Survey of Resources in Behavioral Sleep Medicine Across the Department of Defense, Defense Health Agency

INTRODUCTION

Insomnia affects approximately 40% of active duty service members and adversely affects health, readiness, and safety. The VA/DoD Clinical Practice Guideline for the management of insomnia recommends cognitive-behavioral treatment of insomnia (CBTI) or its abbreviated version (brief behavioral treatment of insomnia [BBTI]) as the first-line insomnia treatment. The goal of this study was to assess CBTI/BBTI resources at MTFs, perceived facilitators and barriers for CBTI/BBTI, and gaps in these treatments across the Defense Health Agency.

MATERIALS AND METHODS

Between July and October 2022, we conducted an electronic survey of CBTI/BBTI resources across Contiguous United States and the District of Columbia (CONUS) and Outside Continental United States (OCONUS) MTFs. The survey was distributed to 154 military sleep health care providers from 32 MTFs, and a link to the survey was posted on two online military sleep medicine discussion forums. Fifteen providers from 12 MTFs volunteered to complete a 30-minute qualitative interview to explore their perception of barriers and facilitators of CBTI/BBTI at their facility.

RESULTS

Fifty-two of 154 providers (33.8%) at 20 MTFs completed the survey. A majority of providers indicated that hypnotics remain the most common treatment for insomnia at their facility. Sixty-eight percent reported that CBTI/BBTI was available at their facility and estimated that less than 50% of the patients diagnosed with insomnia receive CBTI/BBTI. The main facilitators were dedicated, trained CBTI/BBTI providers and leadership support. Referrals to the off-post civilian network and self-help apps were not perceived as significant facilitators for augmenting insomnia care capabilities. The primary barriers to offering CBTI/BBTI were under-resourced clinics to meet the high volume of patients presenting with insomnia and scheduling and workflow limitations that impede repeated treatment appointments over the period prescribed by CBTI/BBTI protocols. Four primary themes emerged from qualitative interviews: (1) CBTI/BBTI groups can scale access to insomnia care, but patient engagement and clinical outcomes are perceived as inferior to individual treatment; (2) embedding trained providers in primary or behavioral health care could accelerate access, before escalation and referral to a sleep clinic; (3) few providers have the time to adhere to traditional CBTI protocols, and appointment scheduling often does not support weekly or bi-weekly treatment visits; and (4) the absence of quality and/or continuity of care measures dampens providers' enthusiasm for using external referral resources or self-help apps.

CONCLUSIONS

Although there is a wide recognition that CBTI/BBTI is the first-line recommended insomnia treatment, the limited scalability of treatment protocols, clinical workflow limitations, and scarcity of trained CBTI/BBTI providers limit the implementation of the VA/DoD clinical guideline. Educating and engaging health care providers and leadership about CBTI, augmenting CBTI-dedicated resources, and adapting clinical workflows were identified as specific strategies needed to meet the current insomnia care needs of service members. Developing protocols for scaling the availability of CBTI expertise at diverse points of care, upstream from the sleep clinics, could accelerate access to care. Establishing standardized quality measures and processes across points of care, including for external providers and self-help apps, would enhance providers' confidence in the quality of insomnia care offered to service members.

Burnout among behavioral health providers in integrated care settings

INTRODUCTION

Burnout in health care, especially among physicians, is a growing concern. It is now well accepted that physician burnout leads to increased depersonalization of patients, lower personal accomplishment, employee turnover, and worse patient outcomes. What is not known, however, is to what extent behavioral health providers (BHPs) in medical settings experience burnout and its associated sequela.

METHOD

Participants (n = 230) from a variety of practice settings and levels of integrated care completed practice and burnout questions via an online survey. Practice-related questions and a modified version of the Maslach Burnout Inventory was administered to BHPs who work in different levels of collaboration with other medical providers.

RESULTS

Overall, BHPs who work primarily in fully integrated care settings reported higher rates of personal accomplishment in their everyday job (B = 1.49; 95% confidence interval [CI] = 0.40, 2.58). Additionally, those who have worked more than 10 years in these types of settings reported both higher personal accomplishment (B = 1.58; 95% CI = 0.68, 2.49) and lower rates of depersonalization (B = -1.32; 95% CI = -2.28, -0.36).

DISCUSSION

In contrast to high rates of burnout among many clinicians in the United States, this is the first study to document relatively low rates of reported burnout among integrated care BHPs. The relationships between lower burnout, working in a fully integrated care practice, and experience as a BHP is important to understand when creating and sustaining team-based primary care jobs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The impact of behavioral health consultations on medical encounter duration in pediatric primary care: A retrospective match-controlled study

INTRODUCTION

The disproportionate time required to effectively manage psychosocial concerns is a key barrier to advancing delivery of behavioral care by primary care providers. Improved time efficiency is one potential benefit of the integration of behavioral health consultants (BHCs) into pediatric care, but few studies have systematically studied this outcome. We examined the impact of embedded BHCs on duration of medical encounters in a pediatric primary care clinic.

METHOD

We conducted a retrospective matched-pairs analysis of encounters involving behavioral consultations versus encounters for similar patients that did not include a consultation (N = 114) using electronic health record timestamp data. We examined both medical duration (i.e., medical provider services) and total duration (i.e., medical services + behavioral consultation).

RESULTS

Patient encounters involving behavioral consultation had a significantly longer (+11.23 min) total duration than matched controls, but significantly shorter (-11.67 min) medical duration.

DISCUSSION

The results indicate BHCs may improve primary care provider efficiency for patients with behavioral concerns, a notable finding given the impact of clinical time-constraints on important health care outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model

INTRODUCTION

Much of behavioral health care takes place within primary care settings rather than in specialty mental health settings. Access to specialty mental health care can be difficult due to limited access to mental health providers and wait times to receive mental health care. The purpose of this study is to determine patient satisfaction with behavioral health consultation visits that take place within the context of the primary care behavioral health consultation model. Patient likelihood to seek out specialty mental health care services if behavioral health consultation services were not provided was also examined.

METHOD

Two primary care clinic systems were examined in this study. The first was a primary care clinic predominately serving low-income patients: 100 individuals participated. The second was primary care in the context of military treatment centers: 539 individuals participated.

RESULTS

Results show that 61% of the patients in the low-income primary care clinic would not attend a specialty mental health appointment versus 30% in the military population.

DISCUSSION

This study suggests that primary care behavioral health is a patient-centered approach to care and reaches populations that otherwise may not receive behavioral health services. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Controlling for caffeine in cardiovascular research: A critical review

Caffeine, the most widely consumed drug in the world, exerts numerous effects on cardiovascular activity. Thus, it is important and advisable to control for caffeine consumption in studies examining caffeine and/or cardiovascular activity and reactivity. This paper 1) reviews the literature concerning caffeine's effects on cardiovascular parameters; 2) summarizes the widely varying protocols used to control for the drug in extant cardiovascular literature, and 3) provide guidelines for caffeine control procedures to minimize potentially confounding acute and withdrawal effects of the drug. An abstention period equal to the average half-life of the drug is recommended for creation of methodological controls for caffeine. Additional methodological recommendations are described concerning factors that moderate the half-life of caffeine. When feasible, researchers should consider and aim to control for caffeine's acute and extended psychophysiological effects. This understudied issue has fundamental implications for caffeine-related investigations and research in psychophysiology and behavioral medicine.

Real-world program evaluation of integrated behavioral health care: Improving scientific rigor

INTRODUCTION

Designing systematic, scientifically rigorous program evaluations (PE) is 1 way to contribute to the significant need to build best practices and a stronger evidence base for integrated behavioral health care. However, there are many potential pitfalls when conducting PE in real-world settings, and many clinicians and administrators may be hesitant to engage in PE due to lack of training or resources. Rigorous PE can be achieved feasibly and efficiently.

METHOD

This article discusses common challenges that arise when conducting PE in integrated behavioral health care settings and illustrates ways to increase the methodological quality of PE efforts using lessons learned from 2 real-world case examples. The first example included a PE of a training program for brief alcohol interventions, and the second example included a PE of a depression medication monitoring service.

RESULTS/DISCUSSION

The case examples demonstrate the need for strategic planning beforehand, including the use of a conceptual framework as well as appropriate study designs/methodology, measurement, and the need for consistency to achieve a well-designed PE. Using the recommendations within this article, it is hoped that the quality of PEs can be improved resulting in more generalizable data that can be used to inform organizations and policymakers to improve health care delivery. (PsycINFO Database Record

Improving the management of behaviour that challenges associated with dementia in care homes: protocol for pharmacy-health psychology intervention feasibility study

INTRODUCTION

The inappropriate use of antipsychotics in people with dementia for behaviour that challenges is associated with an estimated 1800 deaths annually. However, solely focusing on antipsychotics may transfer prescribing to other equally dangerous psychotropics. Little is known about the role of pharmacists in the management of psychotropics used to treat behaviours that challenge. This research aims to determine whether it is feasible to implement and measure the effectiveness of a combined pharmacy-health psychology intervention incorporating a medication review and staff training package to limit the prescription of psychotropics to manage behaviour that challenges in care home residents with dementia.

METHODS/ANALYSIS

6 care homes within the West Midlands will be recruited. People with dementia receiving medication for behaviour that challenges, or their personal consultee, will be approached regarding participation. Medication used to treat behaviour that challenges will be reviewed by the pharmacist, in collaboration with the general practitioner (GP), person with dementia and carer. The behavioural intervention consists of a training package for care home staff and GPs promoting person-centred care and treating behaviours that challenge as an expression of unmet need. The primary outcome measure is the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). Other outcomes include quality of life (EQ-5D and DEMQoL), cognition (sMMSE), health economic (CSRI) and prescribed medication including whether recommendations were implemented. Outcome data will be collected at 6 weeks, and 3 and 6 months. Pretraining and post-training interviews will explore stakeholders' expectations and experiences of the intervention. Data will be used to estimate the sample size for a definitive study.

ETHICS/DISSEMINATION

The project has received a favourable opinion from the East Midlands REC (15/EM/3014). If potential participants lack capacity, a personal consultee will be consulted regarding participation in line with the Mental Capacity Act. Results will be published in peer-reviewed journals and presented at conferences.

Enhancing the Evidence for Behavioral Counseling: A Perspective From the Society of Behavioral Medicine

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care-focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)--a multidisciplinary scientific organization committed to improving population health through behavior change--we review the USPSTF mandate and current recommendations for behavioral counseling interventions and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care-focused behavioral counseling interventions. This perspective highlights five areas for further development, including (1) behavioral counseling-focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care-based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice.

Comparing rating paradigms for evidence-based program registers in behavioral health: evidentiary criteria and implications for assessing programs

Decision makers need timely and credible information about the effectiveness of behavioral health interventions. Online evidence-based program registers (EBPRs) have been developed to address this need. However, the methods by which these registers determine programs and practices as being “evidence-based” has not been investigated in detail. This paper examines the evidentiary criteria EBPRs use to rate programs and the implications for how different registers rate the same programs. Although the registers tend to employ a standard Campbellian hierarchy of evidence to assess evaluation results, there is also considerable disagreement among the registers about what constitutes an adequate research design and sufficient data for designating a program as evidence-based. Additionally, differences exist in how registers report findings of “no effect,” which may deprive users of important information. Of all programs on the 15 registers that rate individual programs, 79% appear on only one register. Among a random sample of 100 programs rated by more than one register, 42% were inconsistently rated by the multiple registers to some degree.

An overview of evidence-based program registers (EBPRs) for behavioral health

Evaluations of behavioral health interventions have identified many that are potentially effective. However, clinicians and other decision makers typically lack the time and ability to effectively search and synthesize the relevant research literature. In response to this opportunity, and to increasing policy and funding pressures for the use of evidence-based practices, a number of “what works” websites have emerged to assist decision makers in selecting interventions with the highest probability of benefit. However, these registers as a whole are not well understood. This article, which represents phase one of a concurrent mixed methods study, presents a review of the scopes, structures, dissemination strategies, uses, and challenges faced by evidence-based registers in the behavioral health disciplines. The major findings of this study show that in general, registers of evidence-based practices are able, to a degree, to identify the most effective practices meet this need to a degree. However, much needs to be done to improve the ability of the registers to fully realize their purpose.

The Behavioural Neurology Assessment

Background:

We present information regarding the standardization, reliability and clinical validity of two versions of the Behavioural Neurology Assessment (BNA). The BNA-Long Form consists of 24 subtests within separate domains: Attention, Memory, Language, Visuospatial Function, Executive Function, and Praxis. The BNA-Short Form consists of 13 subtests within the domains of Attention, Memory, Naming, Visuospatial Function and Executive Function. In addition to individual domain indices, a Grand Total score was calculated for both BNA versions.

Objective:

To standardize the administration and scoring and validate the BNA for detection of dementia.

Methods:

Standardized normative data were obtained on 115 healthy subjects ranging in age from 50 to 95. Test-retest stability was obtained on 19 subjects and clinical validity was investigated by administering the BNA and Mini-Mental Status Examination (MMSE) to 29 patients with dementia and 29 age-matched healthy subjects (controls).

Results:

Age had a significant effect on all but the Visuospatial and Praxis indices of the BNA-Long Form and an effect on Naming and Grand Total score of the Short-Form. Internal consistency (Cronbach's coefficient a) was .87 and .67 for the Long and Short Forms (.95 and .96 for dementia and control groups combined). Test-retest stability was acceptable. Grand Total indices of both BNA versions showed significant, positive correlations with the MMSE. Both BNA versions had superior sensitivity to dementia relative to the MMSE (.93 versus .79). Specificity was equivalent to the MMSE (.93 versus .97).

Conclusions:

Positive predictive values of the BNA and MMSE are equivalent but the BNA provides superior negative predictive value.

Cultural adaptations of behavioral health interventions: a progress report

OBJECTIVE

To reduce health disparities, behavioral health interventions must reach subcultural groups and demonstrate effectiveness in improving their health behaviors and outcomes. One approach to developing such health interventions is to culturally adapt original evidence-based interventions. The goals of the article are to (a) describe consensus on the stages involved in developing cultural adaptations, (b) identify common elements in cultural adaptations, (c) examine evidence on the effectiveness of culturally enhanced interventions for various health conditions, and (d) pose questions for future research.

METHOD

Influential literature from the past decade was examined to identify points of consensus.

RESULTS

There is agreement that cultural adaptation can be organized into 5 stages: information gathering, preliminary design, preliminary testing, refinement, and final trial. With few exceptions, reviews of several health conditions (e.g., AIDS, asthma, diabetes) concluded that culturally enhanced interventions are more effective in improving health outcomes than usual care or other control conditions.

CONCLUSIONS

Progress has been made in establishing methods for conducting cultural adaptations and providing evidence of their effectiveness. Future research should include evaluations of cultural adaptations developed in stages, tests to determine the effectiveness of cultural adaptations relative to the original versions, and studies that advance our understanding of cultural constructs' contributions to intervention engagement and efficacy.

Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach

OBJECTIVE

To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations.

METHOD

We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events.

RESULTS

Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age.

CONCLUSIONS

The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.

The 2012 Don Bloch Award: presented October 5, 2012 at the Collaborative Family Healthcare Association conference, Austin, Texas

In this article, Larry Mauksch thanks the Collaborative Family Healthcare Association (CFHA) board for the honor in receiving the 2012 Don Bloch Award. The Don Bloch Award is presented annually to a person who has made singular contributions to forwarding the cause of collaborative family health care.

The Chronic Care Model for behavioral health care

This paper describes the successful application of the Chronic Care Model (CCM) at Touchstone innovaré, a large mental health agency serving a population of persons with a serious psychiatric condition. Based on our experience with the CCM, it is proposed that it could be applied in behavioral health care in the same manner as it is in physical health care. It is our contention that "chronic condition" should be the key phrase, and that there should not be a distinction in the application of a treatment model, whether the chronic condition is behavioral or physical.

Fetal, childhood, and adolescence interventions leading to adult disease prevention

Lifestyle choices result in the development and increased severity of many adult diseases that can cause death (eg, heart disease, stroke, cancer, obesity). Most health-damaging behaviors are learned during childhood and adolescence, making that time period a critical window of opportunity to teach health-promoting behaviors. Primary care physicians can implement their overall commitment to providing comprehensive health care to patients and their families by following the anticipatory guidelines of their discipline (eg, pediatrics, family and internal medicine) and by educating patients and their families about the recommendations included on the Web sites of the Centers for Disease Control and Prevention Office of Women's Health and Office of Strategy and Innovation.

Quality as the cornerstone of behavioral health: four critical issues

The author emphasizes the need to focus on quality in mental health and addictions treatment. High-quality care means care that is personalized, prevention-oriented, and based on evidence about the benefits, costs, and the desires of each person. Whereas the challenges to improving quality are formidable, four critical issues can and must be addressed: focus on whole health, clinical excellence, workforce, and information technology. With strong leadership, commitment, and persistence, we can have a system that supports recovery and ensures a meaningful life in the community for our sickest and poorest citizens.

Examination of the analytic quality of behavioral health randomized clinical trials

Adoption of evidence-based practice (EBP) policy has implications for clinicians and researchers alike. In fields that have already adopted EBP, evidence-based practice guidelines derive from systematic reviews of research evidence. Ultimately, such guidelines serve as tools used by practitioners. Systematic reviews of treatment efficacy and effectiveness reserve their strongest endorsements for treatments that are supported by high-quality randomized clinical trials (RCTs). It is unknown how well RCTs reported in behavioral science journals fare compared to quality standards set forth in fields that pioneered the evidence-based movement. We compared analytic quality features of all behavioral health RCTs (n = 73) published in three leading behavioral journals and two leading medical journals between January 2000 and July 2003. A behavioral health trial was operationalized as one employing a behavioral treatment modality to prevent or treat an acute or chronic physical disease or condition. Findings revealed areas of weakness in analytic aspects of the behavioral health RCTs reported in both sets of journals. Weaknesses were more pronounced in behavioral journals. The authors offer recommendations for improving the analytic quality of behavioral health RCTs to ensure that evidence about behavioral treatments is highly weighted in systematic reviews.

Monitoring Patient Improvement and Treatment Outcomes in Managed Behavioral Health

This study examined the use of outcome reports sent to clinicians by a managed behavioral healthcare organization to monitor patient progress and its relation to treatment outcome. Results showed that clinicians who reported using outcome information had patients who also reported greater improvement at 6 months from baseline. Improvement per session was greatest among patients whose clinicians reported reading the outcome report and using outcome measures in their clinical practice. Using baseline and ongoing measures to assess patient improvement can provide clinicians with feedback during treatment, which may lead to better clinical outcomes and enable quality management systems in managed care to flag high-risk cases and identify failure of adequate improvement.

Studying family participation in system-of-care evaluations: using qualitative methods to examine a national mandate in local contexts

With the rapid pace of policy and practice changes in children's mental health, there is a need for research to examine, describe, and disseminate information about the translation of policy directives into practice innovations at the local level. National policy mandates for children's mental health have placed expectations on local communities to involve families as partners in the development, implementation, and evaluation of systems of care with little guidance about how to implement program requirements locally. Consequently, there is a gap in the knowledge base regarding how innovations are actually implemented in local community contexts. This article reports on a qualitative study to gain understanding of family participation in evaluations of systems of care from the perspectives of evaluators and family members working together. Findings provided rich examples of the experiences and perceptions of evaluators and family members working on evaluation teams, the challenges they encountered, and effective strategies to meet those challenges.

Creating a recovery-oriented system of behavioral health care: moving from concept to reality

This article describes challenges and successes seen in the first four years of efforts the state of Connecticut has made to reorient its behavioral health system to promoting recovery. Beginning in 2000, the Connecticut initiative was conceptualized as a multi-year, systemic process that involved the following interrelated steps: a) developing core values and principles based on the input of people in recovery; b) establishing a conceptual and policy framework based on this vision; c) building workforce competencies and skills; d) changing programs and service structures; e) aligning fiscal and administrative policies; and, finally, f) monitoring, evaluating, and adjusting these efforts. Following descriptions of the first four steps, the authors offer a few lessons that might benefit other states engaged in similar processes of transformation.