Behavioral Health Interventions in Primary Care with Individuals Managing Chronic Kidney Disease

The article we will be discussing today is an article published in 2019 by Datta and Ogbeide titled “Managing Chronic Kidney Disease: Considerations for Behavioral Health Intervention in Primary Care.” In this article the authors discuss the rising concern of chronic kidney disease (CKD) and how behavioral health interventions can help manage CKD and improve patients’ quality of life.

What did they do?

This review style article discusses CKD as a whole, including treatment considerations that may be applicable to behavioral health providers, and common co-morbid conditions that may advance the disease (i.e. diabetes, hypertension). The authors also propose a pathway for clinical, evidence-based interventions used for diabetes management that can be used in the context of the Primary Care Behavioral Health consultation model, as well as recommendations for how behavioral health providers can connect with primary care.

Why did they do it?

CKD, particularly in advanced stages is a rising concern within the healthcare system. The authors highlight the prevalence of the disease, which has risen more than 20% in the last decade. While cost-effective treatment is available within the primary care setting, there has been little investment into the behavioral health components of treatment and prevention regarding CKD. Currently, the involvement of behavioral health providers in CKD treatment is limited to dialysis preparation, which comes during the later stages of the disease and is often targeted at patients symptoms of depression. However, there is evidence to support that behavioral health intervention at earlier stages of CKD may slow advancement of the disease.

How did they do it?

The authors of this study reviewed various components of the integration of behavioral health care into the primary care setting in the specific context of CKD treatment.

What did they find?

The authors of this review paper provide a great deal of information relative to CKD alone, as well as information relative to the behavioral health components of treatment and prevention. Below we highlight the most important points from each subtopic of the article:

1. The Primary Care Behavioral Health (PCBH) Model and suggested clinical pathways
1. The PCBH consultation model is a population-based model with a focus on directly embedding a BHP into primary care treatment where same-day access is available to patients.
2. Visits in the PCBH model last ~20 minutes, where providers provide brief interventions to patient, unlike traditional psychotherapy.
3. The primary goal of this model of behavioral health integration is to provide behavioral health services to as many patients as possible, particularly those who would not have regular access to mental health treatment.
4. Clinical pathways are meant to standardize the approach to caring for patients with complex illnesses.
5. Clinical pathways for patients with CKD focus heavily on self-management and self-efficacy, highlighting skills sucks as goal-setting, thought challenging, and positive self-reinforcement.
2. Suggested pathways for PCBH relative to co-morbid physical conditions of CKD
1. Diabetes Mellitus - education about self-management skills and the impact of poor diabetes management on the progression of CKD and improving relevant physical health behaviors (e.g. increasing exercise, decreasing sugar intake).
2. Hypertension - self-management education with a focus on modifying or eliminating negative beliefs that may negatively impact stress levels
3. Tobacco Use - education regarding the impact of tobacco use on CKD, identifying thoughts and emotions that initiate tobacco use. The primary goal of visits addressing tobacco use is to prepare the patient for an attempt to quit the habit.
4. Obesity - education on effective weight loss strategies. Focussing on healthy eating habits and exercise, as well as the impact of weight loss on the progression of CKD.
3. Behavioral health conditions
1. Research supports a bidirectional relationship between behavioral health conditions such as depression, anxiety, and substance use, and CKD, suggesting that mental health has a significant impact on the progression of CKD.
2. Interventions for depressive symptoms include the use of a daily mood record, a behavioral health action plan, and the use of problem solving strategies to manage negative emotions.
3. Interventions for anxiety symptoms in individuals with CKD focus on similar areas to that of depressive symptom treatment, but also include the reduction of physical symptoms associated with anxiety.
4. Interventions for substance misuse maintain a focus on education and self-management, but may also include motivational interviewing by the BHP
5. Behavioral health conditions are most prevalent during more advanced stages of CKD when dialysis typically takes place. More than 20% of patients receiving dialysis experience psychological distress, and the authors highlight the importance of the use of motivational interviewing to help combat the high non-adherence rates during late stages of CKD.

We encourage you to read this article and learn more about how these authors very thoroughly and thoughtfully approached this topic.

What does it all mean (our take)?

This article provides another clear indication of the entanglement between medical and mental health conditions. In the world of healthcare, we are continuing to learn more about the impact of mental health intervention on physical wellbeing (and vice versa), a topic that will require continual research. Nevertheless, findings recurrently suggest that an integrated care model, consisting of care provided by behavioral and physical healthcare specialists, will not only lead to best care, but it will also more than likely reduce overall cost of care significantly. This is a model we should continue striving for - and we applaud the authors of this study for highlighting this critically important issue.