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APA Journal: Family, Systems, and Health

Our continuing exploration of medically unexplained symptoms.Open in a New Window

In this issue, the reader will find three articles examining different but converging perspectives on medically unexplained symptoms (MUS). In the first article, Gates, Petterson, Wingrove, Miller, and Klink (2016) examined 110,000 office visits to primary care providers between 2002 and 2010. In the second article, Clarke (2016), an internist and gastroenterologist, presents a model for diagnosing and treating MUS. The person most referenced in the first two articles and author of the landmark study—Kroenke (2016) writes the third article, an invited commentary. Kroenke eloquently reviews the major issues confronting health care clinicians dealing with MUS. We hope that readers of the three articles on MUS in this issue will reflect on their own practice, share these articles and their impressions with colleagues, and consider ways to improve the service and consultation designs in their practice settings. Those who teach behavioral health clinicians and physicians will surely be reinforced or reinvigorated to focus on ways to help patients and colleagues. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Diagnosis and treatment of medically unexplained symptoms and chronic functional syndromes.Open in a New Window

Medically unexplained symptoms and chronic functional syndromes are common but few health care professionals have had formal training about their connection to psychosocial issues. A systematic approach to diagnosis and treatment is described that is based on published evidence and detailed interviews with more than 7,000 of these patients. This approach is designed to meet the needs of primary care teams using techniques for assessing and treating current life stresses, the prolonged impact of adversity in childhood and somatic presentations of depression, posttraumatic stress, and anxiety disorders. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


You can’t treat what you don’t diagnose: An analysis of the recognition of somatic presentations of depression and anxiety in primary care.Open in a New Window

Background: Research suggests that 13–25% of primary care patients who present with physical complaints have underlying depression or anxiety. Objective: The goal of this paper is to quantify and compare the frequency of the diagnosis of depression and anxiety in patients with a somatic reason for visit among primary care physicians across disciplines. Method: Data obtained from the National Ambulatory Medical Care Survey (NAMCS) from 2002 to 2010 was used to quantify primary care patients with somatic presentations who were given a diagnosis of depression or anxiety. The Patient Health Questionnaire (PHQ)-15, Somatic Symptom Scale, and the Child Behavior Checklist for Ages 6–18 were used to define what constituted a somatic reason for visit in this study. Results: Of the patients presenting with a somatic reason for visit in this nationally representative survey, less than 4% of patents in family or internal medicine were diagnosed with depression or anxiety. Less than 1% of patients were diagnosed with depression or anxiety in pediatrics or obstetrics and gynecology. Less than 2% of patients with somatic reasons for visit in any primary care specialty had documented screening for depression. Conclusion: The rates of diagnosis of depression and anxiety in patents presenting with somatic reasons for visit were significantly less than the prevalence reported in the literature across primary care disciplines. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Somatic symptoms deserve our attention.Open in a New Window

This commentary focuses on two articles in this issue which provide important insights regarding the diagnosis and management of medically unexplained symptoms (MUS). Up to half of all outpatient visits are prompted by a physical/somatic complaint of which at least a third are MUS. Analyzing data from the National Ambulatory Care Medical Survey, Gates, Petterson, Wingrove, Miller, and Klink (2016) confirmed the common finding that depression and anxiety in patients presenting with somatic symptoms are underrecognized. Only 1–4% of such patients received a diagnosis of depression or anxiety, a rate that should have been at least four- to sixfold greater. optimize the care of chronic somatic symptoms. In the second article, Clarke draws upon clinical experience spanning several decades and thousands of patients to delineates a pragmatic approach to managing MUS. His six-step strategy augmented by illustrative cases makes more tangible the process of caring for patients with chronic symptoms. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


The Practice Integration Profile: Rationale, development, method, and research.Open in a New Window

Insufficient knowledge exists regarding how to measure the presence and degree of integrated care. Prior estimates of integration levels are neither grounded in theory nor psychometrically validated. They provide scant guidance to inform improvement activities, compare integration efforts, discriminate among practices by degree of integration, measure the effect of integration on quadruple aim outcomes, or address the needs of clinicians, regulators, and policymakers seeking new models of health care delivery and funding. We describe the development of the Practice Integration Profile (PIP), a novel instrument designed to measure levels of integrated behavioral health care within a primary care clinic. The PIP draws upon the Agency for Health care Research & Quality’s (AHRQ) Lexicon of Collaborative Care which provides theoretic justification for a paradigm case of collaborative care. We used the key clauses of the Lexicon to derive domains of integration and generate measures corresponding to those key clauses. After reviewing currently used methods for identifying collaborative care, or integration, and identifying the need to improve on them, we describe a national collaboration to describe and evaluate the PIP. We also describe its potential use in practice improvement, research, responsiveness to multiple stakeholder needs, and other future directions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Development and validation of a measure of primary care behavioral health integration.Open in a New Window

Introduction: We developed the Practice Integration Profile (PIP) to measure the degree of behavioral health integration in clinical practices with a focus on primary care (PC). Its 30 items, completed by providers, managers, and staff, provide an overall score and 6 domain scores derived from the Lexicon of Collaborative Care. We describe its history and psychometric properties. Method: The PIP was tested in a convenience sample of practices. Linear regression compared scores across integration exemplars, PC with behavioral services, PC without behavioral services, and community mental health centers without PC. An additional sample rated 4 scenarios describing practices with varying degrees of integration. Results: One hundred sixty-nine surveys were returned. Mean domain scores ran from 49 to 65. The mean total score was 55 (median 58; range 0–100) with high internal consistency (Cronbach’s alpha = .95). The lowest total scores were for PC without behavioral health (27), followed by community mental health centers (44), PC with behavioral health (60), and the exemplars (86; p < .001). Eleven respondents rerated their practices 37 to 194 days later. The mean change was + 1.5 (standard deviation = 11.1). Scenario scores were highly correlated with the degree of integration each scenario was designed to represent (Spearman’s ρ = −0.71; P = 0.0005). Discussion: These data suggest that the PIP is useful, has face, content, and internal validity, and distinguishes among types of practices with known variations in integration. We discuss how the PIP may support practices and policymakers in their integration efforts and researchers assessing the degree to which integration affects patient health outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Evaluation of online and in-person motivational interviewing training for healthcare providers.Open in a New Window

Introduction: This study examines the outcomes of a 22-hr motivational interviewing (MI) course and compares online and in-person offerings of the course. It also evaluates clinicians’ ability to accurately self-assess their MI skills. Method: 34 clinicians participated in this study and completed MI workshops either in-person or online. Use of MI in an acting patient encounter was recorded early in the training and again following the training. Recordings of these encounters were coded using the Motivational Interviewing Treatment Integrity (MITI) 3.1 coding system. After each acting patient encounter clinicians also self-evaluated their use of MI. Results: Participants showed statistically significant improvement in MI skills measured by the MITI. There were no meaningful differences between the MI skills acquired by the participants in the online group compared with those who completed training in-person. There was little correlation between participants’ self-assessment of MI skills and objective assessment. Discussion: It is feasible to complete MI training through synchronous online workshops. Participant self-assessment of MI skill does not appear to be a useful approach for assessing MI skill. The acquisition of MI skills by health professionals is possible via the Internet. Learning should be assessed using objective measures rather than relying on self-report. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Comparison of integrated behavioral health treatment for internalizing psychiatric disorders in patients with and without Type 2 diabetes.Open in a New Window

Introduction: Type 2 diabetes is often comorbid with internalizing mental health disorders and associated with greater psychiatric treatment resistance. Integrating psychotherapy into primary care can help treat internalizing disorders generally. We explored whether such treatment had comparable effectiveness in patients with and without Type 2 diabetes. Method: Participants were 468 consecutive adults (23% male; 62% Hispanic, Mage = 41.46 years) referred by medical staff for psychotherapy appointments to address internalizing symptoms (e.g., depression). After each visit, patients completed a self-report measure and clinicians assessed patient symptom severity. These data and demographics extracted from electronic medical records were analyzed using descriptive and multilevel modeling analyses. Results: Patients with and without diabetes were similar in types of internalizing disorders experienced and baseline clinician- and self-reported symptomology. Multilevel modeling suggested improvements in self-reported symptomology was comparable across patient groups; however, only patients without diabetes significantly improved according to clinician reports. Discussion: Although findings suggested integrated psychotherapy resulted in comparable patient-reported reductions of internalizing symptoms, these effects were not evident in clinician reports of diabetic patients. Possible reasons for this discrepancy (e.g., reporting biases) are discussed. Integrated psychotherapy for internalizing disorders may be effective for Type 2 diabetic patients, though caution is warranted. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


“I definitely want grandbabies”: Caregivers of adolescents with perinatally-acquired HIV reflect on dating and childbearing.Open in a New Window

Introduction: Parents and caregivers of typically developing teens are often a source of information about sexual health and relationships. However, little is known about the information offered to adolescents with perinatally acquired HIV (APHIV) by caregivers who may provide support and guidance to their teen as they explore sexuality and childbearing. Method: This qualitative exploratory study involved the in-depth interviews of 18 caregivers (17 females), including biological mothers (9), relatives (5), and adoptive/foster mothers (4), who care for APHIV. Interviews explored views regarding their adolescent’s engagement in romantic relationships, sexual behaviors, and childbearing. The guardian’s knowledge of mother-to-child-transmission (MTCT) was also assessed for accuracy. Transcribed interviews were coded for emergent themes. Results: Analyses indicated that the majority of caregivers discussed sexual health and dating with their adolescent. However, guidance regarding disclosure to partners of the adolescent’s HIV status varied. Some biological mothers and all relatives cautioned against disclosure, contrary to foster/adoptive mothers. Most caregivers wanted their adolescent to experience parenthood. Reasons affirming childbearing included the belief their child would be a good parent and wanted to experience parenthood, childbearing as a normative experience, and decreased HIV-related stigma. Biological mothers and most relatives did not know the risk of MTCT, as opposed to all foster/adoptive mothers who accurately stated the risk was 1% to 2%. Discussion: The type of guardian influenced the nature of shared information related to disclosure and risk of MTCT. Sexual and reproductive health education should be provided to caregivers because they could be an important source of information for APHIV. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


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

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 (c) 2016 APA, all rights reserved)


Parents’ integration in the treatment of adolescents with obesity: A qualitative study.Open in a New Window

Introduction: Obesity during adolescence is particularly challenging. Our aims were to identify parents’ and adolescents’ perceptions regarding obesity, as well as family dynamics before and after family-based behavioral therapy (FBBT) to improve obesity. Method: Using a qualitative approach, 23 parents and 21 adolescents aged 12 to 18 years participated in 6 focus groups, before and after FBBT. Focus groups were audio-taped, transcribed verbatim, and analyzed using content analysis. Results: Transcript analyses suggested 3 major themes from both adolescents and parents: obesity as a source of strong negative emotions, adolescents and weight-control responsibility, and disruption in family dynamics. FBBT improved self-confidence and family functioning, allowing for behavioral changes. Both adolescents and their parents felt empowered. Discussion: Family dynamics are an important issue in weight-loss treatment during adolescence. Including both parents and adolescents in therapy is crucial for tackling obesity and addressing health needs related to this age group. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Veterans’ mental health beliefs: Facilitators and barriers to primary care-mental health use.Open in a New Window

Introduction: The Veterans Health Administration (VA) Primary Care—Mental Health Integration (PC-MHI) program aims to increase availability and acceptability of mental health (MH) care by integrating these services into primary care. Little is known about veterans’ perceptions of this of method MH care delivery. This study explored the range of veterans’ beliefs and perceptions of MH and MH services with the aim of describing potential facilitators and barriers to the uptake of PC-MHI services. Method: Team-based qualitative analysis of proceedings from focus groups. Participants included 41 veterans from across service eras. Focus groups were organized by service era and use of PC-MHI services. Codes pertaining to beliefs about MH and MH treatment were identified, grouped into subthemes, and then larger organizing themes. Barriers and facilitators to treatment seeking were identified. Results: Although our study was focused on veteran perceptions of PC-MHI, participants did not appear to discriminate between PC-MHI and other MH services when discussing their decisions to seek services. Facilitators and barriers to MH treatment-seeking included systems, personal and social influences. Stigma was mentioned infrequently relative to other beliefs. Discussion: Veterans with and without experience of PC-MHI services described a variety of beliefs about MH without regard to whether this service location. These findings suggest that while integration increases access, it may not in itself decrease some barriers to seeking treatment. These findings suggest that more work is needed to address the way potential PC-MHI patients decide whether or not to engage in care. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Psychosocial interventions for use in pediatric primary care: An examination of providers’ perspectives.Open in a New Window

Introduction: The integration of psychosocial interventions in primary care settings is 1 mechanism to increase access to mental health care to youth in need. Although the delivery of psychosocial interventions by primary care providers (PCPs) reflects 1 example of this integration, research indicates that various barriers to implementation by PCPs exist. With the goal of informing a framework to guide the selection of treatments amenable to PCP practice, the authors sought to examine which criteria might influence a PCP’s intention to use a given psychosocial intervention. Method: Using survey methodology, 49 PCPs ranked characteristics of interventions for feasibility and applicability to their patient populations and setting. Results: Survey respondents found the following characteristics most important: time to employ, applicability to multiple disorders, ease of use, and ease of learning. Providers who endorsed more negative beliefs and attitudes toward addressing psychosocial concerns in youth were more likely to see certain criteria, such as ease of use and ease of learning, as more important. Discussion: The authors illustrate the potential application of these findings to the selection of psychosocial interventions for use in primary care and discuss future research directions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Partner expressed emotion and diabetes management among spouses living with Type 2 diabetes.Open in a New Window

Introduction: Expressed emotion has been consistently shown to be a significant predictor of relapse and poor disease management across numerous physical and mental health conditions, however very little research has been conducted on its relationship to the management practices of individuals living with Type 2 diabetes. This study examines the relationship between expressed emotion (EE) and diabetes management among couples where 1 spouse has Type 2 diabetes. Methods: The authors surveyed 106 couples where 1 partner was diagnosed with Type 2 diabetes. Partners without diabetes completed questionnaires about their level of criticism, emotional involvement, and warmth toward their partners. Partners with diabetes completed questionnaires on diabetes control, diabetes management practices and attitude toward their diabetes. Results: The authors found that, individuals living with diabetes who had partners with high EE reported significantly poorer diabetes management in all areas (diet, physical activity, and attitude toward diabetes). Diabetes management was found to mediate the relationship between EE and diabetes control. Results suggest that partners with high EE may have a significant influence on diabetes management practices in their partner. Discussion: These findings highlight the important role couple interactions may play in diabetes management. Findings also emphasize the potential benefit of conceptualizing diabetes management from a systems/relational perspective. In addition, greater consideration should be given to using family-based approaches for diabetes management and treatment among coupled individuals living with Type 2 diabetes. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Deficits awareness in persons with mild cognitive impairment and family care partners.Open in a New Window

Introduction: An emerging perspective of dyadic coping with chronic illness argues that concordance in the appraisal of illness is crucial for collaborative attempts at seeking information, making treatment decisions, and planning for long-term management of the illness and psychological and physical adjustments of both the care provider and care recipient. The present study examined whether persons with mild cognitive impairment (PwMCIs) and their family care partners (CPs) exhibited concordance in their awareness of deficits in the PwMCIs. Furthermore, this study explored the differences in concordance based on the relationship of the informant to the PwMCI, specifically spouse CP (SCP) versus adult child CP (ACCP). Method: PwMCI-SCP pairs (n = 55) and PwMCI-ACCP (n = 14) pairs provided reports on their awareness of PwMCI’s functional and cognitive deficits. CPs also reported their knowledge about dementia. Results: SCPs, but not ACCPs, reported greater deficits in everyday activity than PwMCIs’ self-reports. Additionally, compared to SCPs, ACCPs had more accurate knowledge about dementia, and their perception of PwMCI deficits corresponded more closely to PwMCI’s self-perception. Discussion: These findings demonstrate that concordance in awareness of PwMCI deficits varies across functional and cognitive areas and types of dyads. The results also highlight the importance of mild cognitive impairment-related education and support programs for care dyads to strengthen concordance, which is likely an important underpinning for effective coping as the illness progresses. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Multiple sclerosis (MS) in the life cycle of the family: An interpretative phenomenological analysis of the perspective of persons with recently diagnosed MS.Open in a New Window

Introduction: In this study the authors explored how people with recently diagnosed multiple sclerosis (MS) experience their disease within their family lives. Ten people in various stages of the cycle of family life (leaving home, finding a partner, raising children, parenting adolescents, launching children) who had been diagnosed with MS were interviewed in half-structured conversational interviews. Method: Transcriptions were analyzed following a phenomenological approach. Results: Five themes were found: (a) dwindling capacity for housekeeping and childcare (b) struggling to ask for or to accept help, (c) countering awkward attitudes toward my illness, (d) suspecting family members of concealing their, and (e) watching family members wrestle with your illness. Discussion: The participants described that their illness affected their ability to care for their family and home as they used to. Only a couple of studies have addressed the first person perspective of patients on family and MS. The study expands on these studies by exploring not previously examined perspectives on leaving home, finding a partner, parenting adolescents, and launching children. The findings on family and MS, approached as elements of the first person perspective of MS patients, may guide future research. Given the pivotal role of worries on family in patient experience of MS, we argue that acknowledgment of family as a constitutive element of the patient perspective should be integrated in regular MS care. The authors suggest that the clinical handling of MS as a family issue needs to be done thoughtfully and with attention to the specifics of each unique family situation. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Talk to her.Open in a New Window

The author presents a poem that was inspired by the compassionate care provided by a physician to a comatose person in the ICU, whose family member felt helpless in finding a way to care for her. The doctor’s humanity revealed a dimension of care that was healing to all those present. (PsycINFO Database Record (c) 2016 APA, all rights reserved)


Better together: Collaborative family healthcare association and the promise of team-based care.Open in a New Window

In this presidential column is a personal introduction of the new president of the Collaborative Family Healthcare Association (CFHA), Christine Runyan. As president she hopes to continue to support the existing organizational initiatives. CFHA remains a preeminent organization of experts to advocate for meaningful, patient-centered quality metrics and to educate, train, mentor, consult, and realize the vision we have been asserting for 25 years. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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