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

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

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

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

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

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