Session #
October 5, 2012
Behavioral Health Assessment in Integrated
Primary Care:
Conventions, Alternatives, and Mini International
Neuropsychiatric Interview
David R.M. Trotter, Ph.D.
University of Massachusetts Medical School
Kevin M. McKay, Ph.D.
Veterans’ Affairs Medical Center, Providence, RI /
Brown University, Alpert Medical School
Eric S. Zhou, Ph.D.
Dana Farber Cancer Center
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
• Describe current approaches to behavioral health
assessment in Integrated Primary Care (IPC) as well
as the associated strengths and limitations
• Discuss the potential advantages and disadvantages
associated with utilizing brief semi-structured clinical
interviews in IPC
• Identify the basics of administration/interpretation
of the Mini International Neuropsychiatric Interview
(MINI) and be able to cite the psychometric
properties thereof
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:
Please incorporate audience interaction through a
brief Question & Answer period during or at the
conclusion of your presentation.
This component MUST be done in lieu of a written
pre- or post-test based on your learning objectives to satisfy
accreditation requirements.
Overview
• Background & Introduction
• Behavioral Health Assessment in IPC and
Associated Limitations
• An Alternative Approach to Behavioral Health
Assessment in IPC Settings
• The Mini International Neuropsychiatric
Interview
• Summary
Background & Introduction
• Culture and operations of primary care
– Population-based vs. Patient-based care
– Behavioral health providers (BHP) face unique
challenges in primary care settings
Background & Introduction
• Enculturating into primary care settings
– BHP Competencies
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Clinical practice
Practice management
Consultation
Team performance
Documentation
Administration
Behavioral Health Assessment in Primary
Care Settings and Associated Limitations
 Brief functional assessments
 Typically completed in 30 minutes
 Includes presenting problem and screening measures
as well as recommendations to patient and PCP
 Hunter, Goodie, Oordt, & Dobmeyer (2009) prototype
 Understanding of referral question
 Describing role to patient / clarifying problem
 Assessing presenting problem
 Guided open-ended questions
Behavioral Health Assessment in Primary
Care Settings and Associated Limitations
• Advantages associated with functional assessment
– Efficient collection of data
– Can use information to formulate treatment
recommendations
• Potential disadvantages associated with functional
assessment
– Assessment is guided by the referral question.
– Referrals may not be based on a comprehensive
understanding of the patient’s diagnostic profile
• Example
An Alternative Approach to Behavioral Health
Assessment in Integrated Primary Care Settings
 Empirical evidence supporting the use of semistructured clinical interviews
 Close alignment with consensus diagnoses (vs. unstructured interviews)
 Possibly related to the inclusion of specific questions about specific symptom profiles
 Why don’t we use them?
 We assume that they are intrusive, disruptive, and generally interfere
with therapeutic alliance
 Clinicians criticize semi-structured interviews on the grounds that they
take too long to administer
 TRUE
The Mini-International
Neuropsychiatric Interview (MINI)
 The MINI meets the clinician’s need for a semi-structured
interview that can facilitate an accurate diagnostic assessment.
 Assesses 17 Axis I diagnoses (prioritizes current vs. historical
diagnosis)
 Administration:
 Clinician asks screening questions to rule-out diagnosis
 Indorsed rule-out items trigger administration of a diagnostic
module (e.g. MDD, OCD, PTSD)
 Clinician rates patient responses, uses an algorithm/clinical judgment,
and determines a diagnostic profile
The Mini-International
Neuropsychiatric Interview (MINI)
 Validity
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310 participants stratified by age and gender
High inter-rater (k = 0.88 to 1.0) and test-retest reliability (k = 0.76 to 0.93)
Acceptable concordance with the SCID (k > .70)
High concordance with the CIDI
Limitations: limited positive predictive value for GAD; limited ability to
differentiation between specific psychotic diagnoses; produces more false
positives than the SCID
 Clinical utility, feasibility, acceptability
 111 patients admitted to a partial hospitalization program
 Most participants said that they were not bothered by the format (89%), that it
was not lengthy (84%) and than it covered all of their symptoms (94%)
The Mini-International
Neuropsychiatric Interview (MINI)
 Strengths
 May improve clinicians’ accuracy
 Practical: Mean administration time ranging from 16.4 to 21 minutes
 Limitations
 Trade off between speed and comprehensiveness (e.g. excludes some Axis I
disorders)
 Does not assess for lifetime diagnoses (except depression and mania)
 Limited utility in diagnosing Axis II disorders
 Prioritizes diagnostic features over contextual features
 Uses a “yes-no” response format (limited opportunity for in-depth exploration)
 Acceptability in primary care settings has not been examined
 Time is required to score and interpret results
Summary
 Primary care differs from specialty mental health
 BHPs must adapt clinical skills to effectively conduct brief
assessments
 BHP models typically prioritize behavioral/functional
assessment over diagnostic assessment; however, this
approach has limitations
 Brief semi-structured interviews may enhance diagnostic
accuracy
 The MINI is one example of a brief semi-structured
interview that may improve assessment practices for
individuals presenting in primary care
Questions?
• For questions or additional information
regarding this presentation, please contact
Kevin McKay, Ph.D. at:
kevin.mckay@va.gov
kevin_mckay@brown.edu
401-273-7100 x 2199
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
Background & Introduction
Purpose: To enhance the practice of integrated
primary care by introducing an alternative approach
to behavioral health assessment in these settings.
In order to realize this goal we will first provide an
overview of the current approach to assessment in
integrated primary care and continue by examining
the strengths and potential limitations to this
approach. We then described an alternative
approach to assessment, introduce an existing
assessment tool, examine the strengths and
potential limitations thereof, and advocate for its
use in integrated primary care settings.