© Springer International Publishing AG 2017
Sanjeev Sockalingam and Raed Hawa (eds.)Psychiatric Care in Severe Obesity10.1007/978-3-319-42536-8_77. Integrated Models for Severe Obesity Management: Role for Psychosocial Teams
(1)
Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, E8013, Pittsburgh, PA 15203, USA
(2)
Toronto Western Hospital Bariatric Surgery Program, Centre for Mental Health, University Health Network, 200 Elizabeth Street, Toronto, ON, Canada, M5G 2C4
(3)
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
7.1 Introduction
Severe obesity has significant comorbidity with a range of psychiatric disorders . Untreated psychiatric disorders have a significant negative impact on health outcomes, including the management of obesity. There is increasing recognition that integrated behavioral health care improves both health and psychological outcomes while remaining cost-effective. This chapter provides a brief overview of the history of integrated behavioral health care and discusses possible applications to the treatment of severe obesity. We also review the limited literature examining integrated and collaborative care for patients with obesity.
Case Vignettes
Mrs. R is a 38-year-old separated woman who presents to a family medicine clinic to establish care as her previous provider recently retired. Her medical history is notable for hypertension and migraine headaches. Her medications are lisinopril 40 mg daily, fluoxetine 20 mg daily, and a multivitamin. She has no complaints on review of systems. Her height is 64 in/162.56 cm and her weight is 271 lb/123 kg, BMI 46.5. Her PHQ-9 is 10, indicating moderate depression, with which she was diagnosed two months ago. Her blood pressure is 148/92 and all other vital signs are within normal limits. Her exam is notable only for obesity. She had been overweight as a teenager and has not been able to sustain weight loss for any period as an adult. After the birth of her son 5 years ago, she “just kept gaining” and estimates that her weight has been relatively steady over the past year despite attempts to lose weight by reducing sugar intake and not snacking after dinner. She states that she wants to lose weight, but struggles to “be good” and will overeat in social situations and when she has a deadline at work and has to work late. Since separating from her husband 3 months ago, she estimates that she has gained 15 lbs/6.8 kg. She has considered bariatric surgery, but worries about possible medical complications as well as lifetime behavioral changes. She does not wish to pursue pharmacological treatments, saying that she “knows what to do, I just have to do it.” She has never sought group or individual therapy and denies a history of anxiety, mania, substance use, or other psychiatric illness .
Severe obesity is a complicated medical condition with implications for physical and psychological health. As with many other complicated chronic conditions, it is virtually impossible for a primary care provider to satisfactorily address all potential comorbidities within a single 15-min office visit. Further, primary care physicians often lack confidence and training to address behavioral and psychological issues that frequently occur in the severely obese.
While obesity is not itself a psychiatric disorder, patients with severe obesity are more likely than controls to have more than one mental health diagnosis as compared to non-obese controls (17.1 vs. 62.5 %) [1]. As discussed later in this book, the risk for suicidal ideation and suicide attempts is higher in obese patients than in those who are normal weight or overweight [2].
The directionality of the obesity-mental health relationship is unknown, but some work suggests that the stigma of being obese may contribute to some psychiatric burden [3]. While reduction in weight has been associated with improvement in mental health [4], multiple studies suggest the presence of untreated or undertreated psychiatric illness may hinder weight loss efforts. Further, many psychiatric medications are associated with weight gain, perhaps contributing to obesity in patients with mental illness [5].
Given both the high rates of psychiatric illness in the severely obese as well as the potential contribution of psychiatric illness to obesity, psychosocial providers (e.g. therapists, psychiatric nurses, psychologists, and psychiatrists) play an important role in the treatment of obesity and comorbid psychiatric disorders. Models exist for incorporating psychosocial treatment into the management of chronic illness, although little has been written specifically about psychosocial care for obesity in the medical setting. There is sufficient evidence for the chronic care model (CCM) in the management of diabetes and major depressive disorder, conditions that share psychological, behavioral, and physical characteristics with severe obesity. Several models for integrating psychosocial care into the management of the severely obese patient will be examined.
7.2 Opportunities with Integrated Care
The Institute of Medicine specifically added mental and emotional health to its definition of primary care in 1996; and the World Health Organization emphasizes behavioral health as part of a population-based primary care strategy. The American Psychiatric Association, American Society of Addiction Medicine, American Psychological Association, and American Academy of Family Physicians all support integration of behavioral health care in the medical setting. A movement toward the patient-centered medical home (PCMH) has emerged as one way to integrate behavioral and medical health services. In the United States, the Affordable Care Act incentivizes the development of Medicaid health homes, with behavioral health care as part of the primary care delivery system.
Medical providers (particularly PCPs) provide most of the mental health care in the United States [6]. One third of patients with a mental health diagnosis receive care exclusively from their primary care physician [6]; 56 % of patients would initially go to their primary care provider for mental health treatment compared to 26 % who would go to a mental health provider [7]. Among the reasons for preferentially seeing a PCP for mental health concerns are the stigma associated with receiving mental health treatment, limited mental health, and limited access to mental health providers. Integrating medical and behavioral health care addresses these issues and enhances the ability to meet more of a patient’s needs.
The high rates of mental health treatment in the primary care setting match current prescribing practices. In 1993–4, PCPs prescribed 55 % of anxiolytics, 40 % of antidepressants, 54 % of stimulants, and 30 % of antipsychotics in the United States [8]. A 2009 survey of a national prescribing database found an increase in these numbers: primary care providers prescribed 65 % of anxiolytics, 62 % of antidepressants, 52 % of stimulants, 37 % of antipsychotics, and 22 % of antimanic agents [9]. In this survey, psychiatrists prescribed only 23 % of psychotropic medications in the United States.
Yet many with psychiatric illness receive no care at all: 60 % of patients with a mental condition do not receive any behavioral health services [10]. Reasons for this include poor behavioral health insurance coverage, lack of mental health providers, and patients’ belief that their symptoms do not require treatment [2, 11, 12].
7.3 Barriers to Integrated Care
Historically, behavioral and physical health care have operated in silos, with primary care providers reporting low levels of knowledge and comfort with respect to treating mental health conditions [13]. In addition, training and care delivery in each area are remarkably different and most providers require specific training to enable them to work in an integrated setting. There will need to be more emphasis on providing this training and experience to providers before they enter the work force [14].
Regulatory requirements, which vary by location and discipline, present another potential hurdle in the integration of mental health in the medical setting. Credentialing, restrictions on sharing protected health information, and reimbursement are all complex processes in behavioral health settings. These factors must be taken into account in the development of integrated programs. Cohen provides an in-depth discussion of key areas for consideration of the successful integration of primary care and behavioral health [15].
SAMHSA estimates that the Affordable Care Act will provide behavioral health coverage to 60 million US citizens, increasing the demand for therapists, psychologists , and psychiatrists [16]. Unfortunately, this comes at a time when there is a pronounced workforce shortage of 1800 psychiatrists and 6000 core mental health professionals, including social workers, therapists, psychologists, and psychiatric nurses [17]. As with other fields of medicine, this shortage is most pronounced in rural areas; of the 55 % of counties with no practicing mental health providers, all are rural. An examination of the distribution of primary care providers, psychiatrists, and psychologists shows that many rural areas do not have mental health providers rendering integrated care an unattainable option [18]. The reasons for this are numerous: low compensation, limited behavioral health insurance coverage in rural areas, high turnover, uneven concentration of providers in urban and suburban areas, and negative stigma associated with mental illness and the mental health profession [19].
The stigma associated with behavioral health treatment is a compelling barrier that persists for a significant minority of patients, particularly older patients, those from ethnic and racial minorities, and those in rural settings [6, 20]. Integration of behavioral health into the primary care setting is likely to increase access for patients who do not wish to be seen at a behavioral health-only clinic. Further, decision support services allow the PCP to treat the patient in consultation with a mental health provider (frequently a psychiatrist); this allows for high quality, empirically supported expert care while preserving patient comfort with their PCP .
7.4 Models of Integrated Care
There is variability in the degree of collaboration and integration between behavioral and physical health programs, ranging from primary care and behavioral health discussing shared patients as needed to providing services simultaneously [13]. Blount described three different levels of collaboration and integration to help clarify different options and to enhance understanding of research [21]. The first category Blount addresses is coordinated services, which entail communication when necessary about shared patients even though care delivery is in separate settings. The success of this category is dependent on the commitment of providers to this practice and is quite variable. Colocation is the next category described and consists of shared space for medical and mental health providers. This enhanced proximity results in improved communication, education, and quality of patient care, but does not necessarily involve structured communication and coordination between teams. Finally, Blount discusses true integrated care which involves a team approach resulting in one, joint treatment plan [21].
Wagner initially described the chronic care model (CCM) in 1996, recognizing that most primary care delivery systems were designed for acute issues rather than management of chronic conditions. In reviewing programs that successfully manage chronic illnesses , he found four key factors [22]:
- 1.
Patients and providers collaborate on treatment priorities,
- 2.
A clear plan is developed to target priorities and reach goals,
- 3.
Education and behavioral support are provided, and
- 4.
There is regular follow-up.
Bernstein describes the use of patient-centered medical homes (PCMH) to treat patients with obesity and associated complications. The team would potentially consist of a primary care provider, behavioral health provider, dietician, professionals to help with levels of physical activity, and case managers [23].
7.5 Evidence in Support of Collaborative Care Models Outside of Obesity
While the available evidence does not specifically address collaborative care for patients with severe obesity, much has been published on integrated care for depression, anxiety, at-risk alcohol use, and ADHD. A 2012 Cochrane Review found significantly greater improvement in anxiety and depression outcomes for adults treated under a collaborative model of care than those treated by traditional means [24]. A randomized trial of adolescents with depressive disorders was similarly encouraging, demonstrating greater improvement with integrated care than care as usual at 12 months [25]. Several specific models have been extensively researched and warrant further discussion:
7.5.1 IMPACT: Depression Care Management
The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model for depression has been found effective in numerous high-quality studies [26, 27]. These studies have spanned a range of health care settings and have been consistent with a variety of chronic medical illnesses, including cancer and diabetic populations [28]. This model incorporates depression screening with a depression care manager (typically a mid-level provider) who provides evidence-based treatment and monitoring. A psychiatrist consults on patients who do not respond to care as expected [26, 27].
7.5.2 SBIRT: At-Risk Substance Use
The Screening, Brief Interventions, Referral to Treatment (SBIRT) model is effective with substance use disorders in primary care settings [29]. In this model, an evidence-based screening (i.e. AUDIT) is used to determine the risk of the patient’s alcohol use. Patients with moderate to high-risk drinking receive a brief intervention (based on the principles of Motivational Interviewing), while patients who meet criteria for a substance use disorder are referred to specialty treatment. Few studies have looked at MI/SBIRT in obesity and weight management; those that have been published suggest a dose response, with greatest weight loss in patients who received intensive behavioral interventions [29].
Related posts:
Sleep and Severe Obesity
Motivational Interviewing for Severe Obesity
Psychiatric Suitability Assessment for Bariatric Surgery
Overview of Medical and Surgical Treatment of Severe Obesity
Young Adulthood and Obesity Management: Developmental Issues and Transition of Care
Addictive Disorders in Severe Obesity and After Bariatric Surgery
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