The second study found a cognitive behavioral therapy informed computer game to have comparable effectiveness to in person counseling in reducing depressive symptoms among adolescents. The third study found that adolescents with depressive symptoms who received motivational interviewing from their providers were more likely to participate in a web based cognitive behavioral therapy program designed to prevent worsening of symptoms than those who received only brief advice. Finally, there were two studies employing the integration of self-administered manualized cognitive behavioral therapy into primary care management of bulimia nervosa among predominantly young adult women. In one study, manualized treatment was associated with significant reductions in bulimic behaviors compared to wait-listed controls. The second study did not find any reductions in bulimic behaviors associated with the manualized treatment but did find reductions in bulimic behaviors among individuals in medication treatment arms.Our search did not identify any randomized trials examining outcomes for “co-located care” models. We found only two studies that examined behavioral outcomes for youth receiving “co-located care,” pot drying both used technological solutions to create virtual co-location and are included here for reference. One retrospective study of a convenience sample of youth who had received a telehealth behavioral consultation found improved behavioral outcomes at 3 months post consultation. Additionally, a large cohort study of the provision of telephone access to mental health specialists in primary care found high rates of completion of recommended mental health consultation and reduced symptoms over time for referred youth.
We identified four studies meeting the criteria of “integrated care” in the adolescent and young adult age group all of which focused on adolescent depression. Two studies examined adaptations of adult collaborative care models and involved depression care managers in primary care practices who helped primary care providers with depression assessment, symptom tracking, evidence-based treatment delivery, and advancement of treatment based on prespecified algorithms and with input from psychiatric consultants. Both found that the collaborative care was associated with increased treatment engagement and significantly improved outcomes for depression among adolescents compared to usual care. A third study examined the addition of a brief psychotherapy protocol for antidepressant-treated adolescents in primary care and found that psychotherapy was associated with only mild non-significant reductions in depressive symptoms. The authors noted that youth in the intervention arm were more likely to choose to prematurely discontinue antidepressants than those receiving usual care and hypothesized that this discontinuation may have attenuated the effects of the intervention. The final study examined the integration of interpersonal therapy delivered by trained therapists for teens with depression seen in the school based health clinic setting. They found benefit of interpersonal psychotherapy over treatment as usual particularly in youth with high levels of conflict with mothers and social dysfunction with friends.examined adaptations of adult collaborative care models and involved depression care managers in primary care practices who helped primary care providers with depression assessment, symptom tracking, evidence-based treatment delivery, and advancement of treatment based on prespecified algorithms and with input from psychiatric consultants.
Both found that the collaborative care was associated with increased treatment engagement and significantly improved outcomes for depression among adolescents compared to usual care . A third study examined the addition of a brief psychotherapy protocol for antidepressant-treated adolescents in primary care and found that psychotherapy was associated with only mild non-significant reductions in depressive symptoms. The authors noted that youth in the intervention arm were more likely to choose to prematurely discontinue antidepressants than those receiving usual care and hypothesized that this discontinuation may have attenuated the effects of the intervention. The final study examined the integration of interpersonal therapy delivered by trained therapists for teens with depression seen in the school based health clinic setting. They found benefit of interpersonal psychotherapy over treatment as usual particularly in youth with high levels of conflict with mothers and social dysfunction with friends.While behavioral health disorders have a significant impact on the functioning and impairment of adolescents and young adults, our literature review revealed a relatively small number of research studies testing behavioral health integration in this population. This limited body of literature is particularly surprising in light of the extensive array of collaborative care studies addressing these conditions in adult populations and points to the need for further development and testing of interventions among the adolescent and young adult populations. Our review also identified several gaps in the literature in which research would be beneficial in moving the field forward. First, more high-quality research is needed in the implementation of integrated care models for the behavioral health conditions that most commonly occur among adolescents and young adults. A recent Cochrane review identified 79 randomized controlled trials of integrated care models for depression and anxiety among adult populations with overwhelming evidence for effectiveness in reducing depression and anxiety symptoms.
In contrast, our search revealed only three randomized controlled trial studies of integrated care models among adolescents, all of which focused on depression. We did not identify any randomized controlled trials addressing behavioral health integration for anxiety, the most prevalent disorder during adolescence, nor eating disorders among adolescents which are often medically managed in primary care. Similarly, although integrated care models have been tested among younger children with attention deficit disorder, studies have not included adolescents above age 13 years or young adults. Additional opportunities for new research areas include the following: examining effectiveness of brief interventions developed for primary care administration in adult settings among adolescent and young adult populations, evaluation of technological strategies to increase access to psychotherapy in primary care, and improved models for the primary care integration of web-based psychotherapy methods that have been shown to be effective for depression and anxiety in adolescent and young adult populations. Our review also suggested the need for more research addressing how developmental stage affects the types of needed supports and interventions. Prior research suggests that developmental factors can influence the presentation of mental health symptoms,cannabis drying the ability to be independent in care, the impact of stigma, and the efficacy of particular types of interventions. For younger teens, parents are often the ones initiating care which may influence interest and engagement in treatment interventions. The studies in our review differed in the range of included ages, and none were designed with adequate numbers to explore if the intervention was similarly effective across developmental stage. Future studies should address this gap and examine if there are consistent patterns to the types of components required at different ages. One notable area of absence of developmental information was in the young adult population. While most adult studies include individuals who are 18 years and older, our search identified relatively few studies in which integrated behavioral health care was specifically examined in young adults, most of which were focused on substance use in college health settings. However, compared to older adults, young adults have little experience in navigating the system to reach care. More research is needed to determine if existing adult collaborative care models are reaching and meeting the needs of this population. Additionally, more research is needed to identify key strategies to facilitate the dissemination of behavioral health integration models that have been found to be effective in randomized trials into actual primary care practice in the United States. There is good evidence for the effectiveness of integrated care for depression and brief motivational interviewing for substance misuse, but significant work still exists in adopting these programs into practice under the current funding system. While our review did identify descriptive papers of large-scale implementation projects, they did not include rigorous patient-level outcome assessments or comparison groups.
In the US health care system, the funding of activities related to care management and psychiatric supervision has been a particular challenge that will require creative solutions and might benefit from more research. In a recent survey, clinicians identified lack of resources as a key barrier to implementing integrated care plans in Medical Homes. Finally, integrated care practice requires specific skills among providers including shared management plans, group case supervision by psychiatrists, and training for depression care managers. Further investigation is needed on how to train providers for these skills possibly taking an earlier approach to multidisciplinary training between behavioral health and medical trainees. The field of adolescent and young adult health care is rapidly shifting in ways that may create new opportunities for improving behavioral health outcomes for this population. The Affordable Care Act opens new opportunities to serve young adults through expansion of health insurance coverage. The Patient Centered Medical Home model aims to reduce the cost of health care and improve patient experience and population health through the integration of needed services, such as behavioral health, into a single setting. School-based health clinics and college health clinics may provide new opportunities to test models that integrate educational and other social supports. By expanding our research in integrated care among adolescents and young adults, we will be positioned well to maximize these new opportunities and to improve key behavioral health outcomes.The nation’s health care system faces a mandate to improve quality in multiple dimensions, including those identified by the Institute of Medicine: safety, timeliness, effectiveness, efficiency, equitability and patient centeredness. Expenditures and gaps in health care delivery in general are not evenly distributed throughout the population; only 5% of the population account for half of all health care spending, and quality varies considerably across conditions and settings. An effective response to the quality mandate will require a focus on subgroups of patients who have severe or multiple health conditions associated with significantly higher costs and poorer outcomes. Patients with co-occurring behavioral and medical conditions represent such a population. In the National Comorbidity Survey Replication, more than 68% of adults with a behavioral disorder report having at least one general medical disorder, and 29% of those with a medical disorder had a comorbid mental health condition. Research has documented the high rates of psychiatric comorbidity among specific medical conditions, such as HIV, diabetes, asthma and chronic medical illnesses. Conversely, studies have reported high rates of medical comorbidity among patients with psychiatric illness. The co-occurrence of behavioral and medical conditions leads to elevated symptom burden, functional impairment, decreased length and quality of life, and increased costs. For patients with comorbid behavioral and medical conditions, problems with quality of care occur when they are treated in a primary care and/or specialty mental health setting. Even more concerning, premature mortality is elevated two- to four‐ fold. In response to these findings, care delivery models have been developed for patients with comorbid medical and psychiatric conditions. The most effective have been collaborative care approaches that use amultidisciplinary team to screen and track mental health conditions in primary care. These models build on the Chronic Care Model. Yet, even as these models are promoted, the gaps in our knowledge about cooccurrence may have important implications for how these collaborative models are structured. Research to date on the prevalence of co-occurring medical and psychiatric conditions has focused on national surveys, specific illnesses, disease-focused clinics or claims data for health insurance populations, such as Medicaid or Medicare. To our knowledge, no prior study has focused on a large patient population with a predominately employment-based insurance that receives treatment in an integrated health care system.First, employed patients in an integrated health care system represent an important and distinct sub-population of patients receiving care in the delivery model promoted by health care reform. Second, this kind of system generates encounter-based rather than claims-based data. The data are generated from all clinical departments within a comprehensive system of care. To address these gaps, we examine the prevalence of behavioral health conditions in a large integrated health system that primarily serves patients with employment-based insurance. We compare the burden of medical co-morbidity and chronic diseases among those health plan members with a behavioral health condition to matched members without. This provides the opportunity to examine the robustness of the behavioral and medical disease nexus in this sub-population compared to the other sub-populations more commonly studied.