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Original Investigation |

Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health A Meta-analysis

Joan Rosenbaum Asarnow, PhD1; Michelle Rozenman, PhD1; Jessica Wiblin, BA1; Lonnie Zeltzer, MD1,2
[+] Author Affiliations
1Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
2Department of Pediatrics, Mattel Children’s Hospital, University of California, Los Angeles
JAMA Pediatr. 2015;169(10):929-937. doi:10.1001/jamapediatrics.2015.1141.
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Importance  Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health care in the United States and incentivizing integrated medical-behavioral health care as a strategy for improving access to high-quality care for behavioral health conditions, enhancing patient outcomes, and containing costs.

Objective  To conduct a systematic meta-analysis of randomized clinical trials to evaluate whether integrated medical-behavioral health care for children and adolescents leads to improved behavioral health outcomes compared with usual primary care.

Data Sources  Search of the PubMed, MEDLINE, PsycINFO, and Cochrane Library databases from January 1, 1960, through December 31, 2014, yielded 6792 studies, of which 31 studies with 35 intervention-control comparisons and 13 129 participants met the study eligibility criteria.

Study Selection  We included randomized clinical trials that evaluated integrated behavioral health and primary medical care in children and adolescents compared with usual care in primary care settings that met prespecified methodologic quality criteria.

Data Extraction and Synthesis  Two independent reviewers screened citations and extracted data, with raw data used when possible. Magnitude and direction of effect sizes were calculated.

Main Outcomes and Measures  Meta-analysis with a random effects model were conducted to examine an overall effect across all trials, and within intervention and prevention trials. Subsequent moderator analyses for intervention trials explored the relative effects of integrated care type on behavioral health outcomes.

Results  Meta-analysis with a random-effects model indicated a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). Moderator analyses indicated larger effects for treatment trials that targeted diagnoses and/or elevated symptoms (d = 0.42; 95% CI, 0.29-0.55; P < .001) relative to prevention trials (d = 0.07; 95% CI, −0.13 to 0.28; P = .49). The probability was 66% that a randomly selected youth would have a better outcome after receiving integrated medical-behavioral treatment than a randomly selected youth after receiving usual care. The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models.

Conclusions and Relevance  Our results, demonstrating the benefits of integrated medical-behavioral primary care for improving youth behavioral health outcomes, enhance confidence that the increased incentives for integrated health and behavioral health care in the US health care system will yield improvements in the health of children and adolescents.

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Figure 1.
Flow Diagram of Study Selection

RCT indicates randomized clinical trial; TAU, treatment as usual.

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Figure 2.
Overall and Individual Study Effects

Error bars indicate 95% CI. CBT indicates cognitive-behavioral therapy; TBI, traumatic brain injury. Because this figure breaks studies into finer categories than those in the overall moderator analyses, summary effect sizes may differ slightly.

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