As the behavioral health population ages and their medical complexity increases, there is a growing trend in the need for primary care and behavioral health providers to unite and integrate in addressing patients in a more holistic fashion. Perhaps the largest push in the last decade or so has been the move towards screening for and addressing depression within the primary care setting—launched by the landmark IMPACT study by Unutzer and colleagues in 2002. With the recognition that Americans are more likely to access health care via a primary care practice than elsewhere (and more likely to be seen in primary care before attempting suicide, or while experiencing a substance use disorder, etc.), primary care has been a logical home for the treatment of ‘uncomplicated’ depression and anxiety. Primary care providers are increasingly expected to not only address the usual medical needs of patients, but also to consider their mood state, anxiety and problems related substance use disorders (Blount, 2019). It is probably little surprise that most antidepressant prescriptions are now initiated by primary care providers (Barkil-Oteo, 2013).
Of course, really good care often takes a village, or at least a care team. In a growing number of settings, we have seen integrated behavioral health providers and services embedded directly within the primary care clinic (PCDC, 2019). These embedded behavioral health clinicians address a range of presenting concerns from anxiety and grief to bedwetting and parental skills training. This breadth of services can be expanded and generalized even more, to the intersecting space of behavioral and medical concerns, and particularly in addressing diabetes.
Diabetes and Behavioral Health
Diabetes affects over 30 million Americans, and both type 1 and type 2 diabetes are highly comorbid with depressive disorders (Balhara, 2011). The linkage between diabetes and depression is bidirectional and particularly so in the case of acquired type-II diabetes. Diabetes and depression can maintain a sort of symbiotic relationship where low mood can lead to lifestyle changes contributing to developing and/or worsening of diabetes, and coping with diabetes itself and the related symptoms can worsen one’s mood (Talbot & Nouwen, 2000).
Even in the absence of other behaviors, common antidepressant medications are associated with risk for diabetes along with metabolic disorders more generally and this risk only grows in the case of patients prescribed medications used to treat serious mental illness such as clozapine and olanzapine (Balhara, 2011; Annamalai & Tek, 2015). Individuals with mental health conditions are known to have more limited access to medical treatment, only compounding the likelihood of a poor health trajectory in the presence of diabetes (SAMHSA, 2017). The Primary Care Development Corporation (PCDC) along with other organizations and agencies have called for bringing improved and integrated care to Americans wherever they are treated- whether in primary care or behavioral health clinics (PCDC, 2019).
Adapting the Behavioral Health Workforce
In considering the possibility of behavioral health providers taking on a more active role in identifying, treating and managing a primary medical issue, arguments are very real around scope of practice concerns and a codified requirement to do no harm and practice within our clinical abilities in the provision of care. Yet, in the case of diabetes, a behavioral health clinician doesn’t need to claim expertise in endocrinology to develop a basic understanding of the basic pathophysiology underpinning diabetes and the metabolic cycle. Even more concretely, a behavioral health clinician should have or be able to develop the needed skills to help patients develop new behaviors, decrease reliance on maladaptive behaviors, and cope with fear, frustration, confusion, and other barriers to engaging in screening and treatment for diabetes. The American Diabetes Association has advocated for more psychosocial treatment related to diabetes, citing the “complex, multifaceted issues when integrating diabetes care into daily life” (Young-Hyman, de Groot, Hill-Briggs, Gonzalez, Hood & Peyrot, 2016). Opportunities abound for behavioral intervention related to diabetes, whether in an integrated primary-behavioral health clinic or even a traditional mental health clinic.
Behavioral health providers, including care managers, can improve diabetes screening, care, and monitoring in six key steps:
- Obtain training to develop basic competencies in understanding biopsychosocial factors impacting the development and management of diabetes (e.g., jointly offered programs by the American Psychological Association and American Diabetes Association, training offered via PCDC, and others).
- Facilitate screening and intervention through cross-disciplinary communication (e.g., working side by side with nurses, physicians, pharmacists; facilitating warm hand-offs for screening and intervention by medical staff; helping to facilitate a jointly developed care plan and reviewing this with the patient).
- Help patients address behavioral barriers to care (e.g., concerns about needles and monitoring devices, developing medication adherence habits and self-monitoring behaviors).
- Foster communication between patients and their medical teams (e.g., helping patients think through how to have conversations with their medical team about fears or concerns about treatment and expectations, exploring the connection between their mood states and diabetes and how addressing both can improve the experience for the patient).
- Work with patients to address other significant behavioral correlates that increase risk for and worsen the course of diabetes. These include tobacco cessation, decreasing alcohol consumption, increasing exercise, stress management and reinforcing dietary changes. Each of these requires developing new skills and habits and revisiting unhealthy coping mechanisms.
- Incorporate accessible patient health data (Hemoglobin A1c scores, blood glucose levels) as part of the standard review of systems and symptoms in behavioral health notes and discuss with patients how these fit into their overall wellness.
At the organization level, management can support behavioral health staff in helping to address diabetes by advocating for the use of shared metrics for both primary and behavioral health staff (and incentives around meeting these), by improving staff training around diabetes, by providing staff access to the full medical record and huddles to share information, and incorporating supportive structures into workflows (e.g., diabetes reminders should come up in the EHR for patients on medication for SMI; depression screening should come up for patients with poorly managed diabetes). In developing patient care plans, behavioral health staff can also help ensure teams are working towards shared goals by including how behavioral treatment will also address the patient’s goals around preventing or managing diabetes or other medical at-risk conditions.
Change Can’t Wait Until Tomorrow
As the behavioral health population ages, chronic diseases increase in prevalence and complexity, and the further integration between behavioral health and primary care expands, health systems must adapt. Healthcare providers, perhaps now more than ever, must maximize their scopes of practice and come together to more fully meet the needs of the patients we serve. Behavioral health clinicians have an important role in addressing chronic medical conditions, such as diabetes. Through capitalizing on core behavioral health skills such as behavior change principles and addressing barriers to goals, behavioral health providers can adapt the services they offer to complement a wider range of patient needs. We cannot wait for the behavioral health clinicians of tomorrow to emerge with these new skills- we must develop them today and offer a holistic experience for our patients no matter where they are receiving their care.
The Primary Care Development Corporation is a nationally recognized nonprofit providing strategic investment and technical assistance to support and expand health care – primarily in low-income, underinvested communities – to achieve health equity. For more information visit pcdc.org or call (212) 437-3900.
CBC seeks to create a healthcare environment where New Yorkers–especially those most impacted by social determinants of health–receive coordinated, individualized and culturally competent care that is effective in preventing and managing chronic physical and behavioral health conditions. We help New Yorkers live long, healthy and fulfilling lives. www.cbcare.org.