Integrated behavioral health care (IBHC) embeds mental health capacity in medical settings to improve treatment access and engagement for affected individuals. Chronically ill patients with comorbid mental health issues are 2.5 times more likely to engage in IBHC versus treatment as usual.
We are piloting an intervention to conduct depression, anxiety, and psychosocial risk screening for all adolescent patients with chronic illnesses, such as cystic fibrosis, inflammatory bowel disease, and diabetes, and their family caregivers. Through both quality improvement initiatives and randomized control trials, we are testing the feasibility and effectiveness of providing brief, evidence-based behavioral treatment on-site with facilitated community mental health referrals as needed.
Evidenced-based brief psychotherapies, such as cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and dialectical behavioral therapy (DBT), have been shown to reduce depressive and anxiety symptoms and improve functioning in children and adolescents with chronic illnesses. We are currently testing an integrated brief behavioral therapy (IBBT-4) that is delivered within pediatric chronic illness care to treat anxiety and depression symptoms, improve functioning, and promote treatment engagement. IBBT-4 is a 4-session, chronic illness adaptation of the 8-12 session Integrated Brief Behavior Therapy (IBBT) treatment for youth anxiety and depression, which has been piloted in pediatric primary care settings.
The treatment aims to counteract the central processes of avoidance and withdrawal in anxiety and depression by promoting active engagement and reduction of avoidance. In this approach, the exposure element of anxiety treatment and the behavioral activation element of depression treatment are combined into a single approach called “graded engagement.” The treatment also incorporates psychoeducation about depression and anxiety, training in relaxation and distress tolerance, and problem solving, all of which are common elements of effective treatments for anxiety and depression and in enhancing children's wellbeing.
In our 4-session adaptation (IBBT-4), we deliver only the 4 skill-building sessions and empower and support families and youth to continue treatment autonomously with home practice. Evidence suggests that exposure-based anxiety treatments and behavioral activation-based depression treatments can have positive impacts in as few as 4 sessions. Further evidence indicates that after brief training, parents can successfully lead home implementation of exposure treatment for anxiety with minimal contact with a trained clinician.
Other key features of IBBT-4 include:
1) Youth and Family Partnerships in Research and Quality Improvement: As part of a multi-tiered patient and family engagement strategy, we 1) recruited and trained youth and family partners to join our delivery systems research team, 2) enlisted and integrated feedback from our existing Family Advisory and Youth Advisory Councils, and 3) engaged online discussion forums and social media to help guide and inform the research study design, interventions, and outcome measurement strategy. Youth and family partners contribute unique insights on ways to help children feel valued by their family, school, and community and how to best address the needs of the youth in this specific population.
2) Telemedicine Capacity: We encourage families to attend all sessions in person; however in cases where families cannot be present, we make sessions available through a HIPAA- compliant video conferencing application, or by telephone to decrease barriers to accessing care.
3) Task Shifting to Build Capability: IBBT-4 is delivered by an experienced pediatric social worker. Social workers receive training in the IBBT-4 protocol, and participate in regular supervision with Ph.D. level psychologists. The Fink Center employs 3 full-time social workers and currently no doctoral level mental health specialists. Therefore, the sustained presence and future expansion of mental health treatment capacity requires that treatment is delivered by embedded providers with ongoing support.