The National Center for Integrated Behavioral Health at Mayo Clinic has methodological and content expertise in epidemiological and health delivery research, using a variety of designs as well as mixed methods. Mixed methods research uses qualitative and quantitative methods in the same study and is well suited to the development, evaluation, and dissemination of primary care-based training and intervention strategies.

The team trains students, residents and junior investigators in developing successful research careers.

The following ongoing research projects are a springboard for the developmental phases to come and have high potential to improve primary care training programs and enhance integrated behavioral health (IBH) care.

Integration of Behavioral Health in Primary Care for Training and Beyond

Jeanette Waxmonsky, Ph.D., L.P., Melissa K. Filippi, Ph.D., M.P.H., Mark D. Williams, M.D.

The care received by patients with behavioral health conditions remains suboptimal. Most patients with these conditions receive care in a primary care setting. A substantial proportion of patients in primary care who have behavioral health disorders also have comorbid chronic medical conditions.

The goal of this research is to improve access to high-quality behavioral health care, particularly for those from disadvantaged backgrounds or with comorbidities, with a focus on substance use disorders, mood disorders and trauma. This project seeks to enhance the adoption and sustainability of IBH in primary care to maximize opportunities for behavioral health treatment by enabling workforce development to optimize the value of care for diverse populations.

Eliminating Stigma as a Barrier for Integrated Behavioral Health in Primary Care

Sean Phelan, Ph.D., Manisha Salinas, D.R.P.H., Michelle van Ryn, Ph.D., M.P.H.

Stigma is a significant barrier to disclosing mental health and substance use concerns to a health care provider, initiating treatment, and completing treatment, in both a primary care and specialty mental health care setting. Primary care patients who fear being labeled as mentally ill or thinking of themselves as having a mental illness may avoid care. In addition, primary care physicians (PCPs) who endorse stigmatizing ideas about people with poor mental health are less likely to initiate care for mental health and substance use disorders for their patients.

It has been argued that integrating mental health care into primary care will reduce stigma by framing mental health care as a part of whole-body wellness and reducing the need for patients to make and keep referral appointments to specialty mental health care providers. It is also thought that removing the possibility of being seen seeking care at a specialty mental health clinic or thinking about oneself as needing specialty mental health care reduces or eliminates stigma.

However, research in the NCIBH has identified stigma as one of the most significant barriers to initiating and continuing with mental health care in IBH settings, suggesting that barriers remain despite the promise of IBH.

This study includes qualitative interviews with patients, PCPs and residents, a systematic review of educational intervention strategies to develop a model of stigma in IBH, and an agenda to develop targeted training modules for IBH providers and trainees. The project team will develop a foundational training module aimed at primary care residents, nursing trainees and advanced medical students nationally.

Drivers of Opioid Prescription Duration for Acute Pain: A Retrospective Cohort Study of Opioid-Naïve Patients in Primary Care

Rebecca Harris, M.D.

PCPs represent the largest group of opioid prescribers in the U.S. This study examines the opioid-prescribing patterns of PCPs for the treatment of acute pain and the likelihood of long-term use. The study team identifies factors associated with time to opioid discontinuation based on the type, strength and quantity of opioids, as well as by medical condition, geographic region and patient demographics. The goal of the research is to help inform PCPs in assessing the risks associated with differing prescribing practices.

Resident Education in Integrated Behavioral Health: Council of American Family Medicine Educational Research Alliance Program Directors' Survey

Renée Betancourt, M.D., Kent DW Bream, M.D., Mario P. DeMarco, M.D., M.P.H., Peter Cronholm, M.D., M.S.C.E., F.A.A.F.P., Margaret Baylson, M.D., M.P.H.

This project seeks to identify the prevalence of behavioral health instruction in family medicine residency curricula nationally. The project team will analyze which knowledge-based and skills-based topics are being taught within residency programs. The team will also contribute to the national interest in competency-based assessment by studying professional consensus regarding appropriate level of training for behavioral health clinical skills.

This knowledge could lead to more in-depth development of this aspect of the American Academy of Family Physicians' recommended clinical guidelines and help accelerate workforce readiness for models of behavioral health and primary care integration. More importantly, understanding relationships between the attitudes of program directors as to whether residents can or should learn these skills is a question of national regard.

Thought a better understanding of these themes, a standard for best practices can be determined and disseminated in order to prepare residents for professional practice in an IBH environment. In a collaboration with colleagues from Saint Louis University, this project entails a national survey of U.S. Family Medicine Program Directors through the Council of American Family Medicine Educational Research Alliance to analyze these themes.

Determining the Current State and Future Needs of Primary Care Training in Trauma-Informed Care

Melissa Dichter, Ph.D., M.S.W., Peter Cronholm, M.D., M.S.C.E., F.A.A.F.P., Anne Teitelman, Ph.D., F.N.P.-BC, F.A.A.N.P., F.A.A.N.

This project aims to understand the current state of primary care training for medical residents and nurse-practitioner students related to trauma-informed care (TIC), in order to identify best practices, gaps in training, and metrics for ongoing assessment of TIC-related training and training needs.

The research team will identify primary care trainees' perspectives on how training on TIC practices are integrated into their workflow, system-level barriers and facilitators to implementation of TIC practices, and interprofessional development needs to provide improved TIC practices.