Research roundup: Integrating physical and behavioral health interventions into psychological service delivery

This month's roundup features recent research related to the integration of treatment for physical and behavioral problems with regular mental health care

by Practice Research and Policy Staff

April 28, 2011—Evidence suggests that integrating mental health care with primary medical care and other services can enhance patients' access to services, improve the quality and effectiveness of their care, and lower overall health care costs. Research studies have increasingly evaluated the interface between physical and mental health, as well as integrated approaches to mental and physical health care that have implications for the future of psychological practice.

Andersohn, F., Schade, R., Suissa, S., & Garbe, E. (2009). Long-term use of antidepressants for depressive disorders and the risk of diabetes mellitus. American Journal of Psychiatry, 166, 591-598.

Summary

Antidepressant medication is the most common first-line treatment for clinical depression, but the long-term side effects are poorly understood. The present study evaluated the longitudinal risk of developing diabetes among a cohort of 165,958 men and women at least 30 years of age who received antidepressant medication in primary care for a depressive disorder. Use of moderate daily doses of antidepressants for 24 months or longer was associated with an 84 percent increased risk of diabetes, and the risk was similar for tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs).

Practical Considerations

Recent studies have documented a number of adverse effects from the use of antidepressant medications, including sexual dysfunction and suicidal behavior, but the potential long-term harms are not well studied or publicized. Many patients with major depressive disorder (MDD) require long-term antidepressant therapy to ameliorate depressive symptoms and prevent relapse; indeed, in cases of severe recurrent MDD, lifetime maintenance on antidepressants is typically recommended. Among other side effects, antidepressant treatment within the dose ranges described in current treatment guidelines may increase the risk for diabetes.  Although non-pharmacological/psychological therapies are at least as effective as antidepressants for the long-term management of MDD, and they are often preferred by patients, few patients presenting with depression in primary care are referred for or receive psychological therapies.  Psychologists can work with local primary care providers to ensure that appropriate psychological interventions and referrals are available to all patients suffering from major depressive disorders, and especially those concerned about the potential side effects of antidepressant medication or with a strong predisposition for diabetes. Greater integration of psychology with primary care should facilitate patients’ access to psychological therapies for MDD and other mental health disorders.


Davis, C. L., Tomporowski, P. D., McDowell, J. E., Austin, B. P., Miller, P. H., Yanasak, N. E.,  Naglieri, J. A. (2011). 
 Exercise improves executive function and achievement and alters brain activation in overweight children: A randomized, controlled trial. Health Psychology, 30, 91-98. doi 10.1037/a0021766

Summary

One hundred and seventy one sedentary, overweight children (7 to 11 years of age) participated in a controlled study to examine the effects of aerobic exercise on executive (frontal lobe) function and mathematics achievement.  The children were randomly assigned to either a low-dose exercise group (i.e., 20 minutes of vigorous daily exercise followed by 20 minutes of sedentary activity); a high dose exercise group (i.e., 40 minutes of vigorous daily exercise); or a no exercise control group. Executive function was measured with a standardized battery of neurocognitive tests, and a subgroup of the children was evaluated for changes in cerebral blood flow using fMRI.  A significant dose-response relationship was found between exercise and the measures of executive function, with better neurocognitive test performance among children who received the high dose of exercise. Furthermore, children assigned to one of the exercise interventions exhibited significant changes in cerebral blood flow in the regions of the brain associated with executive function and attention.

Practical Considerations

In addition to the well-known benefits of exercise on physical health, this study adds to a growing body of literature showing that exercise can improve mental health, neurocognitive function and cortical activation across the lifespan.  In normal children, participation in regular vigorous exercise may lead to better academic performance, as well as promote the development of adaptive executive functions, such as behavior self-control. Furthermore, exercise may prove to be a helpful adjunctive component to behavioral interventions for children with a wide range of cognitive, attention, emotional and behavioral problems. Integrating “prescriptions” for exercise with ongoing psychological interventions may have many positive benefits for those in treatment.  


Gulliksson, M. M. D. P., Burell, G. P., Vessby, B. M. D. P., Lundin, L. M. D. P., Toss, H. M. D. P., & Svardsudd, K. M. D. P. (2011). Randomized controlled trial of cognitive behavioral therapy vs. standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary prevention in uppsala primary health care project (SUPRIM). Archives of Internal Medicine, 171, 134-140.
  

Summary

Investigators evaluated the effectiveness of a structured cognitive behavioral stress management program to reduce the recurrence of cardiovascular disease (CVD) events in men and women who were hospitalized for a coronary heart event in the past year.  Consecutive patients (N = 371) were randomly assigned to either a skills-based stress management group (CBSM) or to usual medical care.  The CBSM intervention was a highly structured outpatient program entailing 20 two-hour sessions over the course of one year, and patients in both groups were followed for 94 months from baseline. Patients who participated in the CBSM groups had a clinically significant reduction in the incidence of heart attacks and other cardiovascular events.  Moreover, there was an inverse dose-response relationship between program attendance and recurrent cardiovascular events. 

Practical Considerations

The present study found that adding an intensive structured stress management intervention to traditional secondary prevention programs can improve “hard” cardiovascular outcomes, including fatal and non-fatal CVD events. A number of recent studies have failed to demonstrate a benefit from brief psychosocial and cognitive behavioral interventions for patients with co-morbid depression and cardiovascular disease; however, in contrast, the present study demonstrated that long-term psychological interventions based on cognitive behavioral skills and self-management training can  improve cardiovascular health and outcomes among persons with existing coronary heart disease. Providing long-term cognitive behavioral interventions for the primary and secondary prevention of physical health problems, even in the absence of significant psychopathology, may be an effective approach to reducing overall health care costs and overutilization. Given the known benefits of similar cognitive behavioral interventions for depression and anxiety disorders, long-term intensive cognitive behavioral programs may also be effective for the treatment of patients with co-morbid physical and mental health disorders.


McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G., Lavori, P. W. (2010).  Integrating tobacco cessation into mental health care for posttraumatic stress disorder:  A randomized controlled trialJournal of the American Medical Association, 304, 2485-2493. doi

Summary

More than 40 percent of the 400,000 veterans with post-traumatic stress disorder (PTSD) in the United States are nicotine dependent. This study was conducted to determine if integrating a smoking cessation treatment into mental health interventions for PTSD influenced long-term smoking abstinence rates. A sample of 943 smokers in treatment for PTSD at a Veterans Affairs (VA) outpatient PTSD clinic were randomly assigned to receive either an integrated PTSD and smoking cessation treatment or a referral to a separate VA smoking cessation clinic (SCC). Smoking outcome measures included 12-month bioverified abstinence and 7- and 30-day point prevalence abstinence assessed at three-month intervals for 18 months. Post-traumatic stress disorder and depression symptoms were also monitored throughout the study using the PTSD Checklist and Patient Health Questionnaire 9 (PHQ-9). Results indicated that integrated care was more effective in prolonging smoking abstinence than SCC. PTSD symptoms improved for all patients; however, non-quitters (in both groups) reported worsened depressive symptoms on the PHQ-9 when compared to quitters.

Practical Considerations

Smoking cessation treatment for persons suffering from PTSD is rarely incorporated into mental health care, yet may be highly beneficial. As knowledge about the link between physical health and mental health strengthens, it becomes evident that mental health clinicians need to consider how to address patients’ mental and physical health needs together in treatment. Integrated treatments for mental and physical health issues are a potentially time- and cost-effective practice approach to meeting the health care needs of veterans. Due to the intensive nature of the interventions, many mental health providers are well positioned to offer supplementary treatment for smokers undergoing care for PTSD.  Integrating smoking cessation and other lifestyle interventions with mental health treatments has the potential to be a convenient and cost-effective means to improve the health and well-being of millions of Americans receiving care for mental health problems.


Morin, C. M., Vallieres, A., Guay, B., Ivers, H., Savard, J., Merette, C., Baillargeon, L. (2009).  Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. Journal of the American Medical Association, 301, 2005-2015. doi

Summary

This study investigated a two-stage therapy approach comprising cognitive behavioral therapy (CBT) and sleep medication (Zolpidem) for the treatment of chronic insomnia. Initially, one hundred and sixty adults were randomly assigned to either CBT alone or CBT combined with sleep medication for six weeks. Patients in the CBT group were then randomly assigned to six months of maintenance CBT (monthly sessions) or no additional treatment; and patients in the combined therapy group were randomly assigned to six months of maintenance CBT plus intermittent sleep medication as needed or CBT only. Daily sleep diaries and the Insomnia Severity Index were used to determine the effectiveness of each treatment. The addition of sleep medication to CBT produced added benefits during the first stage of therapy, but long-term outcomes were significantly better among patients assigned to discontinue medication during maintenance (monthly) CBT.

Practical Considerations

Because chronic insomnia is not characterized as a primary mental disorder, people most frequently turn to sleeping pills as their means of treatment, and behavioral interventions are commonly overlooked.  Furthermore, even though clinicians frequently take into consideration the fact that coupling treatment with medication proves to be an effective intervention, many may be unaware of the added benefits of modifying these combined approaches throughout extended treatment.  Psychologists could provide a great service to their clients by evaluating for the presence of sleep disturbances and then providing appropriate psychological interventions to improve sleep.  


Webb, M. S., de Ybarra, D. R., Baker, E. A., Reise, I. M., & Carey, M. P. (2010). Cognitive-behavioral therapy to promote smoking cessation among African American smokers: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 78, 24-33.

Summary

African Americans disproportionately suffer from the ill health effects of smoking, yet few research studies to date have investigated smoking cessation interventions to meet the unique needs of this population segment. In order to assess the efficacy of group-based cognitive behavioral therapy for smoking cessation among African Americans, 154 African Americans were randomly assigned to either group cognitive behavioral therapy (CBT) or a general health education control group; both interventions entailed six sessions (60-90 min) over a two-week period, as well as eight weeks of transdermal nicotine patches. Assessments occurred at the end of the six sessions, as well as at three and six months following the interventions. Smoking cessation was measured by self-reported smoking status/abstinence, confirmed biochemically with a breath CO detector. Participants reported significantly higher rates of abstinence in the CBT group across all measurement intervals. This is one of the first studies to demonstrate that group CBT smoking cessation is efficacious among African-American smokers.

Practical Considerations

Intensive cognitive behavioral interventions are effective for the treatment of a wide range of mental and physical health issues, including smoking; however, little research has focused on how to tailor these interventions to optimize the benefits for African Americans and other minorities. This study found that an established group smoking cessation intervention entailing cognitive behavioral skills training and relapse prevention strategies, as well as home practice in the skills they learned in treatment (e.g., mental and behavioral coping skills, cognitive reframing exercise, no-smoking behavioral contracts), can be effective with this population of African Americans. According to the Centers for Disease Control and Prevention, smoking is the leading cause of preventable death in the United States, and dissemination of targeted cognitive behavioral interventions could be one key to alleviating the detrimental effects of this epidemic across all populations. Psychologists have specific skills in behavior change and could provide a valuable service by actively asking all clients whether they smoke and wish to quit and then providing appropriate interventions or resources to support such change.

 

Special thanks to Bonnie Spring, PhD, ABPP, of APA and Behavioral Medicine Director and Co-Program Leader for Cancer Prevention, who assisted on this article.