MIND-BODY INNOVATIONS— AN INTEGRATIVE CARE APPROACH Bromwyn Helene, Ph.D., and Patricia Ford, M.D., M.S.

Integration of behavioral health and medicine has gained increased support recently within the new field of complementary medicine. Providers from both disciplines are acknowledging the ‘‘mind-body’’ connection and recognizing the value of treating the ‘‘whole’’ patient through working within an integrative delivery model. This paper describes two treatment programs which were developed using the principles of the mind-body connection and implemented within an integrative setting at a large HMO. The results of research studies are presented and discussed to demonstrate the efficacy of these programs.

INTRODUCTION Kaiser Permanente’s Northeast Division, formerly Community Health Plan, is a mixed model HMO covering 600,000 members in upstate New York, Vermont, western Massachusetts and Connecticut. Since its inception in 1977, integration of behavioral health and medicine has been practiced. In fact, psychiatrists, psychologists, social workers and substance abuse counselors were included in the founding staff of the then staff model HMO. Several integrative care treatment modalities are practiced Bromwyn Helene, Ph.D., is Staff Psychologist, Northeast Permanente Medical Group. Patricia Ford M.D., M.S., is Clinical Director-PHIP, Northeast Permanente Medical Group Address correspondence to Bromwyn Helene, Ph.D., NPMG Behavioral Health Department, CHP Plaza, Building 5, Latham, NY 12110. PSYCHIATRIC QUARTERLY, Vol. 71, No. 1, Spring 2000 0033-2720/00/0300-0047$18.00/0  2000 Human Sciences Press, Inc.

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within the system including an eating disorder clinic, support/ therapy group for members with terminal illness, and a breast cancer support group. In addition a clinician-patient communication skills workshop was co-facilitated by a team of physicians and clinical social workers. In addition to the above integrative programs, behavioral health practitioners have been incorporated into several primary care health care teams. Patients are seen in joint visits with doctors and social workers, during which the social worker is able to model interviewing techniques for the primary care clinician. Even in areas where the traditional medical model exists, behavioral health practitioners have been involved in educating medical practitioners about depression. Over the past three years, several KPNE clinicians have developed an interest in exploring the use of complementary medicine. The two successful programs described in this article are examples of complementary medicine achieved through the integration of medicine and behavioral health. The Lifestyle Modification Program is a secondary prevention program developed and implemented in 1994 by KPNE staff for members with coronary artery disease. It was modeled after the Dean Ornish MD program (1). The Personal Health Improvement Program (PHIP) is a meditation-based learning program designed and developed by Matthew Budd MD of Harvard Pilgrim Plan (2) to increase members’ ability to improve their physiological and psychological distress. It was implemented at KPNE in 1996.

LIFESTYLE MODIFICATION PROGRAM Description The Lifestyle Modification Program at KPNE was designed and developed by an interdisciplinary team led by Paul Lemanski MD, an internist with an interest in complementary medicine and cardiac health. A counseling psychologist (author), two nutritionists, two yoga instructors, an exercise physiologist and a chef completed the team. Team members had been inspired by the work of Dean Ornish MD (1) which had demonstrated the effectiveness of lifestyle change in improving the cardiac condition of a care-

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fully screened patient population, in a controlled setting, with considerable financial support, and a full time staff. The KPNE team proposed to modify the Ornish program for their HMO members with coronary artery disease. The team believed that the Ornish Program could be ‘‘mainstreamed,’’ i.e. adapted for an HMO population, with staff and financial constraints. Development took place over a year of volunteer effort. The development process was alternately frustrating and exhilarating as the team struggled to reach consensus on all major aspects of the program. Each expressed discomfort as it became necessary to trust the expertise of relatively unknown team members. The program which emerged was administered to 97 members and their partners in five groups of about 20 participants each. Minor programmatic revisions were made after each group; however, the requirements for participation remained the same. Each participant was required to commit to adopting a vegetarian diet with less than 10% of calories from fat, to participate in yoga at class meetings and at home, to follow an individualized exercise program prescribed by the exercise physiologist, and to attend weekly meetings participating in classes and support/therapy groups, (a 3-6 month commitment). Members were also required to attend weekly exercise sessions monitored by the exercise physiologist. The content of the weekly group meetings consisted of classes in the physiology of cardiac illness, low fat cooking, nutrition, and yoga. In addition, support group sessions were scheduled with topics initiated by the facilitator (psychologist) and by group members. Topics included anger management, fear of dying, relationship issues, and the connection between stress and coronary artery disease. All participants were tested pre and post program on physiological and psychological measures. The assessment of quality of life was deemed particularly important by the team psychologist based upon the preponderance of research demonstrating a strong relationship between depression, anxiety, social contacts, sense of support and cardiac disease. For example, cardiac disease has been found to be associated with reductions in quality of life (3,4) and lower quality of life is a predictor of negative health outcome (5). It was felt, therefore, that an improvement in participants’

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quality of life would demonstrate effectiveness of the program and, more importantly, it would improve participants’ survival rates. Methods Instrument: The Quality of Life Inventory (6) was administered to the participants before and after their participation in the Lifestyle Modification Program as part of the overall data collection package. This instrument assesses respondent’s life satisfaction in 16 areas such as vocation, finances, relationships and health. It is a paper and pencil test used extensively in health psychology to measure subjective well-being. Scores range from ⫺6 to ⫹6 with higher scores indicative of higher quality of life. Pre and post program data were collected from 68 program participants. Subjects: The 68 Lifestyle Modification Program participants ranged in age from 42 to 83, with a mean of 58. There were 48 men and 20 women, all residents of the Capital District of New York State and most were members of KPNE. They were predominantly Caucasian, born and raised in the United States. Six participants were African American, five were non-native born to the U.S. Participants’ socio-economic status ranged from low to above average. Results Statistical analysis of the pre and post program quality of life scores was performed using a paired sample t-test with the following results: Pre-test mean ⫽ 2.49 (range ⫺2.0 to 6.0) Post-test mean ⫽ 3.04 (range .9 to 6.0) T (67) ⫽ 3.95 The paired sample t-test results were statistically significant at p ⫽ .001. The results also represent clinical significance as the mean equates to a pre-test score of 46% quality of life while the post-test score equates to 61%; a quality of life increase of 15%.

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Discussion The 68 Lifestyle Modification graduates had a 15% mean improvement in their quality of life scores. In other words, participants felt more satisfied about aspects of their lives they deemed important (health, self-regard, relationships, friendships, philosophy of life, etc.) post program versus pre program. Two explanations follow, one from the field of group therapy and one from the mind-body perspective. The multiple benefits of group therapy have been demonstrated repeatedly, as has the efficacy of group treatment for behavior change—consider AA, Weightwatchers, etc. The theoretical explanations regarding the underlying agents of change in group treatment include the concepts of universality, cohesion and interpersonal learning (7). These concepts were deliberately promoted by the Lifestyle staff through every aspect of the program. For example, participants and staff met together a total of 18 hours the opening weekend of each program to begin the group process. At the conclusion of each program a formal graduation ceremony was held during which each graduate was welcomed into the larger community of graduates. This sense of belonging was further promoted by the invitation to join in post graduate monthly support group meetings and social activities. A monthly newsletter is written and published by graduates to disseminate ‘‘community’’ news. Thus from the group therapy perspective, Lifestyle members’ quality of life improved because the program was designed to promote participants’ identification with a larger group of people, all of whom had the same medical problem, all of whom were working diligently toward the same goal and all of whom experienced interpersonal learning through the group process. An interrelated explanation for the 15% quality of life improvement for Lifestyle graduates comes from the ‘‘mind body’’ perspective. This explanation focuses upon the ‘‘allostatic load’’ (*that part of the nervous system which controls heartbeat, blood pressure, cardio vascular metabolic and immune systems) of the participants. Dr. McEwen states that individuals with chronic illness (e.g. heart disease) have ‘‘heavy’’ allostatic loads caused by their sense of isolation and feelings of an absence of control over their illness (8). Thus from this perspective Lifestyle participants were

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able to reduce their allostatic load by taking charge of their illness through education and support for behavior modification. As their feelings of isolation were reduced, their allostatic load was further lightened leading to improved physical well being and improved quality of life.

PERSONAL HEALTH IMPROVEMENT PROGRAM History and Development The Personal Health Improvement Program is a program developed by Harvard Pilgrim Health Care that is designed to address the needs of primary care patients who suffer from such emotional and stress-related physical complaints. It has been estimated that between 50% and 80% of visits to primary care are for symptoms for which no organic or psychiatric basis can be found. Typical complaints include headache, fatigue, insomnia, stress, anxiety, irritable bowel syndrome, jaw pain, back pain, and other stress-related somatic problems. Patients with such complaints are likely to be high utilizers of medical services as they return again and again for help that conventional medicine alone does not provide. Treating these symptoms in an effective manner has become increasingly important as the human and financial costs of somatization have become clear. In other cases, patients are learning to cope with chronic disease such as multiple sclerosis, asthma or rheumatoid arthritis, or a life-threatening illness like cancer or heart disease. This population can become dissatisfied high users of biomedical services, which alone do not reduce their distress or suffering because of the non-recognition of the emotional component of their experience. Recognizing that these patients have a significant financial impact as well as an impact on clinician satisfaction, KPNE decided to implement the program in 1996. A team of physicians, psychologists, nurse practitioners, physician assistants and clinical social workers was selected to become both PHIP facilitators and champions of the program. After a one-week training class at HarvardPilgrim Health Plan, the team began the work of promoting this new intervention. Because of the multi-disciplinary nature of the

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facilitator team, the program achieved credibility among both medical practitioners and patients. The program was marketed as a learning program which is distinct from traditional mental health groups. Description The program consists of six weekly two hour classes led by a trained facilitator. The classes consist of a combination of group discussion and specific exercises designed to help participants become aware of their own reactions to daily life. Participants are provided with a workbook and home-study questions, as well as an audio-tape to guide them through an awareness meditation which they are asked to do daily. Through active participation in the program, participants learn to observe behaviors which are not useful for them, and design new practices to alter mood and positively affect body processes. Instruments In order to document clinical efficacy, a formal analysis was performed on the first 100 participants. For these participants, questionnaire data were collected at the site of the course by the facilitator directly before the course and after the course, and by mail six months after the end of the course (follow-up). Complete data were collected from 69 individuals. Data collection included an inventory of both physical and psychological symptoms. Participants most often reported that they were seeking help for stress, anxiety and depression. The most common physical symptoms included fatigue, intestinal problems, back pain, headache and insomnia. Physical distress was measured through the Medical Symptoms Checklist (MSCL), an instrument used in previous behavioral medicine studies. (2) The MSCL is a checklist of 30 common physical symptoms, each of which is rated by the respondent on a five point scale for degree of distress, where 0 is ‘‘none at all’’ and 4 is ‘‘extreme.’’ Psychological distress was measured with the Brief Symptom Inventory (BSI), (9) The BSI is a 53-item list of psychiatric symptoms which are rated by participants on a scale of 0 to 4 for levels of distress for the preceding week. Distress associated with anxi-

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ety, depression, and somatization was measured because these emotional factors have been linked to high utilization of medical services. Hostility was measured because it has been shown to predict poor health outcome over time. The raw scores for these scales were T-scored on a non-patient norm (mean ⫽ 50 and S.D. ⫽10), meaning that the average person in the street has a score of 50. Results Participants reported substantial improvement in overall physical distress directly after the course and at the six month follow-up. Additional analyses were performed in order to explore how specific symptoms were affected by PHIP. As predicted, the data showed highly significant reductions in overall psychological distress as well as the four relevant psychological scales. Participants reported an immediate significant decrease in overall psychological distress after the course, and this decrease was maintained at the follow-up. Results are summarized in Table 1. After the course and at the six month follow-up, participants also reported significant decreases in anxiety, depression, hostility and somatization. Since these psychological factors have been linked concurrently to high utilization and predictively to poor health status, improvements in these areas are likely to have substantial positive effects on an individual’s well-being and helpseeking behavior. Eight out of ten of the most common symptoms showed statistically significant improvement after PHIP at the six month followup. The results are important since these are the symptoms most likely to precipitate primary care visits. Improvements in fatigue, headache and sleep problems are particularly noteworthy, since these symptoms are particularly resistant to biomedical treatment despite significant expenditures for tests and procedures. (10) Financial Outcomes In 1998, KPNE analyzed the medical utilization of 63 PHIP participants, comparing their total medical costs for the six months prior to enrollment, to the first six months after completing the

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Table 1 Change in Physical Distress, Pychological Distress and Health & Functional Status N Physical Distress Overall Physical Distress Musculo-skeletal Gastro-intestinal Distress Fatigue Headaches Weakness Sleeping Difficulties Nausea Numbness Chest Pain Shortness of Breath Psychological Distress Overall Psychological Distress Anxiety Depression Hostility Somatization Health Status & Functional Status Relief From Bodily Pain Freedom From Emotional Limitations Vitality Mental Health Overall Health Physical Functioning Freedom From Physical Limitations Social Functioning

61 54 54 54 53 60 54 60 59 60 54

Before PHIP

.89 1.40 .95 2.06 1.51 1.28 1.56 1.25 .98 .77 .72

Directly After PHIP

.79** 1.39 .78 1.92 1.23** 1.08 1.22 .85** .93 .66 .73

6 Month After PHIP

.66*** 1.40 .69** 1.51*** 1.18** .87*** .97*** .74*** .66*** .59* .44***

64 64 64 64 64

65.0 63.6 61.4 60.0 61.2

61.4*** 59.5*** 58.8** 56.2*** 58.2***

59.0*** 56.6*** 57.8*** 54.9*** 56.3***

65 65

53.2 73.9

58.1*** 76.5*

61.5*** 77.2*

64 64 65 65 65 65

44.1 36.7 60.0 53.5 53.1 35.7

58.3*** 61.5*** 68.5** 63.4*** 58.5*** 45.0***

60.8** 64.1*** 70.2** 66.1*** 62.3*** 46.5***

***p ⬍ .01, **p ⬍ .05, *p ⬍ .10

course, and to the subsequent six months. The costs included all reported claims from both medical office and affiliate practices, including all ambulatory and inpatient services. Dental and eye care costs were excluded. Utilization was compared to a control group, which consisted of 46 patients who were referred to the program, and were assessed by the intake specialist as appropriate candidates, but did not enroll. Results of this study show a reduction in cost for both the

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control group and the PHIP participants (see Table 2). However, the utilization reduction for the PHIP participants was significantly greater. Discussion Analysis of the Personal Health Improvement Program shows that this clinical intervention results in a statistically significant improvement in both physical symptoms and psychological distress. The program results in a significant reduction in medical costs compared to a control group. This control group, while not randomly selected, appears to be valid, as the reasons for not enrolling seemed more related to geography, time and cost of the program than to severity of symptoms. It is postulated that the utilization reduction for the control group occurred partly due to the clinician referral to the program and the conversation that the potential candidate had with the PHIP intake nurse. Also, patients are generally referred to this intervention at the height of their high utilization. It is likely that other interventions were utilized instead of PHIP such as a Mental Health referral or other community based intervention. Patient satisfaction with PHIP is high, making it an excellent tool in managing care by both improving quality and reducing costs.

CONCLUSIONS The two interventions discussed in this paper demonstrate the effectiveness of inter-disciplinary teams in managing select populations of patients. With support of the primary treating clinician, these teams can be effective in working with intensively with patients to affect significant behavioral change. This positive behavioral change results in improvement in clinical outcomes. Such programs are ultimately extremely cost-effective, as they empower the patient to take charge of their health, rather than relying on the medical system to ‘‘fix’’ their problems. The participation of clinicians from both behavioral health and clinical medicine enhanced the visibility and credibility among all clinicians, resulting in continuing clinician referrals. Clinicians

6 months prior 0-6 months after 6-12 months after Total per pt savings Savings attributed to PHIP ⫽ $ 512

$1,650 $1,270 $1,010

$76,305 $58,543 $46,759

CONTROL GROUP Per patient difference: n ⫽ 63

$1,028

$ 642

$ 386

$47,857

$ 70,466

$107,693

$ 760

$1,119

$1,709

$1,541

$ 950

$ 591

PHIP GROUP Per patient difference: n ⫽ 46

Table 2 Cost Comparison Before and After PHIP Referral

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from both disciplines are able to reinforce the positive behavior changes at all patient encounters. As health care delivery systems continue to struggle with managing costs and improving customer satisfaction, programs such as these mind-body based interventions should prove to be increasingly valuable.

REFERENCES 1. Ornish DM: Dr. Dean Ornish’s program for reversing heart disease. New York: Random House, 1990. 2. Hellman C, Budd M, Borysenko J, McClelland D, Bensen H: A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behavioral Medicine. 1990; Winter: 165173. 3. Griego LC: Physiologic and psychologic factors related to depression in patients after myocardial infarction: a pilot study. Heart-Lung, 22(5): 392400, 1993. 4. Willund I, Gorkin L, Pawitan Y, et al: Methods for assessing quality of life in the cardiac arhythmia suppression trial. Quality of Life Resource, 1(3):187-201, 1992. 5. Sobel DS: Rethinking medicine: Improving health outcome with cost-effective psychosocial interventions. Psychosomatic Medicine, 57: 234-244, 1995. 6. Frisch MD: Quality of Life Inventory (QOLI). National Computer Systems, Minneapolis, 1994. 7. Yalom ID: The Theory and Practice of Group Psychotherapy. New York: Basic Books, 1985. 8. McEwen B: Protective and damaging effects of stress mediators. Seminars in medicine of the Beth Israel Deaconess Medical Center. New England Journal of Medicine, Vol 338 #3, 1998. 9. Derogatis LR: The Brief Symptom Inventory: an introductory report. Psychological Medicine. 1983; 13: 595-605. 10. Kroenke K, Mangelsdorff AD: Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. American Journal of Medicine. 1989; 86: 262-265.