In the first trial to compare different approaches to delivering substance use and mental health screening in primary care for adolescents, training for physicians and embedding behavioral health clinicians produced better results than usual care. The study, published today in JAMA Pediatrics, was conducted by Kaiser Permanente.
Substance use – smoking, drinking, misusing prescription drugs and using illegal drugs – is associated with the leading causes of death among adolescents and often is related to mental health and other medical problems. Many medical organizations endorse regular screening for substance use and mental health issues beginning in early adolescence. However, it has not been widely implemented in pediatric primary care and few studies have examined implementation outcomes. Previous studies have cited limited visit times and competing priorities in primary care as barriers to implementation.
“Our findings represent a necessary initial step in understanding patterns of implementation in pediatric primary care and can help us to identify the best approach to early and effective interventions to help teenagers address substance use,” said lead author Stacy Sterling, DrPHc, MSW, of the Kaiser Permanente Division of Research. “Many teenagers who drink establish patterns of substance use that will follow them into adulthood, which is why early intervention is important.”
The study was conducted over two years in Kaiser Permanente Northern California’s Oakland Pediatrics Department, which treats a racially and socio-economically diverse population. It involved 5,183 patients, aged 12 to 18, and 52 pediatricians who were randomly assigned to one of three study groups.
In the first group, pediatricians were trained in a systematic protocol known as Screening, Brief Intervention and Referral to Treatment (SBIRT) to assess substance-use risk using evidence-based screening tools, deliver brief interventions, and refer patients to specialty substance-use or mental-health treatment. In the second group, behavioral health clinicians (BHC), trained to deliver SBIRT components, were embedded in the pediatric clinical practice for the duration of the study. In the third group, care was administered as usual with no SBIRT training to providers or access to the embedded behavioral-health clinician provided by the study.
Both intervention groups in the study delivered more brief interventions compared to the usual care group. However, the embedded-BHC group was more likely to deliver brief interventions than the pediatrician-only group (16 percent pediatrician-only, 24.5 percent embedded-BHC, 1.5 percent usual care).
“Our study demonstrates that there are viable options to the traditional care setting, but that barriers to implementation remain, including the belief among many pediatricians that other clinicians are better situated to address behavioral health problems,” said senior author Constance Weisner, DrPH, MSW, chief of Behavioral Health at the Kaiser Permanente Division of Research. “It is critical to develop an approach that addresses both substance use and mental health problems since they often go hand-in-hand.”
The researchers said the findings suggest that embedding non-physician clinicians in primary care may be a cost-effective alternative to pediatricians providing these services. Future analyses of the study data will examine patient outcomes and cost-effectiveness of the two SBIRT approaches.