 10 being awful and unfulfilling, how is the quality of your sleep?
3. What thoughts go through your mind when you are feeling depressed?
4. What environmental cues worsen or trigger your depression?
5. How is your depression affecting your relationship with your wife? How about with your children?
6. How much physical activity do you get in a typical week? How has the amount of physical activity you do been affected by this most recent depression?

e. Intervention

Problem Solving Treatment for Primary Care (PST-PC) would be appropriate for this patient. PST-PC is an evidence-based intervention that has been shown to reduce depressive symptoms and patients have experienced sustained benefits post-intervention (Hegel & Arean, 2011; Oxman, Hegel, Hull, & Dietrich, 2008; Schmaling, 2019). Moreover, studies on one of the main components of PST-PC called behavioral activation have shown significant reductions in symptoms of major depressive disorder in participants (Ekers et al., 2014; Gros & Haren, 2011). Based on Ken’s presenting depressive symptoms, I believe he would benefit from this short-term intervention.

One barrier we might encounter is if I, as the clinician, do not successfully communicate the purpose of PST-PC to Ken. Secondly, there could be some challenges if Ken feels his family does not support him throughout the treatment process, so incorporating family buy-in into the plan could be key. Thirdly, if Ken has a negative problem orientation, we could meet some initial resistance for change. Fortunately, establishing an appropriate problem-solving orientation is built into the PST-PC process (Hegel & Arean, 2011). Thinking about these barriers ahead of time and working out solutions or alternatives with the health care team would be vital in preparing for working through such barriers. Additionally, utilizing teach back for important directions and information I relay to Ken would help minimize confusion or misunderstandings.

If Ken consents to involving his family, I think it would help to build upon his strong relationships with his children and working to increase positive quality time with his wife by incorporating family activities into his behavioral activation plan. Buy-in and support from family is crucial, so even if Ken’s family does not sit in with us during goal-building and progress check-in sessions, I would encourage him to involve his family in treatment assignments outside of sessions and may provide psychoeducation material on depression that he can share with them.

The three treatment goals specific to this patient are (1) the patient will schedule one to three hours each day dedicated to family bonding activities with his children and wife, (2) the patient will limit his news/media consumption to no more than two to three hours per day, and (3) the patient will check in with his parents via phone call or video call two to three times each week.

f. Ethical Issues and Considerations

One of the major ethical considerations to make when working with patients is confidentiality, especially when there is potential risk of self-harm, as well as because family support can be incredibly important for positive, sustained outcomes. For Ken, I considered whether he would want to involve his family in our treatment sessions, but ultimately that would be up to him. I would not contact his family without his consent. Additionally, because Ken experiences symptoms of depression and is at risk for suicide, I would need to break confidentiality if he has active suicidal ideation by notifying appropriate personnel.

g. SOAP Note

S: Depression with HX of present illness, slightly obese. 36-year-old male, currently not on medication. Pt reports major long-term psychodynamic therapy and major antidepressants have little to no effect on depressive symptoms. Pt denies SI, denies HX of medical d/o, substance abuse, or developmental delays. Pt reports difficulty concentrating, thoughts and feelings of sadness/depressed mood most of the day and nearly every day, chronic fatigue, anhedonia, loss of appetite, hypersomnia, and feelings of incompetence, low self-worth, and hopelessness; symptoms have been present for several weeks. Pt reports worsening symptoms due to COVID-19-related restrictions, school cancellation, and increasing sense of worry for parents’ health.

O: Pt is tall, heavyset, and pale. Appearance WNL. Pt presents with depressed affect (alternately sad and flat) but was cooperative and engaging during interaction. Pt is oriented x4, mood is dysthymic.

A: Pt scored 23 on PHQ-9 (Severe Depression). Pt has been experiencing significant internal distress and disruptions in social and occupational functioning related to depressed symptoms. Pt discussed symptoms of depression, linked problems with depressive symptoms, established an appropriate problem-solving orientation, began activity scheduling, and compiled a list of problems. Pt made progress on problem solving for the specific problem of worry about his parents. Pt engaged in safety planning. Differential DX: ADHD, Anxiety d/o

P: (1) Recommendation for PCM: assess SI at each visit; monitor depression w/PHQ-9. (2) Pt will continue PST-PC with IBH clinician. (3) Next session pt will build problem-solving skills and explore solutions to problems from list. (4) Pt will continue to establish goals and schedule activities.

References

Davis, T. S., Guada, J., Reno, R., Peck, A., Evans, S., Sigal, L. M., & Swenson, S. (2015). Integrated and culturally relevant care: A model to prepare social workers for primary care behavioral health practice. Social Work in Health Care. https://doi.org/10.1080/00981389.2015.1062456

Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLOS Journal. https://doi.org/10.1371/journal.pone.0100100

Epel, O. B., Kaplan, G., & Moran, M. (2010). Perceived discrimination and health-related quality of life among Arabs and Jews in Israel: a population-based survey. BMC public health, 10, 282. https://doi.org/10.1186/1471-2458-10-282

Gros, D. F., & Haren, W. B. (2011). Open trial of brief behavioral activation psychotherapy for depression in an integrated Veterans Affairs primary care setting. The Primary Care Companion for CNS Disorders, 13(4), PCC.11m01136. https://doi.org/10.4088/PCC.11m01136

Hegel, T. & Arean, P. (2011). Problem-solving treatment for primary care (PST-PC): A treatment manual for depression. Available at: https://pstnetwork.ucsf.edu/sites/pstnetwork.ucsf.edu/files/documents/Pst-PC%20Manual.pdf

Hobbs J. (2018). White Privilege in Health Care: Following Recognition with Action. Annals of family medicine, 16(3), 197–198. https://doi.org/10.1370/afm.2243

Hunter, C.L., Goodie, J.L., Oordt, M.S. & Dobmeyer, A.C. (2017). Integrated behavioral health in primary care. (2nd ed.). Chicago: Lyceum

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Ng, C. W., How, C. H., & Ng, Y. P. (2017). Depression in primary care: assessing suicide risk. Singapore medical journal, 58(2), 72–77. https://doi.org/10.11622/smedj.2017006

Oxman, T. E., Hegel, M. T., Hull, J. G., & Dietrich, A. J. (2008). Problem-solving treatment and coping styles in primary care for minor depression. Journal of Consulting and Clinical Psychology, 76(6), 933–943. https://doi.org/10.1037/a0012617

Stanhope, V., Heyman, J. C., Amarante, J., & Doherty, M. (2018). Integrated behavioral health care. In J. C. Heyman & E. P. Congress (Eds.), Health and social work: Practice, policy, and research (p. 105–124). Springer Publishing Company. https://doi.org/10.1891/9780826141644.0007

Schmaling, K.B. (2019). Moderators of Outcome in Problem-Solving Therapy for Depression in Primary Care. Psychiatric Services. https://doi.org/10.1176/appi.ps.201900100

Stepanikova, I., & Oates, G. R. (2017). Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race. American journal of preventive medicine, 52(1S1), S86–S94. https://doi.org/10.1016/j.amepre.2016.09.024

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor & Underserved, 9(2), 117–125.

Unützer, J., Callahan, C., & Williams, J., Hunkeler, E. Harpole, L., Hoffing, M., Della Penna, R., Noël, P., Lin, E., Areán, P., Hegel, M., Tang, L., Belin, T., Oishi, S., & Langston, C. (2002). Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial. JAMA: Journal of the American Medical Association. 288. 2836–45. 10.1001/jama.288.22.2836.