HMO Integrates Behavioral Medicineby Shaheen E Lakhan, MD, PhD, MEd, MS, FAAN | March 16, 2006
Many health care organizations have integrated the essential findings of health psychology in the form of behavioral medicine – a multidisciplinary field concerned with behavioral and social aspects of medical conditions. The aim is to erase the lines between mental health and physical health and promote the notion that they are indivisible and inherently linked aspects of wellbeing, namely, on the basic premise that behaviors influence physical health.
Clinical and health psychologists are now extensively collaborating in the medical setting and have found a genuine locus in clinical care. Psychologists and physicians, both psychiatrists and general medical providers, collaboratively perform extensive case-sharing, cross-referrals, patient education, and public policy for mental health (Bush, 2002). The physician normally prescribes medication, evaluates responses, and performs follow-up clinical management, whereas the psychologist provides psychosocial interventions and often monitors and reports medical compliance and side effect profiles to the physician. Furthermore, psychologists are discussing psychoactive agents to their patients as an ethical discretion before securing informed consent for treatment (Littrell & Ashford, 1995). Health psychologists prepare patients for anxiety triggering procedures (i.e. with mental imagery), offer stress coping techniques, and aid in the rehabilitation of chronic pain patients.
Kaiser Permanente, a large health management organization, redesigned their adult primary care operations and medical “modules” to incorporate a full-time Behavioral Medicine Specialist and Clinical Health Educator to the existing six physicians and two nurse practitioners. The following table (taken from Tulkin & Guzman, 1999) presents brief case studies on patient diagnosis at Kaiser:
Depression – A 60 year old man whose wife had died of cancer within the past month. He stated “It’s more difficult than I had anticipated.” He did not have many friends, and was concerned about his isolation. His concentration was poor, his energy was low, and he could not sleep, even on the 25 mg of Elavil [an antidepressant] that has been prescribed by his internist. We discussed the normal process of grieving; he accepted a referral to Medical Social Work to discuss a spousal bereavement group, and his internist raised his Elavil to 50 mg. He will see me again in a month when he returns to see his internist again.
Anxiety – A 50 year old male referred because of symptoms of anxiety, stated that he had been anxious since his early 20’s. It was now getting worse and he reported having palpitations, difficulty swallowing, shortness of breath, and feeling like he will faint. I discussed with him that these were indications of a panic attack. We practiced diaphragmatic breathing, and he accepted a referral to a behavioral health class on anxiety and panic. His internist prescribed Paxil [a mild tranquilizer], starting at 10 mg daily for one week and increasing to 20 mg daily thereafter. The patient will see me again after the class, or earlier if necessary.
Organic – A 59 year old man with diabetes was referred because of symptoms of depression: decreased energy, decreased appetite, sleep problems, and problems with memory and concentration. On examination, however, he stated that he never had problems like this before. He also reported that he had a “bad taste” in his mouth, had kinesthetic distortions (car was moving when it had actually stopped), and felt that people were spying on him. I told the internist that the problem might be organic. After investigating various possibilities, the internist concluded that the symptoms were a reaction to Glucophage (Metformin) [an antihyperglycemic for diabetes], and after the patient stopped the medication, he no longer had the symptoms.
Whether operating in the same clinical environment or different private offices, psychologists and their medical partners value their respective knowledge and therapeutic potentials.
Bush, J. W. (2002). Prescribing privileges: grail for some practitioners, potential calamity for interprofessional collaboration in mental health. Journal Clinical Psychology, 58(6), 681-696.Littrell, J., & Ashford, J. B. (1995). Is it proper for psychologists to discuss medications with clients? Professional Psychology: Research and Practice, 26(3), 238-244.
Tulkin, S. R., & Guzman, J. (1999). Kaiser’s Redesign of Primary Care: New Roles for Health Psychologists. The Health Psychologist.
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