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To Go or Not Go: Patient Preference in Seeking Specialty Mental Health Versus Behavioral Consultation Within the Primary Care Behavioral Health Consultation Model.

Obtaining specialty mental health care can be difficult due to limited access to providers and long wait times (Ede et al., 2015). Extant literature indicates that integrating behavioral health services into primary care settings can reduce medical costs, improve treatment adherence and outcomes, and increase patient and provider satisfaction (Balasubramanian et al., 2017; Bryan et al., 2012; Corso et al., 2012; Hunter et al., 2018; Robinson & Reiter, 2016). Integration of behavioral health has been adopted by major health care systems across the United States and internationally (Gerrity, 2016).

One evidence-based approach to integration is the primary care behavioral health (PCBH) model, a population-based health care delivery method within primary care (Robinson & Reiter, 2016). In this model, a behavioral health provider (known as a behavioral health consultant [BHC]) is embedded into primary care to provide rapid and same-day access to patients seeking assistance for a variety of concerns (e.g., depression, anxiety, chronic health condition management; Hunter, Goodie, Oordt, & Dobmeyer, 2017). This is accomplished using brief, consultative, solution-focused visits. When necessary, the BHC will refer a patient to specialty mental health care (i.e., traditional psychotherapy) if the patient's symptoms or functioning is not improving after a series of BHC visits. Typically, this occurs in only about 15-20% of patients (Bridges et al., 2015).

Patients are significantly more likely to engage in specialty mental health care when indicated after contact with an integrated behavioral health provider (Davis, Moore, Meyers, Mathews, & Zerth, 2016). However, no research to date has examined whether integrated behavioral care improves access for patients who would otherwise not seek treatment. Therefore, we sought to examine whether patients would have sought specialty mental health care in the absence of integrated care. Our study focuses on a low-income primary care clinic and compares main findings with results from a different context, military treatment clinics.


The primary study population was a convenience sample of 100 adult patients at a predominately low-income family medicine residency clinic in South Texas. We invited every fourth patient to complete a short survey packet between March and October 2017. A volunteer research assistant administered surveys after a BHC visit, explained the procedures, and obtained informed consent. Individuals received $5.00 for their participation. The study was approved by the Institutional Review Board committee of the study location's institution.


The surveys included a demographic information sheet as well as patient satisfaction questionnaire related to the PCBH model. We created the patient satisfaction tool following a literature review and adapted from best practice recommendations (see Robinson & Reiter, 2016), and contained 11 items using a 0-to-10 Likert scale. The last question of this survey (not part of the original instrument) was an item querying the participant on likelihood of going to specialty mental health care if PCBH services were not in the primary care practice.

Secondary Study

To provide a comparison for findings, we conducted a secondary study using a convenience sample of 539 patients from family medicine clinics at three military treatment facilities across the United States. We selected this comparison sample due to utilization of the same integrated primary care model (PCBH) in a notably different (i.e., higher income, fully insured) patient population. Participants completed a different satisfaction survey at random during the course of the project period and were uncompensated. These three facilities were part of an internal quality improvement project of the Air Force PCBH program conducted in 2015-2016. Data for this study comes from a retrospective review of patient survey data collected for this process improvement initiative approved by the Uniformed Services University Institutional Review Board. These clinics served active duty service members, retired military veterans, and their families in both urban and rural areas representing broad geographic diversity.

Secondary Study Measures

We examined one item from this patient satisfaction project as it was identical to the question used in primary study on willingness to seek mental health services if PCBH was not available. However, the response options on this item were 7-point Likert scale to be consistent with other items in the Air Force patient satisfaction survey.


Participant demographics from the primary study are listed in Table 1. This is a descriptive study and thus analysis were simple frequencies and mean ratings from survey items. The most common BHC visit reason was a mental health or substance use concern (e.g., depression, anxiety, substance misuse) followed by health behavior change (e.g., tobacco cessation, weight management; in this project, tobacco cessation is classified under health behavior change rather than substance misuse). There was high patient satisfaction with BHC services, with means ranging from 8.6 to 9.9 (SD = 0.6 to 2.4) in the low-income primary care population. Approximately 61% of participants reported they "definitely would not" or "probably would not" attend a specialty mental health appointment in absence of the availability of BHC visits, and 25% were "uncertain."

Results from the secondary study survey do not include demographic variables, although all participants were adults age 18 and older who Department of Defense beneficiaries (i.e., active duty military, family members of military personnel or retired military members and their families). Table 2 displays results from the survey question on the likelihood of seeking mental health services if they were not available in primary care. Approximately 24% of participants indicated they "definitely would not" or "probably would not" and 15% indicated that they are "uncertain" if they would attend a specialty mental health appointment if PCBH was not available. In post hoc analyses, patient satisfaction (likelihood of recommending BHC services) was correlated with likelihood of seeking specialty treatment in the military sample only, r(534) = .13 p < .01.


Results provide insight into the role of the PCBH model in reaching patients who might not otherwise access specialty mental health care. Although a significant portion of PCBH visits may encompass mental health problem areas, the majority of patients would not seek services if they were not available in primary care. These findings were apparent across four separate and diverse treatment facilities, representing a wide variety of patients with unique demographic backgrounds. Results reinforce support for primary care integration and support other findings that many patients struggle to attend specialty mental health care referrals from primary care (Davis et al., 2016; Ruud et al., 2016). However, our results suggest the challenge for mental health care is not simply in facilitating the referral process, because a sizable number of patients may in fact prefer to receive mental health care in a primary care setting.

Some differences did emerge between our two study populations. In the primary study population, the majority of patients indicated they would not seek care if it were not available in primary care, compared to 24% who endorsed this reluctance in the military clinics. A larger group in the low-income clinic was also uncertain about seeking specialty mental health care than seen in military clinics (24% compared to 15%). These findings could be accounted for by differential access to specialty mental health care as a covered benefit in the military health system, which may not be consistent with civilian health care plans. Nevertheless, the finding that almost half of individuals in a health care system where specialty mental health is both covered and reasonably accessible prefer integrated behavioral health in primary care highlights the value of PCBH.

Our study is not without limitations, primarily due to the preliminary descriptive nature of the data collected. Direct comparison between samples is not possible and several confounding variables may contribute to an individual's likelihood to seek care, some of which may differ between military and civilian populations (e.g., insurance coverage for specialty mental health). These findings should encourage further research that examines reasons why certain patients may prefer behavioral health treatment in primary care. Our post hoc analyses suggest that satisfaction with BHC services may correlate with interest in seeking specialty mental health care. More research is needed to understand patient preference for care settings as well as how patient preferences relate to clinical outcomes. There may be concerns about stigma and access to specialty mental health care that may be alleviated by avoiding a specialist's office. Further research to elicit reasons why some patients prefer primary care settings may illuminate ways to improve both primary and specialty behavioral health care. In conclusion, our preliminary findings reinforce the importance of recognizing and respecting patient preferences for BHC services in primary care and highlight the need to expand integrated care resources.


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Bridges, A. J., Gregus, S. J., Rodriguez, J. H., Andrews, A. R., Villalobos, B. T., Pastrana, F. A., & Cavell, T. A. (2015). Diagnoses, intervention strategies, and rates of functional improvement in integrated behavioral health care patients. Journal of Consulting and Clinical Psychology, 83, 590-601.

Bryan, C. J., Corso, M. L., Corso, K. A., Morrow, C. E., Kanzler, K. E., & Ray-Sannerud, B. (2012). Severity of mental health impairment and trajectories of improvement in an integrated primary care clinic. Journal of Consulting and Clinical Psychology, 80, 396-403.

Corso, K. A., Bryan, C. J., Corso, M. L., Kanzler, K. E., Houghton, D. C., Ray-Sannerud, B., & Morrow, C. E. (2012). Therapeutic alliance and treatment outcome in the primary care behavioral health model. Families, Systems & Health, 30, 87-100.

Davis, M. J., Moore, K. M., Meyers, K., Mathews, J., & Zerth, E. O. (2016, November). Engagement in mental health treatment following primary care mental health integration contact. Psychological Services, 13, 333-340.

Ede, V., Okafor, M., Kinuthia, R., Belay, Z., Tewolde, T., Alema-Mensah, E., & Satcher, D. (2015). An examination of perceptions in integrated care practice. Journal of Community Mental Health, 51, 949-961.

Gerrity, M. (2016). Evolving models of behavioral health integration: Evidence update 2010-2015. New York, NY: Milbank Memorial Fund.

Hunter, C. L., Funderburk, J. S., Polaha, J., Bauman, D., Goodie, J. L., & Hunter, C. M. (2018). Primary care behavioral health (PCBH) model research: Current state of the science and a call to action. Journal of Clinical Psychology in Medical Settings, 25, 127-156.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2nd ed.). Washington, DC: American Psychological Association.

Robinson, P., & Reiter, J. (2016). Behavioral consultation and primary care: A guide to integrating services (2nd ed.). New York, NY: Springer.

Ruud, T., Aarre, T., Boeskov, B., Husevag, P., Klepp, R., Kristiansen, S.,... Sandvik, J. (2016). Satisfaction with primary care and mental health care among individuals with severe mental illness in a rural area: A seven-year follow-up study of a clinical cohort. International Journal of Mental Health Systems, 10, 33.

Stacy A. Ogbeide, PsyD, ABPP

University of Texas Health San Antonio

Ryan R. Landoll, PhD, ABPP, Maj, USAF

Uniformed Services University

Matthew K. Nielsen,


Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Nevada

Kathryn E. Kanzler, PsyD, ABPP

University of Texas Health San Antonio

This article was published Online First October 11, 2018.

Stacy A. Ogbeide, PsyD, ABPP, Department of Family and Community Medicine, University of Texas Health San Antonio; Ryan R. Landoll, PhD, ABPP, Maj, USAF, Department of Family Medicine, Uniformed Services University; Matthew K. Nielsen, PsyD, ABPP, Maj, USAF, Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Nevada; Kathryn E. Kanzler, PsyD, ABPP, Department of Psychiatry, University of Texas Health San Antonio.

This study was funded in part by the University Health System Foundation in San Antonio, Texas, and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2 TR001118. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors declare there is no conflict of interest. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all research participants included in the study. Ryan R. Landoll and Matthew K. Nielsen are employees of the U.S. government. Any views expressed herein are those of the authors and do not necessarily represent the views of the U.S. government or the Department of Defense.

Correspondence concerning this article should be addressed to Stacy A. Ogbeide, PsyD, ABPP, Department of Family and Community Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7795, San Antonio, TX 78229. E-mail:

Received January 19, 2018

Revision received August 24, 2018

Accepted September 5, 2018
Table 1
Participant Demographics and Reason for Visit in a Low-Income Primary
Care Clinic

Demographic                        Percentage  M     SD

  Female                           68%
  Male                             32%
Annual income
  <$ 10,000                        71%
  $10,001-30,000                   16%
  $30,001-50,000                   12%
  $50,001-70,000                    1%
  African American                 10%
  Asian American/Pacific Islander   1%
  Latino                           67%
  Multiracial                       2%
  White                            20%
Age (years)                                    46.1  13.3
Years of education                             11.6   2.5
Reason for visit
  Chronic disease                  24%
  Health behavior change           29%
  Mental health/substance use      41%
  Stress management                 6%

Table 2
Likelihood of Specialty Mental Health Referral
(Both Clinic Sites)

Study and description   Percentage

1 (Low-income clinic)
  Definitely would       4%
  Probably would        11%
  Uncertain             24%
  Probably would not    33%
  Definitely would not  28%
2 (Military clinic)
  Definitely would      13%
  Probably would        25%
  Might                 17%
  Uncertain             15%
  Might not              6%
  Probably would not    17%
  Definitely would not   7%

Note. Question: "If behavioral health consultation visits were not
available here in your primary care clinic, would you have gone to a
mental health clinic?"
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Article Details
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Title Annotation:BRIEF REPORT
Author:Ogbeide, Stacy A.; Landoll, Ryan R.; Nielsen, Matthew K.; Kanzler, Kathryn E.
Publication:Families, Systems & Health
Article Type:Report
Geographic Code:1USA
Date:Dec 1, 2018
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