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Research ArticleResearch Briefs

SBIRT as a Vital Sign for Behavioral Health Identification, Diagnosis, and Referral in Community Health Care

Ronald Dwinnells
The Annals of Family Medicine May 2015, 13 (3) 261-263; DOI: https://doi.org/10.1370/afm.1776
Ronald Dwinnells
Ohio North East Health Systems, Inc, Youngstown, Ohio
MD, MBA, CPE
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  • For correspondence: rdwinnells@onehealthohio.org
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  • Author Reply
    Ronald Dwinnells
    Published on: 02 June 2015
  • SBIRT is neither a vital sign nor is it efficacious
    Richard Saitz
    Published on: 01 June 2015
  • Author response: Improving kept referral appointments
    Ronald Dwinnells
    Published on: 17 May 2015
  • SBIRT: Promise Waiting to be Fulfilled
    Jeff Susman
    Published on: 15 May 2015
  • Author response Re:SBIRT is a highly effective tool
    Ronald Dwinnells
    Published on: 14 May 2015
  • Behavioral health is health
    Daniel C. Vinson
    Published on: 14 May 2015
  • SBIRT is a highly effective tool
    Joseph P. Sitarik, DO
    Published on: 14 May 2015
  • Published on: (2 June 2015)
    Page navigation anchor for Author Reply
    Author Reply
    • Ronald Dwinnells, Physician/CEO

    Thank you, Dr. Saitz, for your valuable perspectives and opinions regarding this article.

    For clarification, the intent of the article is to raise awareness amongst my practicing peers that a tool is available to assist in the identification of those having co-morbid behavioral health conditions when coming in for medically related chief complaints. When I reviewed my organization's statistics on the rate of be...

    Show More

    Thank you, Dr. Saitz, for your valuable perspectives and opinions regarding this article.

    For clarification, the intent of the article is to raise awareness amongst my practicing peers that a tool is available to assist in the identification of those having co-morbid behavioral health conditions when coming in for medically related chief complaints. When I reviewed my organization's statistics on the rate of behavioral health diagnosis, the trend was less than 1% for a multi-year period. Surely, many more of our patients have behavioral health issues than that. This, along with some personal experiences led me to implement this process in our clinics. The data was compelling and thus the process was spread to all of our sites as a quality improvement initiative. Identification of these patients are important in order for primary care providers to be aware of conditions which may be affecting their patients. In "real world" medical practice, this identification is not sought out as it is perceived as time consuming, provider discomfort and the perception that patients are not favorable to the process. My next paper addresses these three issues.

    The important point about the fact that people with behavioral disorders do not link with treatment is the importance of real-time or warm hand-offs to behavioral health counselors/ psychologists etc. This then supports the concept of integrative health care delivery. Certainly this would be difficult to do in private practices, however, in large outpatient clinical settings such as our FQHCs this would be an ideal way to provide health care delivery especially to those with limited resources and capabilities.

    Certainly, SBIRT is a concept and not a tangible entity. No, SBIRT is not a vital sign; however, the screening tools that make up an SBIRT process can be construed as a vital sign; a vital sign to help detect a behavioral health problem.

    Yes, I read the JAMA reports and their assessment is compelling. Again, the purpose of the process is to identify and make interventions. We have considerable anecdotal evidence that supports the process where people were directly helped and even saved lives by providing awareness to our physicians and practitioners.

    There is no pretending nor does the paper imply that this simple report suggests we have solved the problems of alcohol and drug disorders. Once again, it is merely a paper to encourage awareness for our medical practitioners so that an intervention may be implemented if necessary.

    Thank you again for your valuable insight and comments.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (1 June 2015)
    Page navigation anchor for SBIRT is neither a vital sign nor is it efficacious
    SBIRT is neither a vital sign nor is it efficacious
    • Richard Saitz, Chair, Dept of Community Health Sciences; Professor of Medicine and Epidemiology

    The fact that screening can identify people with a diagnosis that would not otherwise be identified does not mean that any health benefit accrues. And screening has costs and opportunity costs. SBIRT is not a vital sign. Substance use might be. And certainly knowing whether a patient uses drugs or alcohol excessively is important for safer prescribing and diagnosis of medical and other mental health conditions. But iden...

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    The fact that screening can identify people with a diagnosis that would not otherwise be identified does not mean that any health benefit accrues. And screening has costs and opportunity costs. SBIRT is not a vital sign. Substance use might be. And certainly knowing whether a patient uses drugs or alcohol excessively is important for safer prescribing and diagnosis of medical and other mental health conditions. But identifying patients by screening with risky drug use does not lead to less use. In fact there is high quality randomized trial evidence that there is no efficacy of brief counseling for screening identified patients using drugs in primary care--see JAMA 2014.

    The study reported here finds what is well known - that people with disorders identified by screening might be referred but they do not link with treatment. Glass et al found the same in a review of RCTs published in Addiction this year re alcohol. SBIRT is a nice idea, theoretically based. But it is time to pay attention to the high quality randomized trial evidence in the literature that finds it lacks efficacy. If this were a medication therapy pushed by a pharma company with the current state of evidence there would be an outcry. Instead SBIRT is a bandwagon than continues despite evidence for lack of efficacy.

    Rather than pretend we have solved the serious problem of alcohol and other drug disorders by asking a simple question and briefly counseling, we must do better--by studying and implementing more serious approaches that have promise of imoroving real clinical outcomes. The idea that an improvement in diagnosis and referral that is not completed is evidence to support a practice that should be disseminated is...disappointing at best.

    Competing interests: Writing speaking and expertise in screening and brief intervention, sometimes paid by nonprofit universities and professional societies; editor for textbooks on this topic

    Show Less
    Competing Interests: None declared.
  • Published on: (17 May 2015)
    Page navigation anchor for Author response: Improving kept referral appointments
    Author response: Improving kept referral appointments
    • Ronald Dwinnells, CEO

    Thank you Dr. Susman for your comments regarding the SBIRT paper.

    Certainly, the low kept-appointment rate data is eye-opening and concerning. As physicians, we got pretty good at identifying and diagnosing behavioral health issues; even got good at brief interventions but with such low rates of patients keeping their appointments with counselors, I became concerned about our ethical responsibilities and pot...

    Show More

    Thank you Dr. Susman for your comments regarding the SBIRT paper.

    Certainly, the low kept-appointment rate data is eye-opening and concerning. As physicians, we got pretty good at identifying and diagnosing behavioral health issues; even got good at brief interventions but with such low rates of patients keeping their appointments with counselors, I became concerned about our ethical responsibilities and potential liability issues I may have to face if we weren't able to get them the help they needed. Indeed, I believe in self-responsibilities however, many of our patients do lack the means or wherewithal to get to their appointments, often scheduled 2-3 weeks out (after our identification/diagnosis). For me, the best way to tackle this is to have an integrated service with behavioral health counselors imbedded in the clinical setting so that "real-time" referrals can be made and the so called "warm handoffs" can occur. This is what our health organization is working towards and it will fit right into the Patient Centered Medical Home concept of providing primary health care.

    Again, many thanks for reading my article. The next one will be on SBIRT considerations from a patient, provider and administrative perspective.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (15 May 2015)
    Page navigation anchor for SBIRT: Promise Waiting to be Fulfilled
    SBIRT: Promise Waiting to be Fulfilled
    • Jeff Susman, Dean, COM

    I appreciate Dr Dwinnells' real world application of SBIRT within a community health center. The increase in identification and referral rates are impressive. Unfortunately, ultimate kept-appointment rates, and presumably, influence on outcomes, remained limited. For me, the challenge of positively affecting behavioral health outcomes in the real world, is designing programs that not only enhance identification and re...

    Show More

    I appreciate Dr Dwinnells' real world application of SBIRT within a community health center. The increase in identification and referral rates are impressive. Unfortunately, ultimate kept-appointment rates, and presumably, influence on outcomes, remained limited. For me, the challenge of positively affecting behavioral health outcomes in the real world, is designing programs that not only enhance identification and referral, but ultimately translate to improved patient outcomes. I encourage Dr Dwinnells to continue to look for ways to enhance adherence and make this intervention more robust and ultimately improve outcomes. Thank you for the privilege of reading your exciting article.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (14 May 2015)
    Page navigation anchor for Author response Re:SBIRT is a highly effective tool
    Author response Re:SBIRT is a highly effective tool
    • Ronald Dwinnells, CEO

    Thank you Dr. Sitarik for your comments!

    As you know, one of the prevailing comments from providers is that patients will not want to participate in this activity. They claim that it is too invasive and personally sensitive. The basis of my next paper is on an IRB approved survey of our patients who have gone through our SBIRT process. The findings essentially show that patients are more than willing to be...

    Show More

    Thank you Dr. Sitarik for your comments!

    As you know, one of the prevailing comments from providers is that patients will not want to participate in this activity. They claim that it is too invasive and personally sensitive. The basis of my next paper is on an IRB approved survey of our patients who have gone through our SBIRT process. The findings essentially show that patients are more than willing to be screened for behavioral health issues and overwhelmingly approve the process. The refusal rate to participate during our study period was 3%. Thus, 97% had no problems answering questions about their behavioral health issues. We also did a time study which reveals no negligible increase in the patient's encounter time compared to a similar period prior to implementation.

    We are also near completion of testing an automated system we have developed to administer the SBIRT screening process. This will decrease the "labor" time for our support staff members.

    To improve our kept referral rates, we have moved toward integrating a behavioral health program with our medical and dental programs.

    Thank you again for your comments and best wishes to you!

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (14 May 2015)
    Page navigation anchor for Behavioral health is health
    Behavioral health is health
    • Daniel C. Vinson, Physician

    Dr. Dwinnells' report is a strong reminder that we family physicians need to integrate behavioral and mental health services more closely. Co-location is an attractive model, with the "referral" being initiated with an in-person introduction to the psychotherapist, counselor, or psychiatrist. Of course, these changes would require major changes in the structure and funding of primary care. And such a model needs further...

    Show More

    Dr. Dwinnells' report is a strong reminder that we family physicians need to integrate behavioral and mental health services more closely. Co-location is an attractive model, with the "referral" being initiated with an in-person introduction to the psychotherapist, counselor, or psychiatrist. Of course, these changes would require major changes in the structure and funding of primary care. And such a model needs further study, ideally a randomized clinical trial with practices being the unit of randomization. Thanks for this study. Dan Vinson

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (14 May 2015)
    Page navigation anchor for SBIRT is a highly effective tool
    SBIRT is a highly effective tool
    • Joseph P. Sitarik, DO, Physician

    I find Dr Dwinnells' article concise, well written, and well implemented. The results validate my personal experience. SBIRT is a highly effective tool that facilitates a necessary dialogue between patient and provider. The screening takes little time when implemented routinely during the nursing assessment. The screening tools seems to help break down existing barriers to this dialogue, most notably patients shame and gu...

    Show More

    I find Dr Dwinnells' article concise, well written, and well implemented. The results validate my personal experience. SBIRT is a highly effective tool that facilitates a necessary dialogue between patient and provider. The screening takes little time when implemented routinely during the nursing assessment. The screening tools seems to help break down existing barriers to this dialogue, most notably patients shame and guilt, but also the providers time constraints. Patients living with mental health or substance abuse issues need a willing ear that won't pass judgement or condemnation. They need love, understanding, and support!

    The article also confirms my personal experience, that referral to treatment is most effective when the hand-off to professional counseling can be done immediately, that day, in house!

    Thank You Dr. Dwinnells and I hope to see more follow-up studies and efforts!

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 13 (3)
The Annals of Family Medicine: 13 (3)
Vol. 13, Issue 3
May/June 2015
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SBIRT as a Vital Sign for Behavioral Health Identification, Diagnosis, and Referral in Community Health Care
Ronald Dwinnells
The Annals of Family Medicine May 2015, 13 (3) 261-263; DOI: 10.1370/afm.1776

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SBIRT as a Vital Sign for Behavioral Health Identification, Diagnosis, and Referral in Community Health Care
Ronald Dwinnells
The Annals of Family Medicine May 2015, 13 (3) 261-263; DOI: 10.1370/afm.1776
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Subjects

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  • depression
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