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CME

MANAGING BEHAVIORAL HEALTH


ISSUES IN PRIMARY CARE:
6 FIVE-MINUTE TOOLS

These practical strategies can help family physicians support patients


with depression, anxiety, and other behavioral health issues.

MICHELLE D. SHERMAN, PHD, LAURA W. MILLER, MD, MEGAN KEULER, MD, MPH,
LISA TRUMP, MS, AND MICHELE MANDRICH, MSW
© T R AC I DA B E R KO

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C
onsider this: About three-quarters of the mental illness. Third, family physicians who work in
patients on your schedule today likely have a rural areas may lack adequate behavioral health referral
clinical problem with a significant psychologi- sources or encounter the challenges associated with dual
cal or behavioral component.1 Most patients relationships in small towns. Finally, some insurance
with psychological issues seek help from you, their pri- plans don’t cover behavioral health services or have high
mary care physician, not from a specialty mental health deductibles and out-of-pocket costs for these services,
provider.2,3 Furthermore, caring for patients’ emotional making psychotherapy practically inaccessible.
well-being plays an important part in preventing, diag- This article shares six specific tools primary care
nosing, and treating the top 15 causes of death in the physicians can use to help them care for patients with
United States.4 behavioral health care needs.
One of the most commonly used treatment
approaches for psychosocial problems and emotional
Six five-minute tools
distress is psychiatric medication. Although practice
guidelines support the use of antidepressants for severe Working with patients in severe emotional distress can
depression in adults, greater controversy exists about their be exhausting and overwhelming. Physicians may feel a
effectiveness, acceptability, potential risks, and safety in responsibility to “fix” their patients’ pain, but of course
other groups (e.g., children or patients with mild or there are no quick solutions for life stressors and men-
moderate depression). Further, some patients do not tal illness. Introducing one of the following behavioral

About three-quarters of the patients on your schedule today


likely have a clinical problem with a significant
psychological or behavioral component.

want medications for a variety of reasons such as stigma, health tools may seem like a small step, but it can plant
cost, side effects, and drug interactions. As a result, family a seed of hope for the patient and bolster the physi-
physicians often need additional tools for addressing cian’s sense of efficacy. None of these tools immediately
patients’ behavioral health needs. ameliorates patient suffering and life stressors, but all of
In many practices, embedded behavioral health pro- them can make a positive difference when provided in a
viders work alongside family physicians, helping patients caring environment (see “Being present with distressed
with a broad range of issues including depression and patients,” on page 32). Importantly, all of these skills
anxiety, medication adherence, chronic pain, smok- can be taught to patients in less than five minutes, and
ing cessation, weight loss, and chronic illness manage- you can select the tool that is most appropriate for the
ment. Although these integrated models are growing, particular patient.
it’s imperative for family physicians to have a toolbox 1. Encourage the patient to draw on social supports.
of skills for managing behavioral health issues indepen- An initial approach to many patients’ behavioral health
dently, for several reasons. First, even in fully integrated concerns may be to draw on existing social supports. Ask
clinics, behaviorists are not always available; limited the patient, “Who do you have in your life to support
funding may preclude sufficient staffing of positions, and you in dealing with [fill in the clinical issue]?” Social
behaviorists often have multiple demands on their time. supports may include family, friends, support groups,
Second, some patients are not willing to see a behavioral religious groups, and 12-step programs. Encouraging
health provider, often due to the stigma surrounding patients to draw on social supports may not be effec-

About the Authors


Dr. Sherman is a licensed clinical psychologist and professor in the Department of Family Medicine and Community Health
(DFMCH) at the University of Minnesota in Minneapolis. Dr. Miller is an assistant professor in the DFMCH. Dr. Keuler is a second-
year family medicine resident at the Broadway Family Medicine/North Memorial Family Medicine Residency Program in Minneapolis.
Lisa Trump is a licensed marriage and family therapist and a doctoral candidate in family social science at the University of Minne-
sota. Michele Mandrich is a social worker, certified medical practice executive, and the clinic director of the University of Minnesota
Physicians’ Broadway Family Medicine Clinic. Author disclosure: no relevant financial affiliations disclosed.

March/April 2017 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 31


tive for very isolated patients. However, if tion in the future, such as medication, therapy,
the patient is interested in broadening his or a specialty referral.
or her social network, consider searching 3. Assist the patient in focusing on grati-
online together during the visit so the patient tude. Focusing on positive life events (big or
can leave with contact numbers or websites small) is a tool you and the patient can employ
for volunteer opportunities, social groups, easily in a primary care setting, and it is espe-
community education classes, faith-based cially effective for patients with depression and
resources, or other local resources. anxiety symptoms. Some experts recommend
2. Increase the frequency of visits with daily gratitude journaling, while others indicate
you. For patients who are reluctant to see a that documenting sources of gratitude even
therapist due to stigma, cost, or other con- once per week can boost mood. Regardless
cerns, increasing visit frequency with you, of the frequency, writing or recording these
their family physician, can be a mechanism thoughts in some way appears to be beneficial,

For patients who are reluctant to see a therapist,


Patients with increasing visit frequency with you, their family physician,
psychological
issues often seek
can be a mechanism to offer support.
help from their pri-
mary care physician.
to offer support. Sometimes primary care perhaps because it creates some accountability
physicians minimize the importance of their and room for reflection. Reflecting on even
role and their ability to support patients small positive events, such as a smile from a
Family physicians with behavioral health concerns. However, stranger, the laughter of a child, or a good meal
may need addi- you may be the only person with whom the can be easy places to start. Reviewing this jour-
tional tools for patient can openly share his or her distress nal with the patient periodically may help you
addressing behav- and experience supportive, nonjudgmental lis- identify his or her values and goals, which you
ioral health needs. tening. More frequent contact can strengthen can then use in motivational interviewing to
trust, respect, and comfort in the doctor- elicit other behavior change.
patient relationship, which may increase the 4. Teach breathing and mindfulness
patient’s openness to more intensive interven- exercises. Simple breathing exercises can be
As an initial
useful for many patients in
approach, encour-
age the patient
managing anxiety, depres-
to draw on social
BEING PRESENT WITH DISTRESSED PATIENTS sion, and generalized
supports. Sometimes, the most important skills to use with your distressed
life stress. For example,
patients are not diagnostic, technical skills but your emotional
physicians can teach a
availability and compassion: four-count breathing tech-
nique, wherein patients
• Be present and allow yourself to be emotionally available, breathe in for four counts,
• Use appropriate physical touch and open body language hold their breath for four
(turning away from the computer, for example), counts, blow out gently
for four counts, and then
• Listen without interruption and judgment, and employ
hold the empty breath for
active listening skills such as paraphrasing and reflecting
four counts. Physicians
patients’ feelings,
can quickly model this
• Instill hope and empower the patient by eliciting how technique in the clinic
he or she successfully coped with similar challenges in visit and encourage regular
the past, practice. Patients will find
• E xpress empathy in a genuine, natural manner, thereby
the skill more useful if
fostering a stronger patient-provider relationship.
they have rehearsed it dur-
ing calm, non-crisis times.
Use of this technique at

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BEHAVIOR AL HE ALTH TOOL S

THE DEPRESSION CYCLE


Depression often involves a vicious cycle of sad mood, low energy, avoidance of pleasurable
activities and people, and social isolation – all of which then exacerbate the depression.

Making patients aware of this cycle and encouraging them to participate in pleasant activities even
when they don’t feel like it can help them break the cycle.

SAD
MOOD

SOCIAL LOW
ISOLATION ENERGY Increasing the
frequency of visits
can also be helpful
AVOIDANCE OF to the patient.
PLEASURABLE
ACTIVITIES AND
PEOPLE
Encourage the
patient to focus on
positive life events,
perhaps by keeping
a gratitude journal.
bedtime can also help with insomnia. physical activity goals. It is important to sug-
Mindfulness, prayer, and meditation can gest activities that the patient could pursue
also be helpful for some patients. Physicians easily; for example, a gym membership can
Simple breathing
can guide patients through a simple mindful- be expensive, so explore options such as walk-
exercises are easy
ness exercise, such as the following: “Close ing, biking, stationary exercises at home, or
to teach and can be
your eyes. Take four deep breaths. Focus exercise and yoga DVDs (many of which are useful in managing
on the sound of your breath. Imagine that free online or at the library). Writing out an stress, anxiety, and
you are in a place where you feel calm and actual prescription for this mutually agreed depression.
safe. Connect to the emotions that you are upon plan can be useful and highlight its
experiencing.” importance. Encourage patients to keep a
Breathing and mindfulness exercises are physical activity diary to be reviewed at each
easy to learn and can be very effective, but be visit. At follow-up visits, you can also cel-
sure to check in with the patient at each clinic ebrate successes, re-address barriers, and help
visit to reinforce their use. the patient overcome any obstacles that may
5. Prescribe physical exercise. The physi- have arisen.
cal and mental benefits of regular physical 6. Encourage behavioral activation by
exercise are well documented, and physicians helping the patient create a routine or
can play a pivotal role in helping patients schedule. Depression often involves a vicious
select and engage in appropriate physical cycle of sad mood, low energy, avoidance
activity. Some patients burdened by illness, of pleasurable activities and people, and
chronic pain, and hopelessness experience a social isolation – all of which then exacer-
multitude of barriers to regular physical exer- bate the depression. Behavioral activation is
cise. Physicians can openly talk with patients an approach to addressing depression that
about these concerns and work with them focuses on decreasing avoidance and isola-
to set realistic, appropriate, and attainable tion and increasing engagement in pleasant

March/April 2017 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 33


activities. Recent research has found that like I used to because of my pain,” “I can
behavioral activation is as effective as cogni- barely afford money for the bus much less a
tive-behavioral therapy and can be provided gym membership,” “No one wants to spend
by professionals without formal training in time with me anymore,” or “It’s hopeless.
psychotherapy.5 My life will never get better.” For the major-
Physicians can empower patients to break ity of physicians (and people in general),
the cycle of depression by explaining this the automatic reaction is to try to convince
cycle, noting the consequences of continued patients that things will get better and to try
avoidance and isolation, and urging patients to fix the situation. However, it is important
to engage in some type of pleasurable behav- to anticipate, honor, and explore ambivalence
ior (even if the patient doesn’t feel like doing and barriers, especially in the early stages of
so). Drawing a picture of the depression behavior change.
cycle on paper (see page 33) and planning Motivational interviewing offers several
the behaviors in advance can be helpful for ways to gauge patients’ readiness for change
Physicians can play
patients. Asking patients to track their moods and to address ambivalence. Asking open-
a pivotal role in before and after the planned behaviors can ended questions, uncovering the patient’s
helping patients yield persuasive data to encourage continued motivations for change, highlighting dis-
select and engage activity. Patients cannot wait until they “feel crepancies between the patient’s values and
in appropriate like” doing something; behavioral activation behaviors, and supporting self-efficacy can
physical activity, requires patients to engage in activity regard- all strengthen the patient’s ability to change.
which has mental less of their mood or energy level. Motivational interviewing tools can also help
benefits as well. Patients struggling with depression and patients reflect on their readiness for behavior
anxiety also benefit from creating routines or change and the progress they have already

Explaining the
depression cycle to Focusing on positive life events (big or small)
patients (sad mood,
low energy, avoid- is especially effective for patients with
ance of pleasur-
able activities and depression and anxiety symptoms.
people, and social
isolation) can help
them identify the schedules. For patients with physical or psy- made. One such tool is the confidence ruler:
cycle and break it. chological limitations who cannot regularly “On a scale from 1 to 10, with 10 being most
participate in school or work, creating a regu- confident, how confident do you feel in being
lar routine can provide structure, promote able to make this change?” After hearing the
social connections, and highlight a reason to patient’s number, the physician can ask ques-
Encourage these get out of bed in the morning. Ask the patient tions such as “Why did you choose that num-
patients to create a
to commit to specific activities each day and ber instead of the bottom of the scale?” and
regular routine
note them on a paper or smart-phone cal- “What would it take to move one step higher
to their day.
endar. Patients often realize that their mood on the scale?” People have a tendency to resist
improves when they are busier, thereby creat- change when they are feeling ambivalent or
ing a more positive cycle of enjoyable activi- pressured, so this approach reduces potential
ties, social connections, and better overall resistance by increasing patients’ sense of
quality of life. control and confidence. The focus in behavior
change is taking small steps and recognizing
change is a long-term process – a marathon,
Anticipate and roll with resistance
not a sprint.
Expect that many patients will be hesitant (For more information on motivational
and dubious about the helpfulness of these interviewing, see “Encouraging Patients
tools, at least initially. This reaction can be to Change Unhealthy Behaviors With
part of their negative thinking, a cornerstone Motivational Interviewing,” FPM, May/June
of depression. You might hear from patients, 2011, http://www.aafp.org/fpm/2011/0500/
“Nothing is fun anymore,” “I can’t exercise p21.html.)

34 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2017


BEHAVIOR AL HE ALTH TOOL S

and I think she could help you too. Would you


Preparing the way for more
have a few minutes to meet Dr. X now?”
intensive treatment
5. Instill hope by noting that additional
Many patients benefit enough from these treatment can help. “I have observed that
six skills that they do not need specialized others in your situation have found that talk-
behavioral health care. However, patients ing to a counselor can be really helpful. How
with severe psychological distress, an exten- would you feel about that?”
sive trauma history, comorbid substance
abuse problems, personality disorders, and
The case for brief behavioral
serious family challenges (e.g., family vio-
interventions in primary care
lence) usually need more intensive, special-
ized behavioral health services. As noted The majority of patients seen in primary care
earlier, some patients have considerable will experience one or more psychological or
reservations about seeing a behavioral health behavioral health problems during their life-
care provider. It can be helpful for physicians time. Although some patients need special- For patients who
to think broadly about treatment and referral ized care, primary care physicians should not are resistant to
options for a particular patient, considering discount the potential impact of taking time change, explore
not only individual therapy models but also during clinic visits to employ brief behavioral barriers and help
peer support, 12-step programs, couples/ interventions with patients who struggle them identify small
family therapy, online classes, mental health emotionally or face life crises. Simple actions steps they can take.
apps, etc. such as demonstrating emotional openness,
How physicians talk about behavioral instilling hope, and using active listening can
health issues can shape the patient’s decisions be powerful. With practice, physicians will
and feelings about seeking more intensive feel more confident and effective using the six When patients
treatment. The following five tips (and sample tools described in this article. When referrals need specialized
care, how physi-
scripts) can be useful. are necessary, physicians can greatly influence
cians talk about
1. Focus on the specific issue you’re patients’ willingness to follow through by behavioral health
observing, but avoid labels and psychiatric highlighting the potential benefits of behav- issues can influence
diagnoses. “I know you’ve lost your appetite ioral health services and explicitly addressing whether patients
and have not been sleeping well since you lost patients’ ambivalence and concerns. agree to such
your job” (noting two specific symptoms of treatment.
depression rather than focusing on the label of 1. Robinson PJ, Reiter JT. Behavioral Consultation and
depression). Primary Care: A Guide to Integrating Services. New York:
Springer;2007.
2. Normalize the emotional response and
2. Olfson M, Kroenke K, Wang S, Blanco C. Trends
express empathy/concern. “It’s common to in office-based mental health care provided by psy-
Simple actions such
feel a lot of strong feelings after a parent dies – chiatrists and primary care physicians. J Clin Psychiatry. as demonstrating
being angry at the world, confused, sad, and 2014;75(3):247-253. emotional open-
lost. I know how close you were to your mom, 3. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, ness, instilling hope,
Kessler RC. Twelve-month service use of mental health and using active
and I can tell you’re really sad and hurting. services in the United States: results from the national listening should not
I feel sad seeing you in such pain today.” comorbidity survey replication. Arch Gen Psychiatry.
2005;62(6):629-640.
be discounted.
3. Note how mental health is related to
physical health concerns. “I wonder if your 4. Center for Disease Control. Deaths, percent of total
deaths, and death rates for the 15 leading causes of death,
stress [or sadness, anxiety, etc.] is making your United States and each state, 2014. https://www.cdc.gov/
headaches [or nausea, back pain, etc.] worse. nchs/data/dvs/lcwk9_2014.pdf. Accessed Feb. 1, 2017.
I’m curious what connection you see between 5. Richards DA, Ekers D, McMillan D, et al. Cost and
the two.” outcome of behavioural activation versus cogni-
tive behavioural therapy for depression (COBRA): a
4. Emphasize the power of your relation- randomised, controlled, non-inferiority trial. Lancet.
ship and the team approach. “You don’t have 2016;388(10047):871-880.
to go through this alone. I’m here, and I want
to support you in this difficult time” or “We
believe so strongly in addressing emotional Send comments to fpmedit@aafp.org, or
issues as part of your overall wellness that we add your comments to the article at http://
have behavioral health care providers here in www.aafp.org/fpm/2017/0300/p30.html.
the clinic. Dr. X has helped a lot of my patients,

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