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Are There Barriers To the Appropriate Integration of These Approaches Into Health Care?
One barrier to the integration of behavioral and relaxation techniques in standard medical care has been the emphasis solely on the biomedical model as the basis of medical education. The biomedical model defines disease in anatomic and pathophysiologic terms. Expansion to a biopsychosocial model would increase emphasis on a patient's experience of disease and balance the anatomic/physiologic needs of patients with their psychosocial needs.
For example, of six factors identified to correlate with treatment failures of low back pain, all are psychosocial. Integration of behavioral and relaxation therapies with conventional medical procedures is necessary for the successful treatment of such conditions. Similarly, the importance of a comprehensive evaluation of a patient is emphasized in the field of insomnia where failure to identify a condition such as sleep apnea will result in inappropriate application of a behavioral therapy. Therapy should be matched to the illness and to the patient.
Integration of psychosocial issues with conventional medical approaches will necessitate the application of new methodologies to assess the success or failure of the interventions. Therefore, additional barriers to integration include lack of standardization of outcome measures, lack of standardization or agreement on what constitutes successful outcome, and lack of consensus on what constitutes appropriate followup. Methodologies appropriate for the evaluation of drugs may not be adequate for the evaluation of some psychosocial interventions, especially those involving patient experience and quality of life. Psychosocial research studies must maintain the high quality of those methods that have been painstakingly developed over the last few decades. Agreement needs to be reached for standards governing the demonstration of efficacy for psychosocial interventions.
Psychosocial interventions are often time intensive, creating potential blocks to provider and patient acceptance and compliance. Participation in BF training typically includes up to 10-12 sessions of approximately 45 minutes to 1 hour each. In addition, home practice of these techniques is usually required. Thus, patient compliance and both patient and provider willingness to participate in these therapies will have to be addressed. Physicians will have to be educated on the efficacy of these techniques. They must also be willing to educate their patients about the importance and potential benefits of these interventions and to provide encouragement for the patient through the training processes.
Insurance companies provide either a financial incentive or barrier to access of care depending on their willingness to provide reimbursement. Insurance companies have traditionally been reluctant to reimburse for some psychosocial interventions and reimburse others at rates below those for standard medical care. Psychosocial interventions for pain and insomnia should be reimbursed as part of comprehensive medical services at rates comparable to those for other medical care, particularly in view of data supporting their effectiveness and data detailing the costs of failed medical and surgical interventions.
The evidence suggests that sleep disorders are significantly underdiagnosed. The prevalence and possible consequences of insomnia have begun to be documented. There are substantial disparities between patient reports of insomnia and the number of insomnia diagnoses, as well as between the number of prescriptions written for sleep medications and the number of recorded diagnoses of insomnia. Data indicate that insomnia is widespread, but the morbidity and mortality of this condition are not well understood. Without this information, it remains difficult for physicians to gauge how aggressive their intervention should be in the treatment of this disorder. In addition, the efficacy of the behavioral approaches for treating this condition has not been adequately disseminated to the medical community.
Finally, who should be administering these therapies? Problems with credentialing and training have yet to be completely addressed in the field. Although the initial studies have been done by qualified and highly trained practitioners, the question remains as to how this will best translate into delivery of care in the community. Decisions will have to be made about which practitioners are best qualified and most cost-effective to provide these psychosocial interventions.
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