Integrated Primary Care Readiness and Behaviors Scale: Development and validation in behavioral health professionals.

INTRODUCTION: Although integrated primary care (IPC) is growing, several barriers remain. Better understanding of behavioral health professionals' (BHPs') readiness for and engagement in IPC behaviors could improve IPC research and training. This study developed measures of IPC behaviors and stage of change. METHOD: The sample included 319 licensed, practicing BHPs with a range of interests and experience with IPC. Sequential measurement development procedures, with split-half cross-validation were conducted. RESULTS: Exploratory principal components analyses (N = 152) and confirmatory factor analyses (N = 167) yielded a 12-item scale with 2 factors: consultation/practice management (CPM) and intervention/knowledge (IK). A higher-order Integrated Primary Care Behavior Scale (IPCBS) model showed good fit to the data, and excellent internal consistencies. The multivariate analysis of variance (MANOVA) on the IPCBS demonstrated significant large-sized differences across stage and behavior groups. DISCUSSION: The IPCBS demonstrated good psychometric properties and external validation, advancing research, education, and training for IPC practice. (PsycINFO Database Record

Psychologists in patient-centered medical homes (PCMHs): Roles, evidence, opportunities, and challenges.

The patient-centered medical home (PCMH) is an increasingly common model of health care delivery with many exciting opportunities for psychologists. The PCMH reflects a philosophy and model of care that is highly consistent with psychological science and practice. It strives to provide patient-centered, comprehensive, team-based, coordinated, accessible, and quality and safety-oriented health care delivery to individuals and families. Moreoever, in keeping with changes in the health care system more broadly, the PCMH model prioritizes the integration of behavioral and physical health care, and this emphasis lays the foundation for active and full engagement of psychologists in this context. This article provides an overview of the PCMH and the evidence and roles for psychologists across a range of pediatric, adult, and geriatric health care populations and settings. Current challenges to the necessary expansion of psychology in the PCMH are discussed, with particular attention to the needs for training and advocacy to support the contributions of behavioral health care in the PCMH. Psychology must embrace its rightful place as a health profession and appreciate and highlight the ways in which psychologists can play unique and critical roles in transforming present and future health care delivery models. (PsycINFO Database Record

Implementation of an acceptance- and mindfulness-based group for depression and anxiety in primary care: Initial outcomes.

INTRODUCTION: Depression and anxiety disorders are highly prevalent among primary care patients. Group visits provide a way of delivering interventions to multiple patients at the same time. Group visits for depression and anxiety present an opportunity to expand the reach of behavioral health services for primary care patients. The goal of the current study was to evaluate the implementation of an acceptance and mindfulness-based group for primary care patients with depression and anxiety. METHODS: Adult family medicine patients with Patient Health Questionnaire-9 (PHQ-9) and/or Generalized Anxiety Disorder Scale-7 (GAD-7) scores > 5 were eligible for the group. The group was held biweekly in the family medicine practice with rolling enrollment. The PHQ-9 and GAD-7 were administered at every visit, and changes in depression and anxiety symptoms were analyzed using multilevel modeling. We evaluated feasibility, acceptability/satisfaction, penetration, and sustainability. RESULTS: Over the course of 19 months, 50 patients were referred to the group, and 29 enrolled. The median number of visits attended was four among those who attended more than one group visit. Results revealed that depression and anxiety symptoms decreased significantly over the first four visits attended (d = -.26 and -.19, respectively). Patients who attended more than one group reported high satisfaction. The group was sustainable after the research funding ended; however, penetration was low. DISCUSSION: A rolling enrollment group for patients with depression and anxiety that utilized mindfulness- and acceptance-based treatment principles is feasible to implement in a primary care setting but is not without challenges. Recommendations for ways to enhance implementation and future research are provided. (PsycINFO Database Record

Physician actions following a positive PHQ-2: implications for the implementation of depression screening in family medicine practice.

Systematic screening of depression in primary care settings that have adequate follow-up and treatment is recommended. The Patient Health Questionnaire (PHQ-9) was developed as a depression screening measure for use in primary care. The PHQ-2, which includes just 2 items from the PHQ-9, is designed to be used as a first line depression screening measure, to be followed by the full PHQ-9 when a patient screens positive. However, completion of the first step in the process (PHQ-2) does not necessarily lead to completion of the second step (administration of the PHQ-9 when the PHQ-2 is positive), even when treatment and follow-up are available. The objective of the current study was to describe family medicine physicians' actions following a positive PHQ-2 and factors that affect their use of depression screening measures and treatment decisions. A retrospective chart review of 200 family medicine patients who screened positive on the PHQ-2 during an office visit was conducted. Additionally, 26 family medicine physicians in the practice were surveyed. Only 5% of patients with positive PHQ-2 scores were administered a PHQ-9. Physicians relied on their clinical judgment and prior knowledge about the patient's depression status to inform treatment decisions and cited time constraints and competing demands as reasons for not administered the PHQ-9. Physicians tended to treat depression with adequate doses of antidepressants and counseling. PHQ-2 screening did not necessarily lead to further evaluation, systematic follow-up, or changes in treatment. Implications for the implementation of depression screening in primary care settings are discussed.

Control of estrus and ovulation in beef heifers.

Expanded use of artificial insemination (AI) and/or adoption of emerging reproductive technologies for beef heifers and cows require precise methods of estrous-cycle control. New protocols for inducing and synchronizing a fertile estrus in replacement beef heifers and postpartum beef cows in which progestins are used provide new opportunities for beef producers to synchronize estrus and ovulation and to facilitate fixed-time AI. This article reviews the various estrous synchronization protocols currently available for use in replacement beef heifers. New methods of inducing and synchronizing estrus now create the opportunity to significantly expand the use of AI in the United States cowherd.

Preparing psychologists in academic health centers for the rapidly changing health care environment.

The Association of Psychologists in Academic Health Centers (APAHC) convened its 5th National APAHC Conference in Boston March 3-5 2011. The conference and its theme, "Preparing Psychologists for a Rapidly Changing Health Care Environment," brought psychologists from academic health centers together to examine how psychology can adapt to and help lead health care efforts in the face of health care reform. This paper reports on the conference and introduces the special issue of JCPMS that is dedicated to the conference. The conference theme is framed in the historical context of the four national conferences that preceded it. In examining the focus and topics of the preceding conferences, recurrent themes are identified and progress in certain areas is highlighted.

Functional roles and foundational characteristics of psychologists in integrated primary care.

Psychologists are presented with unprecedented opportunities to integrate their work in primary care settings. Although some roles of psychologists in primary care overlap with those in traditional psychology practice settings, a number are distinct reflecting the uniqueness of the primary care culture. In this paper, we first describe the integrated primary care setting, with a focus on those settings that have components of patient centered medical home. We then describe functional roles and foundational characteristics of psychologists in integrated primary care. The description of functional roles emphasizes the diversity of roles performed. The foundational characteristics identified are those that we consider the 'primary care ethic,' or core characteristics of psychologists that serve as the basis for the various functional roles in integrated primary care. The 'primary care ethic' includes attitudes, values, knowledge, and abilities that are essential to the psychologist being a valued, effective, and productive primary care team member.

Transdisciplinary training: key components and prerequisites for success.

The training of transdisciplinary science is distinct in its intention to develop scientists who synthesize the theoretical and methodologic approaches of different disciplines. As a result, transdisciplinary scientists are better prepared to address the complexities of health problems. The most common form of transdisciplinary training is the multi-mentor apprenticeship model, with each mentor training from his or her own discipline. The transdisciplinary trainee is faced with many challenges, including learning the languages and cultures of different disciplines along with learning how to navigate within and between disciplines. The trainee also confronts unique career development risks. The climb up the academic ladder can be slower, rougher, and less linear than that of the trainee's single-disciplinary-trained peers. A number of factors can help the trainee in overcoming the challenges: being able to develop a core set of values and behaviors that are essential for transdisciplinary scientists; having the commitment and support of training institutions, training directors, and mentors; and having training structures and processes in place to prevent the training and trainee from naturally regressing back to familiar single-disciplinary approaches. There is relatively little known empirically about transdisciplinary training. Future efforts can focus on developing a better understanding of the unique characteristics of transdisciplinary training, identifying the effective elements that relate to training outcomes, defining the critical outcome metrics at different time points during and following training, and creating toolkits to help with training processes.

Stress and headache chronification.

In this special section, the concept of stress has been linked to the chronification of headache and is considered to be one of several likely mechanisms for the progression of an otherwise episodic disorder to a chronic daily phenomenon. The present review discusses the concept of stress and describes the mechanisms through which stress could influence headache progression. The hypothesized mechanisms include stress serving as a unique trigger for individual attacks, as a nociceptive activator, and as a moderator of other mechanisms. Finally, the techniques used in the screening and management of stress are mentioned in the context of employing strategies for the primary, secondary, or tertiary prevention of headache progression.

Effect of personal cancer history and family cancer history on levels of psychological distress.

This study examined the impact of personal and family cancer history on psychological distress. Regression analyses were conducted on a nationally representative sample of adult individuals who participated in the 2000 National Health Interview Survey, USA. Effects on distress of a personal cancer history, any family cancer history, or mother, father, sister or brother with a cancer history were examined. The interaction of personal and family cancer histories and three-way interactions with gender were also assessed. Analyses indicate that having either a personal or family cancer history is linked with significantly greater psychological distress and there is evidence of an interaction. Three-way interactions with gender were not found. Consistent with prior research, results demonstrated that cancer survivors are more distressed than the general population. Results extend prior research by indicating that having a first-degree relative with cancer increases risk for distress, and having personal and family cancer histories may exert a synergistic effect on distress.

Understanding psychological stress, its biological processes, and impact on primary headache.

Psychological stress is generally acknowledged to be a central contributor to primary headache. Stress results from any challenge or threat, either real or perceived, to normal functioning. The stress response is the body's activation of physiological systems, namely the hypothalamic-pituitary-adrenal axis, to protect and restore functioning. Chronic activation of the stress response can lead to wear and tear that eventually can predispose an individual to disease. There are multiple ways that stress and headache are closely related. Stress can (a) be a predisposing factor that contributes to headache disorder onset, (b) accelerate the progression of the headache disorder into a chronic condition, and (c) precipitate and exacerbate individual headache episodes. How stress impacts headache is not often understood. However, stress is assumed to affect primary headache by directly impacting pain production and modulation processes at both the peripheral and central levels. Stress can also independently worsen headache-related disability and quality of life. Finally, the headache experience itself can serve as a stressor that compromises an individual's health and well-being. With the prominent role that stress plays in headache, there are implications for the evaluation of stress and the use of stress reduction strategies at the various stages of headache disorder onset and progression. Future directions can help to develop a better empirical understanding of the pattern of the stress and headache connections and the mechanisms that explain the connections. Further research can also examine the interactive effects of stress and other factors that impact headache disorder onset, course, and adjustment.

The contribution of pain-related anxiety to disability from headache.

Disability associated with headache cannot be fully accounted for by pain intensity and headache frequency. As such, a variety of cognitive and affective factors have been identified to help explain headache-related disability beyond that accounted for by pain levels. Pain-related anxiety, a multidimensional construct, also has been found to contribute to disability in headache sufferers. What is not known is whether pain-related anxiety is unique in contributing to disability beyond the role of headache-specific cognitive factors and emotional distress. The present study examines the influence of pain-related anxiety on disability, after controlling for pain, cognitive (self-efficacy and locus of control), and affective factors (emotional distress) in a sample of 96 primary headache sufferers. Pain, headache-related control beliefs, and emotional distress accounted for 32%, with locus of control related to health care professionals contributing unique variance. In the full model, with the addition of pain-related anxiety, only pain-related anxiety was a unique predictor of disability. These findings suggest that pain-related anxiety may have a unique and important role in contributing to disability in headache sufferers.

Guidelines for trials of behavioral treatments for recurrent headache, first edition: American Headache Society Behavioral Clinical Trials Workgroup.

Guidelines for design of clinical trials evaluating behavioral headache treatments were developed to facilitate production of quality research evaluating behavioral therapies for management of primary headache disorders. These guidelines were produced by a Workgroup of headache researchers under auspices of the American Headache Society. The guidelines are complementary to and modeled after guidelines for pharmacological trials published by the International Headache Society, but they address methodologic considerations unique to behavioral and other nonpharmacological treatments. Explicit guidelines for evaluating behavioral headache therapies are needed as the optimal methodology for behavioral (and other nonpharmacologic) trials necessarily differs from the preferred methodology for drug trials. In addition, trials comparing and integrating drug and behavioral therapies present methodological challenges not addressed by guidelines for pharmacologic research. These guidelines address patient selection, trial design for behavioral treatments and for comparisons across multiple treatment modalities (eg, behavioral vs pharmacologic), evaluation of results, and research ethics. Although developed specifically for behavioral therapies, the guidelines may apply to the design of clinical trials evaluating many forms of nonpharmacologic therapies for headache.

Behavioral headache research: methodologic considerations and research design alternatives.

Behavioral headache treatments have garnered solid empirical support in recent years, but there is substantial opportunity to strengthen the next generation of studies with improved methods and consistency across studies. Recently, Guidelines for Trials of Behavioral Treatments for Recurrent Headache were published to facilitate the production of high-quality research. The present article compliments the guidelines with a discussion of methodologic and research design considerations. Since there is no research design that is applicable in every situation, selecting an appropriate research design is fundamental to producing meaningful results. Investigators in behavioral headache and other areas of research consider the developmental phase of the research, the principle objectives of the project, and the sources of error or alternative interpretations in selecting a design. Phases of clinical trials typically include pilot studies, efficacy studies, and effectiveness studies. These trials may be categorized as primarily pragmatic or explanatory. The most appropriate research designs for these different phases and different objectives vary on such characteristics as sample size and assignment to condition, types of control conditions, periods or frequency of measurement, and the dimensions along which comparisons are made. A research design also must fit within constraints on available resources. There are a large number of potential research designs that can be used and considering these characteristics allows selection of appropriate research designs.

Efficacy and effectiveness approaches in behavioral treatment trials.

The objective is to clarify the distinction between efficacy and effectiveness approaches and to discuss how these approaches can be used in a complementary way in the development, evaluation, and implementation of behavioral treatments for primary headache in various settings. Efficacy studies, with an emphasis on internal validity, are experiments that evaluate treatment response in an ideal, highly controlled research environment. Despite their methodological strengths, efficacy studies are limited in their ability to estimate the treatment effects that can be expected in clinical practice settings. Effectiveness studies, with an emphasis on external validity, are outcome studies with less controls that evaluate treatment response in settings more representative of clinical practice. Effectiveness studies, however, are limited in their ability to determine the causal link between treatment and response. Based on the four-phase model used in new drug development, a three-phase linear progression model is presented for behavioral treatment studies. This model provides for pilot testing, efficacy testing, and effectiveness testing of behavioral treatments so that there is appropriate evaluation from initial promise of a developing treatment to implementation and dissemination to various treatment delivery settings.

Moderators and mediators of behavioral treatment for headache.

Although work has been done establishing the efficacy of behavioral treatments for headache, almost no work has been done using appropriate methodology to evaluate what types of patients in which settings (termed "moderators") are likely to benefit from treatment and what treatment components account for treatment response (termed "mediators"). The current article provides an overview of moderators and mediators and their assessment and analysis as they pertain to clinical trials. The article also discusses the need for moderator and mediator hypotheses to be theory driven. A brief consideration of potential moderators and mediators of behavioral treatment for headache is then presented. The article concludes with a discussion of methodological issues to be addressed when conducting moderator and mediator analysis for behavioral treatment for headache.

Cognitive-behavioral group treatment for disabling headache.

OBJECTIVES: Severe, disabling headache is costly to individual sufferers, through pain and reduced functioning, and to society, through decreased work productivity and increased health care use. First-line prophylactic agents combined with triptans do not adequately benefit many disabled headache sufferers. We sought to investigate whether a cognitive-behavioral treatment targeting the psychological and behavioral factors that contribute to disabling headache may provide additional benefit and whether using a group format may provide a more intensive clinic-based treatment without increasing the cost of service delivery. DESIGN: We developed and piloted a cognitive-behavioral group treatment for chronic, disabling headache. We evaluated its effectiveness in decreasing headache, reducing symptomatic medication use, and improving quality of life. SETTING: A behavioral headache management program of an academic medical center. PATIENTS: Sixty-two individuals suffering from primary headache disorder with moderate to severe headache-related disability who completed treatment. INTERVENTIONS: Individuals completed a pretreatment evaluation, the 10-session cognitive-behavioral group treatment, and a 1-month-posttreatment evaluation. OUTCOME MEASURES: The impacts of treatment on headache (frequency, intensity, and duration), medication use, and quality of life were assessed. RESULTS: Separate multivariate analyses of variance revealed significant improvements in headache, symptomatic medication use, and quality of life. Overall, 50% of participants experienced at least a 50% reduction in headache frequency from pre- to posttreatment. CONCLUSIONS: The findings provide preliminary evidence that delivering a clinic-based, group-format cognitive-behavioral treatment to moderately to severely disabled headache sufferers can decrease headache activity, reduce symptomatic medication use, and improve quality of life.

Training the transdisciplinary scientist: a general framework applied to tobacco use behavior.

The complexity of public health problems, including the problem of tobacco use behaviors, calls for formal efforts to train transdisciplinary scientists. These scientists can approach problems by using new conceptual frameworks and methodological tools that integrate different disciplinary perspectives. Transdisciplinary training focuses on developing strong scientists with superb core skills while protecting against creating scientists who are "jack of all trades, master of none." Transdisciplinary training is relatively new, with no accepted training model in place. In this paper, we provide a general framework for transdisciplinary training at the advanced graduate and postgraduate levels, with particular reference to tobacco use behaviors. We identify the core attitude, knowledge, and skills competencies that are essential to conducting tobacco use research with a transdisciplinary approach. We outline the structural components of transdisciplinary training that allow for the development of the competencies and discuss what facilitates the transdisciplinary training process. We also discuss the numerous challenges and obstacles to transdisciplinary training. These include the readiness of early-career trainees to undergo transdisciplinary training, professional development risks taken by trainees, administrative and budgetary obstacles inherent in traditional academic institutional structures, and the limited opportunities established scientists have for transitioning their research programs in a transdisciplinary direction. If these obstacles can be overcome, the potential exists for a new generation of transdisciplinary scientists to be trained and be well positioned to make important and unique advances in our understanding of tobacco use and other public health problems.

Psychologic and behavioral management of tension-type headache: treatment procedures.

Used as an adjunct or alternative to medication treatment, psychologic and behavioral approaches to tension-type headache decrease headache frequency, affective distress, and headache-related disability. These approaches directly address the psychologic and behavioral factors that contribute to the disorder and to the individual headache episodes. There is well-established evidence of efficacy for the three broad approaches: relaxation training, electromyographic biofeedback training, and cognitive-behavioral stress management. Treatment has been difficult to access, with most care provided by behavioral specialists in tertiary care settings using clinic-based or home-based treatment protocols. Recent attempts to make treatment more accessible to a wider range of tension-type headache sufferers include using medical personnel to deliver treatment from physician practices and using existing and emerging technologies to provide care in a purely self-administered format without face-to-face contact with therapists. These attempts are promising, but remain preliminary; therefore, there is a need for further development and testing.