Expanding Use of Brief Behavioral Interventions in Collaborative Care

Most psychotherapies have been designed for weekly one-hour sessions with a specialty mental health provider. To be delivered effectively in primary care, behavioral interventions must take no more than 30 minutes; follow a structured, patient-centered approach; be applicable to diverse patient populations; and have a substantial research evidence base.

Problem solving treatment for primary care (PST-PC) has one of the strongest evidence bases in this setting and is one of the most widely used interventions for depression. PST-PC involves six to 10 sessions of 30 minutes each to help patients solve “here and now” problems contributing to their depression. Problems range from concrete stresses like housing, finances, and transportation to difficulties with health and self-care, lack of pleasant and rewarding activities, social isolation, and interpersonal conflicts. Patient values and preferences are intrinsic to PST-PC, in that clinicians attempt to empower patients to identify problems in living from their own perspective, see connections between these problems and their depressive symptoms, prioritize which issues they wish to focus on, and choose ways in which to take action. Numerous trials have found that PST-PC significantly improves depression symptoms and functioning in a wide range of patient populations.

In light of growing evidence that a variety of paraprofessionals can provide straightforward behavioral interventions, we have developed training in Patient Activation for nonlicensed staff members. This intervention is designed to support other formal mental health interventions used by the rest of the primary care team.

Patient Activation uses evidence-based strategies drawn from formal Behavioral Activation and helps depressed patients engage in activities they once found rewarding and enjoyable but have abandoned after becoming depressed. These activities include social, physical, and other pleasant daily activities.

Patient Activation can be delivered in two to six sessions of 30 minutes each. While we have not yet collected formal data on Patient Activation, case managers trained in the intervention report improvements in their patients’ depressive symptoms and quality of life.

In an effort to streamline and disseminate training in behavioral interventions, we have incorporated self-paced, interactive online modules. These modules offer a variety of skill-building exercises to facilitate learning of core skills, such as how to describe and successfully engage patients, how to help patients set weekly achievable goals, and how to develop detailed action plans.

Full certification in PST-PC as offered by the AIMS Center typically requires between 16 to 22 hours of clinician time over the course of six months. The training process involves multiple opportunities to practice core PST-PC skills without the need for in-person training, participation in monthly group supervision calls, and mastery of PST-PC via audiotape review and feedback. While 16 to 22 hours represents significant improvement in training time required by traditional psychotherapy, we continue to develop innovative technology-based methods to reduce this time while at the same time preserving high-level standards for clinician competency.

It is our hope that ongoing efforts to tailor behavioral interventions to primary care and streamline training methods will expand the use of brief behavioral interventions in primary care and thereby improve the mental health care that patients receive. ■